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Ann Thorac Surg 2001;71:314-318
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Blunt chest trauma with deep pulmonary laceration

^a Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan

Accepted for publication June 12, 2000.

Address reprint requests to Dr Nishiumi, Department of Surgery, Tokai University School of Medicine, Bohseidai, Isehara, Kanagawa, 259-1193 Japan
e-mail: nishiumi{at}is.icc.u-tokai.ac.jp

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Deep pulmonary laceration (DPL) is rare and its survival rate is low. The present study focused on the prognostic factors of DPL.

Methods. The present study concerned 17 DPL patients treated in Tokai University Hospital between 1988 and 1998. The prognostic factors of DPL were compared with systolic blood pressure (SBP), PaO₂, and the volume of intrathoracic blood loss. Characteristic findings of initial chest roentgenograms of DPL were investigated.

Results. Eleven patients were saved and 6 patients died. An SBP of less than 80 mm Hg on arrival at the hospital and a blood loss of more than 1,000 mL through the chest tube within 2 hours after arrival were poor prognostic factors. Hypoxemia on arrival was not a poor prognostic factor. Chest roentgenograms showed macular infiltrative shadow with moderate lung collapse and deviation of the mediastinal shadow toward the unaffected side. Selective bronchial occlusion with a Univent prevented suffocation by intrabronchial blood.

Conclusions. Two poor prognostic factors of DPL are SBP less than 80 mm Hg on arrival and blood loss of more than 1,000 mL through the chest tube within 2 hours after arrival.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Deep pulmonary laceration (DPL) often results in death before the patient arrives at a medical facility, and thus DPL cases are rare even in hospitals equipped with an emergency care center. On the other hand, if the initial treatment is based on accurate diagnosis by prompt assessment of the pathology and by diagnostic imaging, DPL is a treatable condition in which the patient’s life can be saved. The present study focused on the prognostic factors of DPL and its characteristic features on the initial plain chest roentgenograms.

	Material and methods

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Seventeen DPL patients were treated at Tokai University Hospital between 1988 and 1998. There were 550 cases of blunt chest trauma requiring hospitalization during this period, and DPL accounted for 3.1% of them. All DPL patients were male with a mean age of 19 years (range, 16 to 34 years).

The prognostic factors of DPL patients who survived and those who died were compared in regard to systolic blood pressure (SBP) on arrival at the hospital, the partial pressure of arterial oxygen (PaO₂) on arrival, and the volume of blood through the chest tube on the affected side within 2 hours after arrival.

The plain chest roentgenograms taken before insertion of the chest tube were reviewed in 13 patients.

The initial treatment of DPL was evaluated. Selective bronchial occlusion on the affected side was performed by intubation with a Univent (Fuji Systems Corporation, Tokyo, Japan) and positioning of the endobronchial blocker in the affected main bronchus (or intermediate bronchus if the affected site was confined to the right middle or lower lobe) [1].

	Results

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The cause of DPL was a traffic injury in every case, and the accidents consisted of motorcycle accidents in 15 cases and automobile accidents in 2 cases. The lives of 11 patients were saved (survival rate: 65%), and the other 6 patients died (mortality rate: 35%). Hemorrhagic shock was the direct cause of death in 5 cases, and hypoxemia was in only 1. The major mechanism of the hemorrhagic shock in these 5 cases was uncontrollable intrathoracic hemorrhage in 2 cases and intraperitoneal hemorrhage due to rupture of the liver or injury to the inferior vena cava in the other 3. Deep pulmonary laceration occurred in the right lung in 12 cases and in the left lung in 5. Complications caused by DPL were observed in 2 cases: intracerebral air embolism in 1 case and postoperative thoracic empyema in the other, and both were healed by treatment.

Prognostic factors of DPL were compared with SBP, PaO₂, and the volume of blood loss through the chest tube.

Systolic blood pressure on arrival
All patients who survived had a SBP of 80 mm Hg or higher, whereas 4 (60%) of the 6 patients who died were in a state of shock with a SBP less than 80 mm Hg. Thus, low SBP (less than 80 mm Hg) was significantly more frequent among those who died (Fig 1).

View larger version (14K): [in this window] [in a new window]   Fig 1. Systolic blood pressure on arrival at the hospital.

View larger version (12K): [in this window] [in a new window]   Fig 2. PaO2 on arrival at the hospital.

View larger version (14K): [in this window] [in a new window]   Fig 3. Volume of blood loss through the chest tube on the affected side within 2 hours after arrival at the hospital.

