16.1

Thoracic Injuries

Chapter 16

Thoracic Injuries

Introduction

About 15% of war injuries involve the chest. Of those, 10% are

superficial (soft tissue only) requiring only basic wound

treatment. The remaining 90% of chest injuries are almost all

penetrating.

Those injuries involving the central column of the chest (heart,

great vessels, pulmonary hilum) are generally fatal on the

battlefield. Injuries of the lung parenchyma (the vast majority)

can be managed by the insertion of a chest tube and basic wound

treatment. Although penetrating injuries are most common,

blunt chest trauma may occur and can result in disruption of the

contents of the thorax as well as injury to the chest wall itself.

Blast injuries can result in the rupture of air-filled structures

(the lung) as well as penetrating injuries from fragments.

The immediate recognition and treatment of tension

pneumothorax is the single most important and lifesaving intervention in the treatment of chest injuries in

combat. Distended neck veins, tracheal shift, decreased

breath sounds, and hyperresonance in the affected

hemithorax, and hypotension are the cardinal signs.

None or all may be present. Immediate decompression

is lifesaving.

With the advent of body armor, it is hoped that the majority of

thoracic injuries seen in past conflicts will be avoided.

Unfortunately, there will be individuals who will not have such

protection, as well as others who will sustain chest injuries

despite protection.
16.2

Emergency War Surgery

Anatomic Considerations

 Superior border is at the level of the clavicles anteriorly and

the junction of the C7-T1 vertebral bodies posteriorly. The

thoracic inlet at that level contains major arteries (common

carotids, vertebrals), veins (anterior and internal jugulars),

trachea, esophagus, and spinal cord.

 Within or traversing the container of the chest itself are found

the heart and coronary vessels, great vessels including arteries

(aorta, arch, inominate, right subclavian, common carotid,

left subclavian, and descending aorta), veins (superior and

inferior vena cava, azygous vein, brachiocephalic vein),

pulmonary arteries and veins, distal trachea and main stem

bronchi, lungs, and esophagus.

 The inferior border is described by the diaphragm, attached

anteriorly at the T6 level and gradually sloping posteriorly

to the T12 level.

Penetrating thoracic injuries below the T4 level (nipple

line) have a high probability of involving abdominal

structures (Fig. 16-1).

Evaluation and Diagnosis

Knowledge of the mechanism of

injury (eg, blast, fragment, among

others) may increase the index of

suspicion for a particular injury. A

complete and accurate diagnosis is

usually not possible because of the

limited diagnostic tools available in

the setting of combat trauma. Nonetheless, because injuries to the chest

can profoundly affect breathing and

circulation (and on rare occasion, the

airway), a complete and rapid assessment of each injury is mandatory.

 If the casualty is able to talk, there is reasonable assurance

that the airway is intact.

Fig. 16-1. Thoracic incision

of abdominal contents.

T4 T4
16.3

Thoracic Injuries

Life-Threatening Injuries

Injuries not immediately obvious, yet requiring urgent

attention, include tension pneumothorax, massive

hemothorax, and cardiac tamponade.

 Tension Pneumothorax.

ο A patient with a known chest injury presenting with an

open airway and difficulty breathing has a tension

pneumothorax until proven otherwise and requires rapid

decompression and the insertion of a chest tube.

 Massive Hemothorax.

ο The return of blood may indicate a significant intrathoracic

injury. Generally, the immediate return of 1,500 cc of blood

mandates thoracotomy (especially if the wound was

sustained within the past hour). With less blood initially,

but a continued loss of 200 cc/hour for over 4 hours,

thoracotomy is indicated.

ο Casualties with massive thoracic hemorrhage require

damage control techniques (see Chapter 12, Damage

Control Surgery).

 Cardiac Tamponade.

ο Distended neck veins (may be absent with significant

blood loss) in the presence of clear breath sounds and

hypotension indicate the possibility of life-threatening

cardiac tamponade.

ο Fluid resuscitation may temporarily stabilize a patient in

tamponade.

ο Perform an ultrasound (US) with a stable patient.

♦ If positive, proceed to the OR (pericardial window,

sternotomy, thoracotomy). Any pericardial blood

mandates median sternotomy/thoracotomy.

♦ A negative US requires either repeat US or pericardial

window, depending on level of clinical suspicion.

ο Pericardiocentesis is only a stopgap measure on the way

to definitive surgical repair.
16.4

Emergency War Surgery

 Open pneumothorax (hole in chest wall) is treated by placing

a chest tube and sealing the hole. Alternatives include oneway valve chest dressings or a square piece of plastic dressing

taped to the chest on three sides.

 Flail chest (entire segment of the chest wall floating due to

fractures of a block of ribs, with two fractures on each rib)

will require treatment (either airway intubation or observation) based on the severity of the underlying lung injury.

