THORACIC TRAUMA

CONTENTS

Preface xiStephen R. Hazelrigg

Overview of Thoracic Trauma in the United States 1Sandeep J. Khandhar, Scott B. Johnson, and John H. Calhoon

The treatment of thoracic trauma continues to evolve over the years. Initial care of thesepatients is straightforward and often performed adequately by emergency room physi-cians and general surgeons. Tertiary care of these patients is multidisciplinary in nature,however, and communication with the thoracic surgeon is essential to minimize mortal-ity and long-term morbidity. Improvement in the understanding of the underlying mo-lecular physiologic mechanisms involved in the various traumatic pathologic processes,and the advancement of diagnostic techniques, minimally invasive approaches, andpharmacologic therapy, all continue to contribute to decreasing the morbidity and mor-tality of these critically injured patients.

Pulmonary Contusions and Critical Care Management in Thoracic Trauma 11John P. Sutyak, Christopher D. Wohltmann, and Jennine Larson

Many victims of thoracic trauma require ICU care and mechanical ventilatory support.Pressure and volume-limited modes assist in the prevention of ventilator-associated lunginjury. Ventilator-associated pneumonia is a significant cause of posttraumatic morbidityand mortality. Minimizing ventilator days, secretion control, early nutritional support,and patient positioning are methods to reduce the risk of pneumonia.

The Management of Flail Chest 25Brian L. Pettiford, James D. Luketich, and Rodney J. Landreneau

Flail chest is an uncommon consequence of blunt trauma. It usually occurs in the settingof a high-speed motor vehicle crash and can carry a high morbidity and mortality. Theoutcome of flail chest injury is a function of associated injuries. Isolated flail chest may besuccessfully managed with aggressive pulmonary toilet including facemask oxygen,continuous positive airway pressure, and chest physiotherapy. Surgical stabilization isassociated with a faster ventilator wean, shorter ICU time, less hospital cost, and recov-ery of pulmonary function in a select group of patients with flail chest. There is no rolefor stabilization for patients who have severe pulmonary contusion. Supportive therapyand pneumatic stabilization is the recommended approach for this patient subset.

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Traumatic Injury to the Trachea and Bronchus 35Riyad Karmy-Jones and Douglas E. Wood

Tracheobronchial injuries are uncommon, occurring in as few as 0.5% of patients whopresent following injury. The incidence may be as high as 8%, however, following pene-trating neck injury, and 2% following blunt chest or cervical injury. They often present asimmediately life-threatening injuries, but may present in a more occult fashion with lateonset of hemoptysis, recurrent pneumonia, or ‘‘asthma.’’ Diagnosis often requires a highdegree of clinical suspicion. Management must be immediately directed to securing theairway, which may require advanced bronchoscopic skills. Subsequent repair must takeinto account the severity of associated injuries and exact location and degree of airwaydisruption.

Hemothorax Related to Trauma 47Dan M. Meyer

Management of hemothoraces related to trauma follows basic tenets well respected byboth trauma and cardiothoracic surgeons. In most instances, a nonoperative approachis adequate with a defined group of patients requiring only tube thoracostomy. It is onlyin a true minority of individuals that operative intervention necessary. For both bluntand penetrating injuries, the presence of retained hemothorax is well treated by early in-tervention with thoracoscopic techniques, shown to decrease hospital stay and costs.Controversial areas including the use of prophylactic antibiotics, sequence of operativeintervention in patients with combined thoracoabdominal trauma, and the use of emer-gency department thoracotomy, remain a challenge but recent literature can serve toguide the clinician.

Blunt Traumatic Lung Injuries 57Daniel L. Miller and Kamal A. Mansour

Approximately one third of patients admitted to major trauma centers in the UnitedStates sustain serious injuries to the chest. The lungs, which occupy a large portion ofthe chest cavity and lie in close proximity to the bony thorax, are injured in the majorityof these patients directly or indirectly. A significant number of lung injuries are also as-sociated with trauma to other critical thoracic structures. This article discusses blunttrauma injuries of the lung, which include pulmonary contusions, hematomas, lacera-tions, and pulmonary vascular injuries.