As the initial treatment of DPL, a chest tube was inserted and selective bronchial occlusion on the affected side was performed in each patient by intubation with a Univent and positioning of the endobronchial blocker in the affected main bronchus or intermediate bronchus [1]. Selective bronchial occlusion was performed at 10 to 155 minutes after arrival, with a mean interval of 77 minutes. Surgical treatments in DPL patients were 4 suture repairs of the lacerated lung, 10 lobectomies, and 1 pneumonectomy. Two exploratory thoracotomies were performed because of intraoperative cardiac arrest.

Case 1
The patient was an 18-year-old man who fell while riding a motorcycle. On arrival at the hospital, his respiratory rate was 36 breaths per minute, and blood pressure was 124/76 mm Hg. Blood gas analysis showed a PaCO₂ of 41 mm Hg and a PaO₂ of 61 mm Hg. An initial plain chest roentgenogram revealed right pneumothorax with deviation of the mediastinal shadow toward the left, indicative of tension pneumothorax. Although the right upper lobe was severely collapsed, the right lower lobe was moderately collapsed and exhibited intralobar small macular infiltrative shadow. The right lower lobe also showed generally lower radiolucency in the right thoracic cavity, suggesting moderate intrathoracic hemorrhage (Fig 4). These findings led to a diagnosis of right lower lobe DPL. The right main bronchus was occluded with a Univent 30 minutes after arrival, and left unilateral pulmonary mechanical ventilation was instituted. The volume of blood loss through the right chest tube before surgery was 700 mL. A right posterolateral thoracotomy was performed 70 minutes after arrival. The right inferior pulmonary vein was blocked with an aortic clamp [2]. A 1,200-mL hematoma was removed from the right thoracic cavity. The right lower lobe was reddish brown and bulging due to intrapulmonary hemorrhage combined with pulmonary parenchymal edema, and there was a laceration 10-cm in length and 7-cm in depth extending from S6 to S8. The right inferior pulmonary vein, right inferior pulmonary artery, and right lower lobe bronchus were cut, in that order, to complete right lower lobectomy. He was discharged on the 23rd hospital day.

View larger version (164K): [in this window] [in a new window]   Fig 4. A plain chest roentgenogram in the supine position taken 30 minutes after injury in case 1. There is right pneumothorax with a collapse rate of 25% and deviation of the mediastinal shadow toward the left side. Although the right upper lobe is severely collapsed (white arrow), the right lower lobe is moderately collapsed (black arrow) and exhibits intralobar small macular infiltrative shadow. The right thoracic cavity generally has lower radiolucency. There are fractures of the right sixth through eighth ribs and subcutaneous emphysema on the right side.

View larger version (135K): [in this window] [in a new window]   Fig 5. A plain chest roentgenogram in the supine position taken 42 minutes after the injury in case 2. There is left pneumothorax with a collapse rate of 27% (black arrows), the left diaphragm shows depressed concavity, and there is deviation of the mediastinal shadow toward the right side. The left lung is moderately collapsed and contains severe infiltrative shadow. The left thoracic cavity shows decreased radiolucency, reflecting a large volume of left intrathoracic hemorrhage.

	Comment

Top Abstract Introduction Material and methods Results Comment References

The volume of intrathoracic hemorrhage in DPL was reported to be 700 mL or less by Moghissi [5] and 800 mL or less by Hankins and co-workers [4]; they stated that intrathoracic hemorrhage exceeding these levels should arouse a suspicion of vascular injury [4, 5]. However, in our cases the volume of blood loss through the chest tube within 2 hours after arrival was 700 mL or more in 9 patients and was 1,000 mL or more among the 6 patients who died. The DPL patients had intrathoracic hematoma in addition to a volume of blood loss through the chest tube. Thus we should believe that the true volume of blood loss from the thoracic cavity in DPL patients is about twice as the volume of blood loss through the chest tube.

Based on these results, we believe that patients in a state of shock with SBP less than 80 mm Hg on arrival and those who have lost 1,000 mL or more of blood through the chest tube within 2 hours after arrival are likely to have a poor prognosis of DPL.

The initial plain chest roentgenograms of DPL patients on arrival are the most important examination for the diagnosis of DPL. According to Hankins and coworkers [4] and Moghissi [5], the plain chest roentgenograms of DPL are characterized by hemopneumothorax, with the extent of pneumothorax limited to within 5 cm of the apex area and the collapse rate never exceeding 30%. They also reported that no radiographic findings are pathognomonic of DPL. In the present study we described characteristic features of the initial plain chest roentgenograms of DPL. All 13 patients for whom plain chest roentgenograms taken before insertion of the chest tube were available exhibited pneumothorax accompanied by moderate lung collapse with no cases of complete collapse. These roentgenograms showed macular infiltrative shadow at the injured lung. Deviation of the mediastinal shadow toward the unaffected side was found in 9 of the 13 cases. These same changes were found in some cases reported elsewhere [3, 4, 6, 7]. Every surgeon who has ever performed thoracotomy on a DPL patient should know that the injured lung is bulging with reddish brown and never collapses even after bronchial occlusion on the affected side. The absence of collapse of the injured lung due to pulmonary hemorrhage and pulmonary parenchymal edema is the most conspicuous characteristic of DPL.