In cases where intubation is not required, repeated intercostal

nerve blocks with a long-acting local anesthetic such as

Marcaine may be very helpful in relieving pain and limiting

atelectasis and other pulmonary complications.

Surgical Management

Most penetrating chest injuries reaching medical

attention are adequately treated with tube thoracostomy

(chest tube) alone.

Tube thoracostomy (chest tube).

 Indications.

ο Known or suspected tension pneumothorax.

ο Pneumothorax (including open).

ο Hemothorax.

ο Any penetrating chest injury requiring transport (mandatory in case of aeromedical evacuation).

 Procedure (Fig. 16-2).

ο In cases of tension pneumothorax, immediate decompression with a large bore needle is lifesaving. An IV

catheter (14/16/18 gauge at least 2–3 inches in length) is

inserted in the midclavicular line in the second interspace

(approximately 2 fingerbreadths below the clavicle on the

adult male). Entry is confirmed by the sound of air passing

through the catheter. This must be rapidly followed by

the insertion of a chest tube.

ο In a contaminated environment, a single gram of IV

cefazolin (Ancef) is recommended.

ο If time allows, prep the anterior and lateral chest on the

affected side with povidone-iodine.
16.5

Thoracic Injuries

ο Identify the incision site along the anterior axillary line,

intersecting the 5th or 6th rib.

ο Inject a local anesthetic in the awake patient, if conditions

allow.

ο Make a transverse incision, 3–4 cm in length, along and

centered over the rib, carrying it down to the bone.

1 2 3 4 5 6 7 8

9 10

7

6

5

Lungs

4 5

6

Anterior

Axillary Line

c

d

e

4 5 6 7 8

9 10 1 2 3

b

4 5

6

6th Rib Site

Chest tube 

Suction/ Open

Heimlich valve

OR

a

Fig. 16-2. Procedure for tube thoracostomy.
16.6

Emergency War Surgery

ο Insert a curved clamp in the incision, directed over the

top of the rib, and push into the chest through the pleura.

A distinct pop is encountered when entering the chest and

a moderate amount of force is necessary to achieve this

entry. A rush of air out of the chest will confirm a tension

pneumothorax. Insertion depth of the tip of the clamp

should be limited by the surgeon’s hand to only 3 or 4 cm

to make sure that the clamp does not travel deeper into

the chest, resulting in damage to underlying structures.

ο Spread the clamp gently and remove. The operator’s finger

is then inserted to confirm entry.

ο Insert a chest tube (24 to 36 French) into the hole. All chest

tube side-holes must be in the chest. If no chest tubes are

available, an adult endotracheal tube may be used.

ο Attach a chest tube to a Heimlich valve, sealed pleurovac,

or bottles. In a resource constrained environment, a cutoff glove or Penrose drain may be attached to the end of

the chest tube.

ο Secure the tube with suture, if possible, and dress to

prevent contamination.

Resuscitative Thoracotomy

ï Only indicated in penetrating chest injury in extremis

or with recent loss of vital signs.

ï These patients are generally unsalvageable, even with

unlimited resources and no other significant casualties.

ï If performed, a rapid assessment of injuries should be

made, and in the case of unsalvageable injuries, the

procedure should be immediately terminated.

Procedure

 With the patient supine, make an incision in the left

inframammary fold starting at the lateral border of the

sternum extending to the midaxillary line (Fig. 16-3).

 The procedure should be abandoned upon the discovery of

devastating injuries to the heart and great vessels.
16.7

Thoracic Injuries

 If no injury is found in left

chest, rapidly extend the

incision across the midline,

crossing through the sternum

with a Lebsche sternum knife,

performing a mirror-image

thoracotomy (clamshell,

Fig. 16-4). When doing this

procedure you will cut across

both internal mammary

arteries, which will be a significant source of bleeding.

 Elevating the anterior chest

wall will expose virtually all mediastinal structures.

 Open the pericardium and assess the heart.

 Priorities are to stop bleeding and restore central perfusion.

ο Holes in the heart and/or great vessels should be

temporarily occluded.

♦ Temporary occlusion can be achieved with fingers, sidebiting clamps or Foley catheters with 30 cc balloons.

Any other sterile device of opportunity is acceptable.

ο Major pulmonary hilar injuries should be cross-clamped

en masse.

ο Descending aorta located, cross-clamped, and cardiac

function restored via defibrillation or massage. (Make sure

to open the mediastinal pleura over the aorta to securely

apply the vascular clamp.)

ο If unable to restore cardiac function rapidly, abandon the

operation.

 With successful restoration of cardiac function, injuries should

be more definitively repaired.

