Damage-control techniques in the management of severe lung trauma

Abstract

Background Damage Control (DC) has improved survival from severe abdominal and extremities injuries. The data on the surgical strategies and outcomes in patients managed with DC for severe thoracic injuries is scarce. Methods Retrospective review of the patients treated with DC for thoracic/pulmonary complex trauma at two level I trauma centers from 2006 to 2010. Subjects 14 and older, were included. Demographics, trauma characteristics, surgical techniques, and resuscitation strategies were reviewed. Results A total of 840 trauma thoracotomies were performed. Damage control thoracotomy (DCT) was done in 31 (3.7%). Pulmonary trauma was found in 25 of them. The median age was 28 (IQR 20–34) years, Revised Trauma Score was 7.11, (IQR 5.44–7.55), and Injury Severity Score was 26 (IQR 25–41). Nineteen patients had gunshot-wounds, four stab-wounds and two blunt trauma. Pulmonary trauma was managed by pneumorrhaphy in three cases, tractotomy in 12, wedge resection in one and packing as primary treatment in 8. Clamping of the pulmonary hilum was used as a last resource in 7 cases. Five patients returned to the ICU with the pulmonary hilum occluded by a vascular clamp or an en masse ligature. These patients underwent a deferred resection within 16 to 90 hours after the initial DCT. Four of them survived. Bleeding from other intra-thoracic sources was found in 20 cases: major vessels in nine, heart in three, and thoracic wall in nine. DCT mortality in pulmonary trauma was 6/25, (24%) due to coagulopathy or persistent bleeding in five cases and to multiorgan failure in one. Conclusion This series describes our experience with DCT in severe lung trauma. We describe pulmonary hilum clamping and deferred lung resection as a viable surgical alternative for major pulmonary injuries, and the use of packing as a definitive method for hemorrhage control.

Chinese expert consensus on echelons treatment of thoracic injury in modern warfare

“…During pneumonectomy, the hilum should be clamped slowly to allow the other lung to adapt. The amount of fluid during resuscitation should be minimized to avoid the occurrence of acute right heart failure [ 36 , 37 ]. Suture and ligation of hilar vessels and bronchial tubes should be performed individually with the support of pleura or other flexible soft tissue such as the internal jugular muscle.…”

Thoraxtrauma: Diagnostik und Therapie

“…Hierbei wird der Penetrationskanal mit Klammernahtgeräten (Linear Cutter) oder Gefäßklemmen in ganzer Ausdehnung eröffnet und anschließend die rupturierten Bronchien und Gefäße gezielt umstochen [17]. Diese Technik ist parenchymsparend und verbessert somit die Prognose der Patienten [18].…”

A clinical series of packing the wound tract for arresting traumatic hemorrhage from injuries of the lung parenchyma as a feasible damage control technique

“…The wide acceptance of damage control surgery for abdominal trauma allowed the translation and application of the concept to vascular [2] and chest trauma [3, 4]. Within the fields of thoracic trauma, the surgical treatment of pulmonary wounds has evolved toward more conservative procedures such as tractotomy and packing.…”

“…Nowadays, most of the lesions are managed by tractotomy, which is associated with less morbidity and mortality [5–7]. This procedure minimizes local trauma and speed-up the procedure, which allows faster hemorrhage control [3, 4, 8].…”

“…Despite the potential benefit of being a life-saving procedure, there remains a paucity of evidence on the feasibility of the use of thoracic packing as a damage control technique in the management of lung trauma. As of the writing of this paper, only two reports describe the use of pulmonary packing as a management strategy for injuries of the lung parenchyma [3, 12]. We describe a series of four patients with lung trauma in which packing of the pulmonary wound tract was used as the primary and unique surgical strategy for arresting hemorrhage from injuries of the lung parenchyma.…”