Chest trauma: “Damage Control” Begins in the emergency room

Bradley J Phillips; Lauren Turco

doi:10.4103/jctt.jctt_3_17

REVIEW ARTICLE

Year : 2017 | Volume : 2 | Issue : 1 | Page : 3-9

Chest trauma: “Damage Control” Begins in the emergency room

Bradley J Phillips¹, Lauren Turco²
¹ CHS International, Baghdad Embassy Hospital, Cape Canaveral, FL, USA
² Department of Surgery, University of Kansas Medical Center, Kansas City, KS, USA

Date of Web Publication

15-Dec-2017

Correspondence Address:
Bradley J Phillips
CHS International, Baghdad Embassy Hospital, Cape Canaveral, FL
USA

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jctt.jctt_3_17

Abstract

Background: Patients with severe thoracic injuries and subsequent physiological decline may not be candidates for initial definitive treatment. Despite limited data, this subset of patients may benefit from the implementation of thoracic damage control, which should begin in the emergency room. Methods: A literature search was conducted through Medline following PRISMA guidelines. Articles that focused on damage control surgery, the use of damage control techniques in traumatic injuries, and the use of damage control in civilian populations were selected. Due to the paucity of literature and lack of Level I evidence on this subject, studies published in any year were considered. Results: A search of the literature yielded 119 studies. Most of these were excluded based on inclusion and exclusion criteria. Thirty-five articles were selected for review. The majority of these were classified as Level III, IV, or V evidence. Limitations: Limitations of this article are similar to all PRISMA-guided review articles: The dependence on previously published research and availability of references. Conclusion: Effective “Damage Control” following a traumatic injury begins with initial management in the emergency department, which is followed by an abbreviated operation, equally aggressive critical care, and a planned reexploration. Additional studies are required to examine the adaptation of specific damage control techniques to thoracic injuries, but patients with severe chest trauma can benefit from initiation of damage control strategies in the emergency room.

Keywords: Chest trauma, damage control surgery, emergency department thoracotomy

How to cite this article:
Phillips BJ, Turco L. Chest trauma: “Damage Control” Begins in the emergency room. J Cardiothorac Trauma 2017;2:3-9

How to cite this URL:
Phillips BJ, Turco L. Chest trauma: “Damage Control” Begins in the emergency room. J Cardiothorac Trauma [serial online] 2017 [cited 2023 Jun 1];2:3-9. Available from: https://www.jctt.org/text.asp?2017/2/1/3/220845

Introduction

Patients with severe traumatic injuries may not be candidates for immediate conclusive treatment. Uncontrolled hemorrhage, if not rapidly controlled, can lead to shock, metabolic derangement, and eventually death. Therefore, temporizing techniques can be used as currency to buy time for physiological correction in exsanguinating patients before definitive treatment. This strategy, known as damage control, has become increasingly utilized in the management of traumatic injuries. A “damage control approach” classically involves three stages: hemorrhage control, aggressive resuscitation, and delayed definitive treatment.

The appropriate implementation of damage control has led to increased survival rates in even the most severely injured patients. Significant hemorrhage and physiological deterioration are considered the most important selection criteria to apply a “damage control.” Injury severity, coagulopathy, hypothermia, and acidosis have been reported as individual predictors of mortality.^[1] Therefore, the severely injured patient presenting with this “triad of death” should prompt consideration of employing damage control techniques.^[1]

The utilization of damage control surgery is now considered routine for severe abdominal trauma; only recently, however, has this strategy been utilized in thoracic trauma. The general principles and goals of thoracic damage control (TDC) are similar to those employed in abdominal trauma with expeditious management of unstable patients remaining the primary focus. However, severe thoracic injuries are often rapidly fatal without prompt intervention.^[2],[3] It is imperative, therefore, that similar strategies be implemented as soon as possible. The patient most likely to require TDC is the unstable patient with penetrating chest trauma.^[3]

Currently, there are limited data available on the use of damage control in thoracic injury. The literature that is available describes the treatment of anatomical injuries in sufficient detail but lacks crucial physiological data and outcomes.^[1] In some of these studies, emergency department thoracotomy (EDT) is considered fundamental to the successful implementation of TDC.^[3] While others do not include EDT as a damage control procedure,^[4],[5],[6] we believe that the successful application of TDC should begin in the ED or trauma bay to optimize outcomes in patients with severe chest trauma.