Esophageal Trauma 63Ayesha S. Bryant and Robert J. Cerfolio

Injury from blunt or penetrating trauma to the esophagus is relatively rare. Treatmentstrategy is contingent on the clinical status of the patient, associated injuries, the degreeof esophageal injury, and the time of injury until diagnosis. Although nonoperative in-tervention may be acceptable in highly selected patients with contained injuries or thosewho are more than 24 hours removed from the injury and are clinically stable, operativeintervention is the most conservative and safest approach. This article provides informa-tion on the methods of injury, the diagnosis, and different treatment strategies for trau-matic esophageal injuries, and iatrogenic and corrosive esophageal injures. Theprinciples applied in the management of these types of injuries can be applied to alltypes of esophageal insults.

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Video-Assisted Thoracic Surgical Applications in Thoracic Trauma 73Ibrahim B. Cetindag, Todd Neideen, and Stephen R. Hazelrigg

Video-assisted thoracic surgery (VATS) has been used in thoracic trauma for treatment ofretained hemothorax, persistent pneumothorax, the diagnosis of diaphragmatic injuriesafter penetrating trauma, posttraumatic empyema, management of ongoing bleeding, re-trieval of foreign bodies, and for traumatic chylothoraces. In some instances VATS hasproved more effective than conservative treatment or chest tube placement. Thoraco-scopy has proved to have a high degree of sensitivity and specificity in detecting dia-phragmatic injuries. The main contraindication to VATS in trauma is patients whorequire emergency treatment because of hemodynamic instability; in these patients athoracotomy or sternotomy should be used.

Traumatic Diaphragmatic Injuries 81James R. Schaff and Keith S. Naunheim

The best tool to guide the clinician toward the appropriate diagnosis of traumatic dia-phragmatic hernia is a high index of suspicion in patients with blunt or appropriate pe-netrating trauma. Although laparoscopic or thoracoscopic management of such patientsmay become prevalent with increasing experience, at present the open approach andsimple repair remain the mainstays of management. The patient’s survival still dependsmore on the severity of concomitant nondiaphragmatic injuries and in many cases thediaphragmatic laceration is the least worrisome and least morbid of the patient’s injuries.Operative repair results in a good outcome in most patients in the absence of other ser-ious injuries.

Cardiac Trauma 87Richard Embry

Fifty years ago, nearly all significant cardiac injuries were fatal, many were untreatable,and most undiagnosed until the autopsy suite. In the last 20 years, however, dramaticimprovements in prehospital trauma management, new diagnostic modalities, and theavailability of cardiac surgery in many hospitals have rendered treatable most cardiacinjuries. Knowledge of various types of cardiac injuries, the methods available to facil-itate rapid diagnosis, and familiarity with techniques for surgical repair are no longeran academic exercise but a life-saving necessity.

Overview of Great Vessel Trauma 95William T. Brinkman, Wilson Y. Szeto, and Joseph E. Bavaria

Traumatic injury to the aorta and the brachiocephalic branches are potentially lethal in-juries. Specialized preoperative imaging and medical management can lead to better out-comes in this group of patients. In addition, improved surgical techniques for spinal cordprotection have led to decreased morbidity in surgical candidates. Thoracic endovascu-lar stent grafts remain a promising technique; however, long-term data currently are notavailable.

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The Endovascular Approach to Acute Aortic Trauma 109Riyad Karmy-Jones, Stephen Nicholls, and Thomas G. Gleason

Endovascular repair of the traumatically injured thoracic aorta has emerged as an excep-tionally promising modality that is typically quicker than open repair, with a reducedrisk of paralysis. There is a specific set of anatomic criteria that need to be applied, whichcan be rapidly assessed by the CT angiogram. The enthusiasm for endovascular repairmust be tempered by recognition of the complications and lack of long-term follow-up, particularly in younger patients. Surgeons who are skilled in open aortic repair mustnot only be involved, but should take on a leadership role during the planning, deploy-ment, and follow-up of these patients. As more specific devices become available, andmore follow-up is accrued, the role of endovascular stents will continue to grow.

Index 129

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