The thoracic computed tomography is great value in the diagnosis of blunt chest trauma, but it is not essential to make a diagnosis of DPL, because the initial plain chest roentgenogram allows this diagnosis to be made accurately. Moreover, we believe that appropriate initial treatment, including selective bronchial occlusion and thoracotomy, has to be given priority over the thoracic computed tomography.

Whenever DPL is diagnosed, our initial treatment was to insert a chest tube and to perform selective bronchial occlusion with the endobronchial blocker of a Univent by thoracic surgeons [1, 8]. As soon as the endotracheal tube is inserted, a large volume of blood from the airway often enters the endotracheal tube, and bronchial occlusion is needed urgently by positioning the endobronchial blocker of a Univent in the main bronchus or intermediate bronchus on the affected side without using the bronchoscope. This procedure prevents intrabronchial blood in the affected lung from entering the unaffected lung through the airway, thereby ensuring that the patient does not drown in his or her own blood. This procedure may have contributed to the decreased mortality from hypoxemia and may have been responsible for the increased survival rate in our cases [1, 5, 9]. This procedure also prevents air embolisms in the pulmonary circulation from the affected lung [2]. In our institution, this procedure is guided by auscultation and the plain chest radiography. The bronchoscope is reserved for use after bronchial occlusion, because blood spurting from the airway interferes with observation of the focus when the bronchoscope is performed before bronchial occlusion. In addition, the bronchoscope may facilitate the entry of blood into the airway on the unaffected side, causing increased hypoxemia. Therefore, the bronchoscope should be performed after bronchial occlusion to verify the presence/absence of injury to the trachea and central bronchus [8].

According to Hankins and coworkers [4], the surgical indication for DPL is massive hemothorax (200 mL in 1 hour) or massive air leakage. In our institution, however, the surgical indications for DPL are determined based on the initial plain chest radiographic findings and the presence of uncontrollable intrathoracic hemorrhage. Because we occlude the selective bronchus, air leakage in DPL patients is eliminated or minimized. If massive air leakage persists after bronchial occlusion, injury to the trachea or central bronchus to the occluded site should be suspected. We believe that it is difficult to save the life of any blunt chest trauma patient, not only DPL patients, whose volume of blood loss through the chest tube reaches 1,000 mL within 2 hours after arrival by means of conservative procedures. Therefore, such patients whose volumes of blood loss through the chest tube are more than 500 mL during 30 minutes after arrival and consistently more than 200 mL per hour should undergo immediate thoracotomy.

After thoracotomy, the pulmonary vein should be first occluded to prevent air embolism [2]. Lobectomy or suture repair of the lacerated lung is then chosen, depending on the severity of the pulmonary injury. Selective bronchial occlusion with a Univent should not be released until the procedure on the bronchus is complete; otherwise blood in the airway of the affected lung will enter the unaffected lung.

Conclusions

1. The two poor prognostic factors of DPL were (1) a stage of shock with SBP less than 80 mm Hg on arrival and (2) the volume of blood loss through the chest tube of more than 1,000 mL within 2 hours after arrival. Hypoxemia on arrival was not a poor prognostic factor of DPL.
   
2. The initial plain chest roentgenograms of DPL patients showed the injured lung containing macular infiltrative shadow with moderate lung collapse and deviation of the mediastinal shadow toward the unaffected side.
   
3. Patients with DPL should be treated urgently by selective bronchial occlusion with a Univent to prevent intrabronchial blood in the affected lung from entering the unaffected lung. Thereupon lobectomy or suture repair of the lacerated lung should be performed.
   

	References

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6. Kaseda S., Aoki T., Hangai N., Yamamoto S., Kitano M., Yajima Y. A case of deep laceration of the lung treated with video-assisted thoracic surgical lobectomy. J Trauma 1997;43:856-858.[Medline]
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8. Iwasaki M., Kaga K., Ogawa J., Inoue H., Shohtsu A. Bronchoscopy findings and early treatment of patients with blunt tracheobronchial trauma. J Cardiovasc Surg 1994;35:269-271.[Medline]
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hiroshi Inoue Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nishiumi, N. Articles by Inoue, H. Search for Related Content PubMed PubMed Citation Articles by Nishiumi, N. Articles by Inoue, H. Related Collections Lung - other