Methods

A literature search following PRISMA guidelines was conducted through Medline Complete using the key phrases “thoracic damage control,” “damage control for thoracic trauma,” and “damage control thoracic surgery.” Studies were selected based on predetermined inclusion and exclusion criteria. Those that discussed damage control surgery, the use of damage control techniques in traumatic injuries, and the use of damage control in civilian populations were included. Studies regarding the application of damage control techniques in nontraumatic injuries and military populations were excluded. Recent publications were also preferred, but due to the paucity of literature and lack of Level I evidence on this subject, studies published in any year were considered.

Results

A search of “thoracic damage control,” “damage control for thoracic trauma,” and “damage control thoracic surgery” yielded 90 studies. Nineteen additional studies were identified through other sources. After removing duplicates, 70 studies remained. Application of the previously stated inclusion and exclusion criteria narrowed the selection to 35 studies, which were reviewed [Figure 1].

Figure 1: PRISMA diagram

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All studies were classified according to the levels of evidence as described by Sackett [Table 1]. The majority of these were classified as Levels III, IV, or V. Fourteen studies (40%) were classified as Level III [Table 2]. Of these studies, 4 were retrospective comparative studies. Twelve studies (34%) were classified as Level IV [Table 3]. The remainder (26%) were classified as Level V [Table 4]. Of these, 3 were practice management guidelines regarding EDT. None of the studies were classified as Levels I or II.

Table 1: Levels of evidence

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Table 2: Level III evidence-published studies

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Table 3: Level IV evidence-published studies

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Table 4: Level V evidence-published studies

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Discussion

Damage control in the emergency department: Initial evaluation and management

Patients with severe chest trauma require a rapid, systemic evaluation. The Advanced Trauma Life Support (ATLS) system is widely accepted as the standard of care for the initial assessment and treatment of all trauma patients. This sequence includes primary survey, resuscitation, secondary survey, and definitive management. The primary survey attempts to identify and treat immediate life-threatening conditions. Therefore, this step is of paramount importance in the initial evaluation of damage control candidates. The mnemonic “ABCDE” is frequently used to recall the order in which problems should be addressed: Airway, Breathing, Circulation, Disability, and Exposure.

The establishment of an adequate airway is the highest management priority in trauma patients. Any patient presenting with a Glasgow Coma Scale of 8 or less requires placement of a definitive airway through orotracheal or nasotracheal intubation. If an adequate airway cannot be established by either of these methods, surgical cricothyroidotomy should be attempted. Once an airway has been secured, oxygenation and ventilation should be assessed through inspection, palpation, auscultation, and percussion. The goal is to detect and treat any immediately life-threatening thoracic injuries, such as tension pneumothorax (TP) and massive hemothorax. This is the beginning of a “damage control attitude.”

TP occurs when air becomes trapped in the pleural space, usually following a penetrating injury to the lung. Without prompt intervention, TP can result in potential occlusion of the airway and impairment of venous return. Clinical findings include hypotension, distended neck veins, tracheal deviation, absent or decreased breath sounds, and hyperresonance to percussion. The diagnosis of TP is usually confirmed via chest radiography, but suspicion in a severely injured trauma patient is sufficient for intervention. Initial treatment is emergent needle decompression, in which a large-bore needle or plastic cannula is inserted into the second intercostal space along the midclavicular line. This converts the TP into a simple pneumothorax. The cannula should remain in place until definitive treatment through the placement of a thoracostomy tube.

Hemothorax occurs when blood accumulates within the pleural cavity. It is usually the result of blunt or penetrating traumatic injury to the chest. Similar to TP, a massive hemothorax (rapid accumulation of >1500 mL of blood) can impede ventilation and venous return. Clinical findings are also similar to those seen in TP. The two may be distinguished by percussion: Hemothorax presents with dullness on percussion, while TP presents with hyperresonance on percussion. Chest radiography is the preferred means of initial diagnosis, but an extension of the Focused Assessment with Sonography for Trauma (FAST) scan is becoming rapidly superior in a trauma setting. Hemothorax is managed by draining the blood within the thoracic cavity through tube thoracostomy.

In patients with thoracic trauma, external hemorrhage is best controlled by direct pressure to the wound. Peripheral or central large-bore access for resuscitative fluids should be established. If either of these methods fail, venous cut-down of the saphenous vein is an alternative. Massive transfusion protocol should be initiated, and a blood sample should be sent promptly for typing. A system of continuous cardiac and blood pressure monitoring should also be in place for the duration of the patient assessment.

An important cause of circulatory insufficiency in thoracic trauma patients is pericardial tamponade. Pericardial tamponade is classically manifested by Beck's triad of hypotension, distended neck veins, and distant heart sounds. Emergency treatment includes the creation of a pericardial window or pericardiocentesis. A pericardial window allows the fluid surrounding the heart to drain into the abdominal or chest cavity. Pericardiocentesis involves placing a needle into the pericardial sac through the left sternocostal margin or subxiphoid approach. For the trauma patient in extremis, the placement of an indwelling catheter should be considered until operative techniques are possible.

