7. Emergency care thoracotomy

Emergency care thoracotomies are considered to be life-saving procedures for a limited patient group. Nowadays, the already effective and still developing emergency transport methods, and the fact that resuscitative interventions are performed before the patients arrive at the hospital, mean that a higher number of almost-morbid patients actually arrive at the hospital. The rate of survival following an emergency care thoracotomy has been reported to vary between 0 and 64%, with the best outcomes achieved for isolated penetrating cardiac injuries. On the other hand, this rate varies between 1 and 3% in cases of blunt and multiple trauma, for which the time of transfer to a hospital is longer. Emergency care thoracotomies are performed on almost-morbid patients in the emergency unit by making a left anterolateral incision between the 4th and 5th intercostal space. Emergency care thoracotomies should not be confused with thoracotomies performed in an operating room or in intensive care during the first hours following the initial injury [35, 36]. The reasons for an emergency care thoracotomy include the drainage of the pericardial tamponade, the control of intrathoracic or cardiac bleeding, the control of massive bronchovenous air embolisms, or bronchopleural fistula, open cardiopulmonary resuscitation or temporary occlusion of the descending thoracic aorta (crossclamp placement) (Table 2) [36].

Contraindications for emergency care thoracotomies include cardiopulmonary resuscitation lasting longer than 15 minutes for penetrating chest traumas, cardiopulmonary resuscitation lasting longer than 5 minutes for blunt chest traumas, non-traumatic arrest, severe head trauma, severe multi-system injuries, the absence of appropriately trained staff and insufficient equipment. The preferable incision for emergency care thoracotomy is an anterolateral thoracotomy, which is carried out on the side with the predicted injury following a physical examination. The incision is performed transversely, the chest cavity is entered through the

• Prehospital cardiopulmonary resuscitation that lasts less than 5 min in patients exposed to blunt trauma

Serious continuous systolic hypotension after injury (≤60 mmHg) caused by:

• Air embolism

6. Tube thoracostomy

1. Drainage ≥1500 mL after initial tube thoracostomy, 2. 200 mL/h drainage during the first 2–4 h of follow-up, 3. 100 mL/h drainage during the first 6–8 h of follow-up,

Table 1. Emergency thoracotomy indications in hemothorax.

Figure 2. Thorax CT: Hemothorax following thoracic trauma.

4. ≥1500 mL/day drainage during the first 24 h, 5. Progression of shock despite treatment.

102 Trauma Surgery

an emergency bilateral tube thoracostomy [9, 13, 33].

A tube thoracostomy is performed for the treatment of traumatic pneumothorax and/or hemothorax, and it is an essential surgical intervention in cases requiring drainage of the pleural cavity in patients suffering a chest trauma. A tube thoracostomy is indicated for all open thoracic injuries, for pneumothorax of more than 10% and for radiologically-confirmed hemothorax. Even if there is no apparent pneumothorax and/or hemothorax, a tube thoracostomy could still be performed in intensive care patients with severe chest traumas who require mechanical ventilation. If a patient with penetrating or blunt chest trauma is transferred to the emergency unit when the vitals are completely lost, or about to be lost, it would not be erroneous to perform

A tube thoracostomy is generally performed from the anterior axillary line, at the level of the 5th intercostal space from the lateral edge of the pectoralis major muscle. This is the region where the chest wall is at its thinnest, and is ideal for a tube thoracostomy. After local anesthesia, a skin incision is made 1–2 cm below the space where the chest tube is to be inserted, and using a clamp, the intercostal muscles are separated from the lower ribs to allow entry to the pleural space. Generally, a 28 or 32 F chest tube is inserted through this obliquely formed tunnel, and a closed underwater drainage system is formed by connecting the tube to the chest bottle. The chest tube should be directed as far as possible towards the apex for

Table 2. Indications of emergency care thoracotomy.

Rescuable cardiac arrest after injury

<sup>•</sup> Prehospital cardiopulmonary resuscitation that lasts less than 15 min in patients exposed to penetrating trauma

<sup>•</sup> Cardiac tamponade

<sup>•</sup> Bleeding (intrathoracic, intraabdominal, extremity, cervical)

4th or 5th intercostal space and a chest retractor is inserted. After the bleeding is controlled and a steady heartbeat has been achieved, the patient must be transferred to the operating room as soon as possible [36].

sternum. Bleeding may occur following rib fractures and the tearing of the thoracic wall muscles. As the thoracic wall has a large vascular supply, subcutaneous bleeding develops frequently, and this is more common in the elderly. Conservative treatment methods and blood

Emergency and Current Approaches to Thoracic Traumas

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The most common type of injury, and one encountered in approximately 35–40% of all thoracic trauma cases, is rib fracture. Rib fractures are more frequent in the elderly due to the decreased elasticity of the thoracic wall. An anterior trauma to the thoracic wall generally results in rib fracture from the outer surface, while lateral traumas cause internal rib fractures. Rib fractures are mostly encountered along 4–9 and the middle axillary line, while fractures of the first and second ribs are generally rare, as these are supported by the clavicle, scapula and shoulders. That said, these ribs may be broken due to very high-energy trauma, and fractures of this kind may well be accompanied by subclavian vessel and brachial plexus injuries. It should be highlighted that rib fractures may be accompanied by lung, bronchus or cardiac injuries. Additionally, abdominal organ injuries, such as the liver and spleen, may occur in the presence of 9th–12th rib fractures, while trauma to the anterior thoracic wall may result in costochondral detachment, which is a more painful condition that requires a longer duration of treatment [22, 26, 31].

Painful tenderness is the most important symptom in the event of rib fracture, and the symptom generally increases with coughing, deep breathing and movement. Friction between the broken rib ends may be felt during a physical examination. Almost half of all rib fractures go unnoticed in lung radiographies, while thoracic CT is more specific for their diagnosis [22, 26]. The treatment of rib fractures is based on pain control and respiration exercises. Pulmonary rehabilitation, including respiration exercises, is crucial in preventing pain-induced secretions, lack of expectoration, atelectasis and pneumonia. Early-term complications of rib fractures include pneumothorax and hemothorax, and late-term complications include atelectasis and pneumonia. A tube thoracostomy is inevitable in the presence of hemothorax and pneumothorax, and surgical fixation becomes necessary when the fractured tips are displaced, and when there are fractures to more than one consecutive rib. Morbidity and mortality in rib fractures depend on the age of the patient, the number and localization of the fractured ribs, and the

Flail chest may develop in the event of a fracture of three or more consecutive ribs, and can result in the paradoxical respiration of the thoracic wall in at least two places, preventing the formation of negative inspiratory pressure and lung expansion on the affected side of the thorax. Expiration, on the other hand, is not sufficient, due to the lack of adequate positive airway pressure as the concerned region moves outwards during expiration. This impairs

degree of the concomitant trauma (Figure 4) [6, 31, 37].

transfusions, if required, are often sufficient for its management [26, 31].

10. Rib fractures

11. Flail chest