Subxiphoid Pericardial Window

Subxiphoid pericardial window should not be attempted

in an unstable patient. Unstable patients with penetrating

injuries suspicious for cardiac injury should undergo

immediate median sternotomy/thoracotomy.

Fig. 16-3. Incision for resuscitative

thoracotomy.
16.8

Emergency War Surgery

Procedure

 With the patient supine, make a 4–5 cm longitudinal incision

just on and below the xiphoid process through the skin and

fascia.

 Bluntly dissect superiorly toward the heart exposing the

phrenopericardial membrane below the heart.

Fig. 16-4.

Supraclavicular approach.

Supraclavicular Extension
16.9

Thoracic Injuries

 Place two stay sutures into the membrane and sharply incise

between them, with care to avoid the heart, opening the

pericardial sac and exposing the underlying beating heart.

Median Sternotomy

 Indications.

ο Suspected cardiac injury in an unstable patient.

ο Positive pericardiocentesis/subxiphoid pericardial

window.

ο Suspected injury to the great vessels in the chest.

ο Suspected distal tracheal injury.

 Procedure.

ο In the supine position, make a midline skin incision from

the sternal notch to just below the xiphoid.

ο Through blunt/sharp dissection, develop a plane for

several centimeters both superiorly and inferiorly beneath

the sternum.

ο Divide the sternum with a sternal saw or Lebsche knife.

Keep the foot of the knife/saw tilted up toward the

undersurface of the sternum to avoid cardiac injury. Bone

wax can be used to decrease bleeding on the cut edges of

the sternum.

ο Separate the halves of the sternum using a chest retractor.

ο Carefully divide the pericardium superiorly, avoiding the

innominate vein, exposing the heart and base of the great

vessels.

In general, exposure to the heart and great vessels is best

achieved through a median sternotomy. For proximal left

subclavian artery injuries, additional exposure (trap

door) may be necessary.

ο Close with wire suture directly through the halves of the

sternum, approximately 2 cm from the edge, or around

the sternum through the costal interspaces using wire

sutures.

ο Place one or two mediastinal tubes for drainage, exiting

through a midline stab wound inferior to the mediastinal

skin incision.
16.10

Emergency War Surgery

Trap Door Extension

Other Approaches

 Supraclavicular.

ο Indication.

♦ Mid to distal subclavian artery injury.

ο Procedure.

♦ Make an incision 2 cm above and parallel to the clavicle,

beginning at the sternal notch and extending laterally 8 cm.

Trap door (Fig. 16-5).

ο Indication.

♦ Proximal left subclavian artery injury.

ο Procedure.

Fig. 16-5. Trap door procedure.
16.11

Thoracic Injuries

♦ Perform supraclavicular approach as above.

♦ Perform a partial median sternotomy to the fourth

intercostal space.

♦ At the fourth intercostal interspace, incise the skin

laterally in the submammary fold to the anterior axillary

line.

♦ Divide the sternum laterally and continue in the 4th

intercostal space (ICS) to the anterior axillary line. The

internal mammary artery will be divided and must be

controlled.

♦ It may be necessary to either fracture or remove a section

of clavicle to gain adequate exposure of the proximal

left subclavian artery.

♦ Approach distal left subclavian artery injuries through

a supraclavicular incision.

 Thoracoabdominal.

ο Indication.

♦ Combined thoracic and abdominal injuries.

ο Procedure.

♦ The resuscitative thoracotomy can be continued

medially and inferiorly across the costal margin into

the abdominal midline to complete a thoracoabdominal

incision.

♦ Alternatively, a separate abdominal incision can be

made.

♦ With right-sided lower chest injuries, the liver and

retrohepatic vena cava can be exposed well using a right

thoracoabdominal approach.

Specific Injuries

 Vascular.

ο Initially, holes in vessels should be digitally occluded.

Stopgap measures include placing Fogarty or Foley

catheters, side-biting clamps, or in the case of venous

injuries, sponge sticks.

ο Total occlusion or clamping may temporarily be necessary

to allow resuscitation to continue and restore cardiac

function.
16.12

Emergency War Surgery

ο If cardiac function cannot be restored within 5 to 10

minutes, the procedure should be abandoned (on-the-table

triage).

ο Repair of vessels should follow the principles detailed in

vascular repair: attempting primary repair if possible, with

the use of prosthetics if primary repair is not feasible.

Consider shunting as an alternative.

 Heart.

The usual result of high-velocity injuries to the heart is

irreparable destruction of the muscle.

ο Isolated punctures of the heart should be exposed (opening

the pericardium) and occluded by finger pressure. Other

methods include the use of a Foley catheter or skin staples.

ο Use pledgeted horizontal mattress sutures (2-0 prolene)

on a tapered needle for definitive repair. Care must be

taken to avoid additional injury to coronary vessels.

