Page 1637 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1156 PART 10: The Surgical Patient

an alternate route for anterior penetrating wounds. When the thoracic graft prosthesis. If available, a preheparinized shunt may be used in these
cavity is entered, the pericardium is identified, and a longitudinal inci- circumstances to bypass the lacerated area of the aorta and maintain
sion is made in it, care being taken to avoid transection of the phrenic perfusion of the distal aorta and spinal cord while the repair is under-
nerve. Blood is aspirated, and the laceration in the heart is identified taken. Occasionally, access to the bleeding source will require extension
and controlled quickly by digital pressure. With finger control of the of the unilateral thoracotomy incision into the opposite chest by transec-
bleeding point, interrupted sutures are placed and maybe secured with tion of the sternum (clam shell incision). Ligation of the internal mam-
Teflon pledgets to repair the laceration. The pericardium may be then mary arteries will be necessary once the circulation is restored.
resutured, with a small opening (approximately 1 cm) left to prevent reac-
cumulation of blood in the pericardial sac. Other reported techniques
for repair of the cardiac laceration include temporary Foley catheter THE MASSIVELY BLEEDING PATIENT
insertion into the cardiac wound, followed by inflation of the balloon of As indicated previously, it is not always possible to determine precisely
the catheter and repair of the laceration. Skin staples also may be used whether massive bleeding arises from a thoracic or an abdominal
to close the cardiac wound. In very rare circumstances, the laceration source. Therefore, it is crucial that the entire abdomen and chest be
involves the coronary arteries. Formal repair of the artery will require prepared and draped for exposure in the OR. In these circumstances,
heart-lung bypass and may be accomplished in the acute setting if the if the bleeding is into the right chest and the apparent
https://kat.cr/user/tahir99/ site of impact
resources are immediately available. If the patient’s condition stabilizes or penetrating injury is in the lower right chest below the nipple line,
and the bleeding and laceration have been controlled, then definitive laparotomy through an upper midline incision should be conducted
therapy for the coronary artery laceration may be pursued subsequently because the source of the hemorrhage is usually a liver injury with
on a semielective basis. In placing sutures for the cardiac repair, care penetration of the right hemidiaphragm. Where ultrasound assessment
should be taken to avoid incorporating and ligating coronary arteries. is immediately available, this may allow more precise location of the
■ MASSIVE HEMOTHORAX source of the hemorrhage and thus guide the location of the incision in
the abdomen or thorax. Failure to reveal an abdominal source of hemor-
Although most patients with traumatic hemothorax are relatively stable rhage at laparotomy will necessitate an anterolateral thoracotomy on the
and do not require immediate surgical intervention, a few present with right side, which usually will reveal lacerated intercostal arteries, which
massive intrathoracic hemorrhage. This condition requires prompt should be identified and ligated. As indicated earlier, injuries to the low-
diagnosis and immediate treatment to ensure survival. The mechanism pressure pulmonary vasculature usually are not associated with massive
of injury may be blunt or penetrating and generally involves disruption hemorrhage, and the bleeding stops spontaneously, particularly with
of a major central vascular structure or laceration of a systemic artery reexpansion of the lung and decompression of the pleural space. If the
such as an intercostal artery or internal mammary artery. Intrathoracic impact is to the right upper chest or to any portion of the left chest, then
hemorrhage usually arises from parenchymal lesions of the lung and massive hemorrhage should be treated by anterolateral thoracotomy on
stops spontaneously, particularly with reexpansion of the lung. The the bleeding side, and the incision should be extended as necessary to
patient with massive intrathoracic hemorrhage presents initially with obtain control of the bleeding site. Occasionally, bleeding into the chest
severe hypotension from blood loss and later with hypoxemia from arises from a penetrating injury to the base of the neck. In these cir-
collapse of the lung caused by the mass effect of the blood in the cumstances, the chest should be opened through a median sternotomy,
involved thoracic cavity. Apart from severe hypotension and tachycar- with the option of extending laterally into the chest as well as above
dia, these patients demonstrate dullness to percussion and decreased air the clavicle to convert the incision to a trapdoor type of exposure. The
entry on the involved side and a shift of the mediastinum to the opposite median sternotomy under these circumstances allows better exposure of
side. The central venous pressure or jugular venous pressure is usually the vascular structures of the base of the neck than would be available
low, but it may be elevated in the unusual circumstance that a mass effect through an anterolateral thoracotomy. 1
from the blood contained in the thorax produces a mechanical obstruc- ■
tion to venous inflow into the chest. MASSIVE PNEUMOTHORAX AND TRACHEOBRONCHIAL INJURY
The diagnosis is confirmed and treatment instituted by insertion Most patients with traumatic pneumothoraces present with signs char-
of a large-bore chest tube, through which a large volume (frequently acteristic of a pneumothorax but without any major degree of hemody-
close to 2000 mL) of blood drains immediately, to be followed by a namic compromise, and the pneumothorax responds very promptly to
continuous drainage of blood at rates approximating 100 mL/h. If either chest tube insertion. Occasionally, however, the pneumothorax persists
of these conditions is present, the patient is considered to have a mas- despite adequately functioning large-bore chest tubes and is accompa-
sive hemothorax requiring surgical intervention. These should not be nied by massive subcutaneous emphysema and continued hypoxemia
considered absolute indications for thoracotomy but merely guidelines. and respiratory instability. The patient usually also has some degree of
The most important indicator of whether or not surgical intervention is hemoptysis, which may be evidenced by blood draining through the
necessary is whether the patient’s hemodynamics improve significantly endotracheal tube if the patient has been intubated, as is often the case.
and remain so after chest decompression and with fluid resuscitation. This scenario suggests the presence of a large tracheobronchial lacera-
If bleeding continues at a rapid rate, or if the patient’s hemodynamic tion and requires immediate surgical intervention.
status cannot be normalized with rapid infusions of blood and crystal- The patient is placed immediately on 100% oxygen. If time allows,
loid, surgical intervention is warranted. The involved chest is opened bronchoscopy should be performed to identify the level of the lacerated
through a posterolateral incision. Once the blood has been evacuated bronchial tree. However, thoracotomy is warranted even if the lesion
from the pleural space, a search is made for the bleeding point. It is is not identified or there is insufficient time to perform bronchoscopy.
frequently necessary to clamp the hilum of the lung temporarily and to It is essential that one be certain that the chest tubes are functioning
release it intermittently in order to identify the area of bleeding, which is adequately in these circumstances, and if mechanical problems are ruled
repaired by direct suture. Occasionally, massive hemorrhage necessitates out, the patient should be taken to the OR promptly. Occasionally, for a
resection of the involved lung, which should be accomplished quickly right-sided bronchial leak, insertion of a balloon-tipped catheter down
using staple devices. Very occasionally, the bleeding is from a ruptured the right mainstem bronchus may allow ventilation of the normal left
thoracic aorta. Usually patients with free bleeding into the thoracic lung after the right bronchus is occluded by inflation of the balloon.
cavity from a ruptured aorta exsanguinate at the scene or immediately This measure temporarily stabilizes the patient by decreasing the air
thereafter. However, in certain instances, it is possible to salvage some leak on the involved side. It is technically very difficult to accomplish,
of these patients by clamping the aorta proximal and distal to the lac- however, and should not take priority over getting the patient to the
eration and expeditiously repairing the laceration or inserting an aortic operating room as quickly as possible. For a left-sided bronchial tear,

section10.indd 1156 1/20/2015 9:21:08 AM