ATLS procedures are slightly modified in thoracic trauma in that both resuscitation and secondary survey are performed simultaneously. While resuscitative efforts begin, an initial appraisal of the wound should be attempted by either physical examination or radiographic imaging. Chest radiography, FAST examination, and chest tube output should guide any necessary immediate intervention.

Recently, FAST scan has become an invaluable tool for evaluating the thoracic trauma patient in extremis. FAST should be performed on all thoracic trauma patients that cannot be cleared by physical examination alone. In the context of traumatic chest injuries, FAST is most useful for the detection of hemopericardium and pericardial tamponade. This is particularly noteworthy because of the classic signs of Beck's triad, as previously discussed, have limited diagnostic value in penetrating cardiac trauma (citation). The presence of fluid surrounding the heart as detected on FAST scan should prompt urgent consideration of pericardiocentesis.

Thoracostomy tubes can be utilized for diagnostic purposes as well as definitive treatment. In thoracic trauma patients, indications include suspicion or presence of pneumothorax, hemothorax, or hemopneumothorax. Expansion of the pleural space by air (pneumothorax), blood (hemothorax), or both (hemopneumothorax) impedes pulmonary mechanics and ventilation. Tube placement allows continuous large-volume drainage of intrapleural contents until the underlying pathology can be definitively addressed. In the case of pneumothorax or hemothorax, one or more thoracostomy tubes should be placed along the anterior axillary line at the level of the fifth intercostal space.

Damage control in the emergency department: The “emergency department thoracotomy”

Background of emergency department thoracotomy

EDT is a potentially life-saving procedure performed outside the operating room in patients with severe chest trauma. The goals of EDT include hemorrhage control, release of cardiac tamponade, facilitation of open cardiac massage, prevention of air embolism, and temporary occlusion of the thoracic aorta. In the damage control setting, EDT is performed as an effort to temporize the sequelae of traumatic injuries until they can be definitively managed in an operating room.^[7] EDT may also function as a triage instrument by ensuring that patients with lethal injuries are not routinely brought to the OR.^[2]

Since it was first reported in 1966, multiple studies have reported outcomes, indications, techniques, and risks associated with the procedure. Survival rates associated with EDT are generally poor. In one of the largest reviews to date, the American College of Surgeons Committee on Trauma found an overall survival rate of 7.83%.^[8] However, this should not discourage use of EDT in the appropriate conditions.

Indications of emergency department thoracotomy

The decision to perform EDT should be based on whether the patient is likely to benefit from the procedure, has a reasonable chance of survival, and cannot tolerate a delay in operative intervention. Specific indications for EDT have long been a subject of intense debate. Both the Eastern Association for the Surgery of Trauma and Western Trauma Association have formulated evidence-based guidelines regarding its use. The decision to perform the procedure is dictated by the presence or absence of signs of life, mechanism of injury, and location of injury [Table 5]. If signs of life are present on arrival and the patient is in a state of profound refractory shock despite initial interventions, EDT should be considered. If signs of life are absent on arrival, blunt trauma patients with >10 min of prehospital cardiopulmonary resuscitation (CPR), and penetrating trauma patients with >15 min of prehospital CPR are pronounced dead. Gunshot wounds, stab wounds, and motor vehicle collisions comprise the majority of injuries warranting TDC.^[1] Survival rates following EDT in thoracic trauma are highest in patients with penetrating injuries. An overall analysis of available literature conducted by Burlew et al. indicated a success rate of 15%. Penetrating cardiac wounds, in particular, demonstrated the highest rates of survival after EDT (35%). Survival rates are consistently lowest for those with blunt thoracic trauma. In the same study by Burlew et al., the success rate of EDT in this subset of patients was <2%. Therefore, EDT is generally contraindicated in blunt thoracic trauma.^[9],[10]

Table 5: Emergency department thoracotomy survival rates (adapted from East guidelines)

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Technique of emergency department thoracotomy

If the patient is unresponsive to procedures performed as part of the primary survey and deemed a candidate, EDT should be performed. The patient's left arm should be placed above the head to provide unimpeded access to the left chest before starting the procedure. Conventionally, EDT begins with a left anterolateral thoracotomy. An incision is made below the nipple in the fifth intercostal space with a lateral extension from sternum to stretcher, gently curving toward the patient's axilla. In patients with penetrating wounds to the right chest, a bilateral, or clamshell, thoracotomy is the preferred incision. This allows simultaneous access to a right-sided injury and left-sided heart for open cardiac massage.

