Thoracic damage control surgery

Abstract

Thoracic damage control surgery (TDCS) is a decision making tool and derivate of the damage control concept (DCC), where physiological stabilization has a priority over anatomical reconstruction under the pressure of time. Intrathoracic haemorrhage control and pleural decompression are the two main immediate tasks of TDCS, while definitive procedures follow when the patient is stabilised in 24-48 hours. The focus of the thoracic surgeon is on the prevention of the haemorrhage induced coagulopathy, metabolic acidosis and hypothermy formed triad of death. Surgical haemorrhage control and pleural space decompression are to be performed. The individual patients benefit from TDCS procedures whose condition is too severe for a complex immediate reconstruction (polytrauma). Life threatening chest injuries in multiple/mass casualty scenarios in civilian and military environment alike are triaged and treated accordingly. Onset of acute mismatch between the resources (available hands, OP theaters, resources, hardware) and the needs (number and severity of chest trauma cases), a mindset shift should take place, where time and space the two main limiting factors. Airway obstruction, tension haemo/pneumothorax falls into the preventable death category. Chest drainage and emergency thoracotomy are the two main procedures offered by TDCS. An intervention structured organ/injury specific list of procedures is detailed. This is a mix of emergency surgery and cardiothoracic surgery, where less is more. TDSC is not the Holy Grail found to solve all complex thoracic trauma cases, but is a good tool to increase the chance for survival in challenging, and frequently quite hopeless situations.

Surgical stabilization of serial rib fractures is advantageous in patients with relevant traumatic brain injury

“…Ideally, patients are operated on within the first week after trauma to prevent pneumonia and respiratory failure requiring mechanical ventilation [ 12 , 13 , 15 , 25 , 26 ]. Currently, no consensus exists for SSRF indications in patients with multiple injuries and polytrauma [ 13 , 21 , 27 ].…”

“…But TBI treatment in polytrauma patients is a particular challenge for trauma surgeons and emergency physicians alike due to the imminent multifactorial risk of secondary brain injury and the tight time frame to avert additional brain injury and to improve patient prognosis [17][18][19]. Therefore, precipitative SSRF in polytrauma management may represent a preventable 'second hit' that aggravates patient recovery and prognosis [20,21]. Well-founded decision making, therefore, is mandatory in this vulnerable patient cohort.…”

Controle de danos para lesão de artéria subclávia

“…A ligadura fica reservada para casos graves, quando parada cardíaca por hipovolemia pode ocorrer no intraoperatório. Caso isso ocorra, estão indicadas manobras de toracotomia de reanimação, como clampeamento da aorta descendente, pericardiotomia longitudinal, permitindo massagem cardíaca interna, com 60-100 bpm, e desfibrilação direta, que deve ser feita com a carga de 10-30 Joules 8,14,24,25 . Todas essas manobras foram executadas no caso descrito.…”

Bilateral Gunshot Wounds to the Chest at Different Levels of Medical Care

“…Surgical treatment of such wounded in the early stages consists in performing surgical treatment of gunshot wounds, draining the pleural cavities, if indicated -emergency thoracotomy, sternotomy, or their combination [10,12]. A promising direction is the use of a videothoracoscopic method of treatment; however, it is limited by an insufficient technical base and partly by the absence of a thoracic surgeon in these conditions [2,14].…”