Extreme care must be taken to avoid tearing the cardiac

muscle.

ο Atrial repairs may include simple ligature, stapled repair,

or running closures (Fig. 16-6).

ο Temporary inflow occlusion may prove helpful in repair.

ο More complex repairs are impractical without cardiac

bypass.

 Lung.

ο Tube thoracostomy alone is adequate treatment for most

simple lung parenchymal injuries.

ο Large air leaks not responding to chest tubes or that do

not allow adequate ventilation will require open repair (see

tracheobronchial tree below).

ο Posterolateral thoracotomy is preferred for isolated lung

injuries. Anterior thoracotomy may also be used.

ο Control simple bleeding with absorbable suture on a

tapered needle. Alternatively, staples (TA-90) may be used

for bleeding lung tears.
16.13

Thoracic Injuries

ο Tractotomy: Open any bleeding tracts (through and

through lung penetrations) with a GIA stapler and ligate

bleeding points.

Do not simply close the entrance and exit points of

penetrating tracts in the lung. With positive pressure

ventilation, the risk is air embolism. The more central

the injury, the higher the risk.

ο Resection for bleeding may be indicated with severe

parenchymal injury. Anatomic resections are not indicated

and simple stapled wedge excisions recommended.

ο Uncontrolled parenchymal/hilar bleeding, or complex

hilar injuries with massive air leak should be controlled with

hilar clamping and repair attempted. Pneumonectomy is

performed as a last resort (90% mortality).

Fig. 16-6. Repair of penetrating cardiac injury.
16.14

Emergency War Surgery

 Tracheobronchial tree.

ο Suspect the diagnosis with massive air leak, frothy

hemoptysis, and pneumomediastinum.

ο Confirm by bronchoscopy.

ο Airway control is paramount.

ο Median sternotomy is best approach.

ο Repair over endotracheal tube with absorbable suture –-

may require segmental resection. Bolster with pleural or

intercostal muscle flap.

ο Temporizing measures include:

♦ Single lung ventilation.

♦ Control the airway through the defect.

 Esophagus.

ο Isolated thoracic esophageal injuries are exceedingly rare.

They will usually be diagnosed incidentally associated

with other intrathoracic injuries.

ο Diagnostic clues include pain, fever, leucocytosis, cervical

emphysema, Hamman’s sign, chest X-ray (CXR) evidence

of pneumothorax, mediastinal air, and pleural effusion.

Contrast swallow may confirm the diagnosis.

ο Start IV antibiotics as soon as the diagnosis is suspected,

and continue post-op until fever and leucocytosis resolve.

This is an adjunctive measure only. Surgery is the

definitive treatment.

ο For stable patients in a forward location, chest tube

drainage and a nasogastric tube placed above the level of

injury is a temporizing measure. Ideally, primary repair is

performed within 6–12 hours of injury. Beyond 12 hours,

isolation of the injured segment may be necessary.

The preferred approach for intrathoracic esophageal

injuries is posterolateral thoracotomy; right for upper

esophagus and left for lower esophagus.

ο Locate the injury by mobilizing the esophagus. Primarily

repair with a single layer of 3-0 absorbable suture and cover

with pleural or intercostal muscle flap.
16.15

Thoracic Injuries

ο Drainage with chest tubes (one apical, one posterior) is

recommended.

ο If unable to primarily repair (as with a large segmental

loss or severely contaminated/old injury), staple above

and below the injury, place a nasogastric (NG) tube into

the upper pouch and place a gastrostomy tube into the

stomach. Drain the chest as indicated above. Complex

exclusion procedures are not indicated in a forward

operative setting.

ο An alternative when the esophageal injury is too old for

primary repair is to close the injury over a large T-tube,

which converts the injury to a controlled fistula. The

mediastinum is then widely drained using chest tubes or

closed suction catheters placed nearby. After a mature

fistula tract is established, slowly advance the T-tube and

later the mediastinal drains can be slowly advanced.

 Diaphragm.

ο All injuries of the diaphragm should be closed.

♦ Simple small lacerations (< 2 cm) should be reapproximated with interrupted nonabsorbable 0 or 1-0

horizontal mattress sutures.

♦ Lacerations larger than 2 cm should be approximated

as above, then reinforced with a running suture to assure

an airtight closure.

♦ Care should be exercised in the central tendon area to

avoid inadvertent cardiac injury during the repair.

ο If there is significant contamination of the pleural space

by associated enteral injuries, anterior thoracotomy and

plueral irrigation and drainage with two well-placed chest

tubes should strongly be considered.

♦ Inadequate irrigation and drainage leads to a high

incidence of empyema, especially of the fungal variety.
16.16

Emergency War Surgery