Following the incision of choice, the skin, subcutaneous fat, and chest wall musculature are quickly divided with a scalpel. A small incision is made through the intercostal muscles, followed by complete transection with Mayo scissors or trauma shears. Most physicians insert two fingers of his or her free hand into the incision so as to avoid lacerating the lung or heart with the scissors. In the case of left anterolateral thoracotomy, a rib spreader is placed and positioned with the handle toward the table in case the incision needs to be extended. If clamshell thoracotomy is performed, the rib retractor should be placed at the sternum to facilitate separation of the chest wall.

The lung is then retracted anteromedially by placing the left hand posterior and lateral to the lung with the palm against the parenchyma. If the inflated lung significantly impairs visualization, the lung can be momentarily deflated by disconnecting the endotracheal tube from the ventilator or Ambu bag. Ventilation of the contralateral lung by advancing the endotracheal tube into the right mainstream bronchus is another viable option. On visualization of the thoracic cavity, suction can be used to evacuate any blood or clots. It is important to note that the internal mammary arteries may be transected as a consequence of dividing the sternum transversely. While bleeding may be minimal at first, re-establishment of perfusion can result in significant hemorrhage. Therefore, these vessels should be ligated empirically in the case of accidental transection.

If cardiac tamponade is present or suspected, pericardiotomy should be performed. Injury to the phrenic nerves, which run vertically along the lateral edges of the pericardium, is avoided by performing the procedure anterior to their anatomic location. If the pericardium is not tense with blood, it can be picked up with toothed forceps at the apex and opened with scissors. A knife or sharp-point of scissors may be required to initiate the incision if the pericardium is under tension. Using scissors, the incision is extended from the apex of the heart to the root of the aorta. This allows for complete delivery of the heart if cardiac repair or compressions are required.

Following pericardiotomy, the patient's cardiac activity should be evaluated. Those in asystole without cardiac tamponade are declared dead, while those in asystole with cardiac tamponade are treated. Cardiac compressions are initiated if necessary. Several techniques have been described, but the bimanual technique has been shown to be superior. Epinephrine can be injected into the left ventricle while vigorously massaging the heart to enhance coronary vessel perfusion. The heart is then defibrillated using internal paddles. Following several minutes of resuscitative efforts, patient viability should be re-assessed.

Treatment of specific injuries

If an intrinsic rhythm has been established, certain injuries can be treated in the ED according to underlying pathology. Cardiac bleeding can be initially controlled with digital pressure. Once initial resuscitative efforts are underway, the patient should be transported to the operating room immediately if it is available. If not, damage control principles continue to apply: stop the hemorrhage and temporize any causative insult. Ventricular wounds can be repaired with 3-0 running or horizontal mattress sutures. In the more muscular left ventricle, bleeding can also be temporized with a skin-stapling device. Venous and atrial wounds can be repaired with simple running or purse-string sutures. Depending on the location of the injury, intrathoracic hemorrhage may be controlled with hilar cross-clamping, digital occlusion, or packing.

Air embolism is a complication of pulmonary parenchymal injury and is usually identified at the time of EDT. The diagnosis of air embolism can be easily missed because its signs and symptoms mimic those of hypovolemic shock. Once identified, treatment requires immediate cross-clamping of the pulmonary hilum to prevent further propagation. The patient should be placed in the Trendelenburg position to direct emboli away from the brain and toward less critical organs. Needle aspiration is used to remove any residual air in the heart or aortic root, while cardiac massage can dissolve air in the coronary arteries.

Persistent hypotension (systolic blood pressure <70 mmHg) following thoracotomy and pericardiotomy should prompt consideration of aortic cross-clamping. Temporary occlusion of the descending thoracic aorta facilitates resuscitative efforts by maximizing both coronary and cerebral perfusion. The aorta is typically cross-clamped inferior to the left pulmonary hilum. Access to the aorta is often hindered by the lungs or excessive hemorrhage. Therefore, manual blunt dissection is the most feasible and realistic technique. To isolate the aorta, Metzenbaum scissors can be used to divide the mediastinal pleura. The placement of a nasogastric tube may help distinguish the anterior esophagus from the posterior aorta. The physician then uses a finger to direct the space between the esophagus and aorta. After using the same finger to hook and retract the aorta laterally, a De-Bakey or Satinsky clamp should be placed around the aorta. If it cannot be easily isolated, digital occlusion of the aorta against the spine is an alternative solution. However, these authors strongly prefer to isolate and clamp the aorta. It should be noted that aortic cross-clamping has been associated with a poor outcome during EDT. This is likely due to the significant hemodynamic compromise that necessitated the procedure rather than the procedure itself.^{[3],[7],[11],[12],[13]}

