Ann Thorac Surg 2010;89:238-239. doi:10.1016/j.athoracsur.2009.10.040
© 2010 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited Commentary
Cameron Wright, MD
Department of Thoracic Surgery, Massachusetts General Hospital, Blake 1570, 55 Fruit St, Boston, MA 02114
(Email: wright.cameron{at}mgh.harvard.edu).
The authors report an interesting series of blunt trauma patients who had deep pulmonary lacerations during a 20-year period stratified by the adoption of a modified advanced trauma life support (ATLS) protocol in 2000 [1]. The overall survival was 69%. We are not informed regarding the mortality of the two time periods, which is a significant regrettable omission. The poor prognostic factors were signs of shock on admission, and more blood loss at the time of chest tube insertion (or within 2 hours of insertion) and at thoracotomy. The authors conclude that their protocol for treatment of these patients, which emphasized early thoracotomy (ie, before 800 cc is drained in the chest tube in the first 2 hours) will improve survival. The drainage criteria proposed by the authors are significantly less than the standard ATLS guidelines (approximately 1,500 cc immediately or > 200 cc/hr to 400 cc/hr for more than 2 to 4 hrs). The authors also propose being very aggressive with resection of these injuries, and they state that injuries > 2 cm should be treated by lobectomy rather than tractotomy and suture ligation.
Patients typically present with a shock-like appearance with bright red hemoptysis. Hypoxemia is common due to aspirated blood. The initial chest roentgenogram often shows a partial pneumothorax with some degree of tension, an infiltrate in the lung, and blood in the pleural space. A computed tomographic scan can refine the diagnosis, but this is only performed if the patient is stable.
The authors' management protocol is proactive and has much to recommend it. After a chest roentgenogram, a chest tube is placed and the output is monitored. If more than 500 cc is removed, they clamp the tube and repeat the roentgenogram. If there is a significant residual hemothorax, they prepare for a thoracotomy. If there is a small amount of residual hemothorax, they use water seal drainage and allow further drainage. If there is greater than 800 cc of drainage within 2 hours, they prepare for a thoracotomy. Once a decision for an operation is made, they leave the tube clamped until a thoracotomy is performed to attempt some degree of tamponade of the bleeding. A bronchial blocker is placed on the injured side to prevent blood entry into the good lung and to reduce the chance of air embolism. Posterolateral thoracotomy is the preferred approach. The hilum is first controlled by the surgeon's hand, then by a vascular clamp. Small injuries (< 2 cm) are repaired, and larger injuries are treated by definitive anatomic resection. They suggest the extent of injury is underappreciated based on the external appearance alone. A 69% survival of such severely injured patients is quite respectable.
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- Nishiumi N, Inokuchi S, Oiwa K, Masuda R, Iwazaki M, Inoue H. Diagnosis and treatment of deep pulmonary laceration with intrathoracic hemorrhage from blunt trauma Ann Thorac Surg 2010;89:232-239.[Abstract/Free Full Text]
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Diagnosis and Treatment of Deep Pulmonary Laceration With Intrathoracic Hemorrhage From Blunt Trauma
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