Risks of emergency department thoracotomy

It is important to note that EDT can pose serious risks to the healthcare team. Given the sharp instrumentation, suboptimal visualization, and speed that accompanies the procedure, exposure to blood-borne pathogens is a significant possibility. This risk is only further substantiated by reported HIV, hepatitis B, and hepatitis C seropositivities as high as 4%, 20%, and 14%, respectively, in some urban EDs.^[13],[14]

Damage control in the operating room

Once hemostasis has been achieved and a perfusing rhythm established, the patient should be promptly transported to the operating room. Injuries can then be treated according to their respective pathologies. For the majority of myocardial injuries, primary repair is often the best and simplest option. Distal coronary vessel insults can be ligated with the knowledge that intraoperative myocardial infarction and postoperative ischemia are possible.^[15] Proximal coronary vessel injuries are usually fatal.^[3] When repair is complete, the pericardium is left open to prevent further injury in the event of cardiac swelling.^[7] Small peripheral lung injuries can be successfully managed with wedge resection. Through-and-through injuries without the involvement of the hilum are most amenable to pulmonary tractotomy.^[16],[17] Pulmonary injuries that encroach upon the hilum often require lobectomy or pneumonectomy, but high mortality rates make this technique less than desirable.^[3],[7],[18] Primary repair is preferred in the standard repair of thoracic vessels.^[3],[7] However, in the event that primary repair is not possible, synthetic grafts, temporary intraluminal shunts, Fogarty catheters, or ligation may be used.^{[3],[7],[9],[19],[20],[21]} Penetrating tracheal wounds and small esophageal injuries are generally responsive to primary repair.^[3],[7]

Packing may be a useful damage control strategy in intra-abdominal bleeding. However, there is some concern that thoracic packing may compromise cardiac filling and lung expansion.^{[1],[22],[23]} Reports by Caceres and Lang described the application of this technique with some success.^[9],[21] The chest cavity is then temporarily closed to facilitate rapid transport to the Intensive Care Unit (ICU) where resuscitation is more efficient.

Damage control in the Intensive Care Unit

Aggressive resuscitation in the ICU is the next step in the damage control sequence. It is important to note that this is a continuation of resuscitative efforts that were originally initiated in the emergency room or trauma bay. These efforts must be maintained on arrival in the ICU and return to the operating room. The likelihood of a good outcome depends on the speed with which hypothermia, acidosis, and coagulopathy are corrected. Patients who have had temporizing procedures should be returned to the operating room once normal physiology has been established.^[3]

Complications

Complications of TDC reported in the literature include acute renal failure, bacteremia, pneumonia, adult respiratory distress syndrome, and empyema.^[1] O'Connor also reported a case of thoracic compartment syndrome that developed in a patient following pleural packing and skin closure. The pathophysiology of thoracic compartment syndrome is similar to cardiac tamponade; increased intrathoracic pressure compromises venous return, resulting in decreased cardiac output.^[1] Additional reported complications include pericardial tamponade and air leak.^[3]

Damage control patients have a high rate of mortality, which is not surprising given their initial presentation. Mortality rates reported in the literature range from 23% to 69%.^{[1],[4],[5],[6],[22]} Differences in patient age, damage control techniques employed, and severity and mechanism of injury have been attributed to such wide variation. The lowest overall mortality rate (23%) was reported by O'Connor et al. in a series of 44 patients. Within the same study, the extent of lung resection influenced mortality, with the highest mortality rate (67%) in patients who endured pneumonectomy.^[1] Similar findings have been demonstrated in other studies.^{[15],[24],[25]}

Limitations

Limitations of this article are similar to all PRISMA-guided review articles with an overall dependence on previously published research and availability of references. In addition, with this specific topic, there is a lack of Level I and Level II studies; most recommendations are based on small case series and expert opinion.

Conclusion

Patients with severe chest trauma and subsequent physiological derangement may benefit from damage control techniques. TDC should begin with initial management in the trauma bay, followed by an abbreviated operation, aggressive critical care, and a planned second look re-exploration. The successful implementation of TDC requires the use of simple and rapid definitive procedures beginning in the ED. EDT is a vital component of damage control in the chest and should be considered as such. Therefore, it is imperative that the emergency physician be familiar with EDT and other TDC techniques to ensure the best chance for a favorable outcome.

Acknowledgments

The authors would like to thank our research student, J. Shaw for her help and assistance with this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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