Damage Control for Thoracic TraumaMICHAEL J. MACKOWSKI, M.D., REBECCA E. BARNETT, M.B.B.S., B.SC.,BRIAN G. HARBRECHT, M.D., KEITH R. MILLER, M.D., GLEN A. FRANKLIN, M.D.,JASON W. SMITH, M.D., J. D. RICHARDSON, M.D., MATTHEW V. BENNS, M.D.

From the Department of Surgery University of Louisville School of Medicine, Louisville, Kentucky

Damage control surgery involves an abbreviated operation followed by resuscitation with plan­ned re-exploration. Damage control techniques can be used in thoracic trauma but has been in­frequently reported. Our goal is to describe our experience with the use of damage control techniques in treating thoracic trauma. A retrospective analysis of all patients undergoing damage control thoracic surgery related to trauma from January 1,2010, to January 1, 2013, at University of Louisville Hospital, a Level I trauma center. Variables studied included injury characteristics, Injury Severity Score, surgery performed, duration of packing, length of stay (LOS), ventilator days, transfusion requirements, complications, and mortality. Twenty-five patients underwent damage control surgery in the chest with packing, temporary closure, and planned re-exploration after stabilization. Seventeen patients underwent anterolateral thoracotomy, and eight patients underwent sternotomy. The mean LOS and duration of temporary packing was 20.6 and 1.4 days in the thoracotomy group, respectively, and 19.5 and 1 day in the sternotomy group, respectively. The overall mortality rate was 40 per cent, 35 per cent in the thoracotomy group and 50 per cent in the sternotomy group. Like in severe abdominal trauma, damage control techniques can be used in the management of severe thoracic injuries with acceptable results.

P atients sustaining thoracic trauma represent a special injured population and providing care

for these patients can be very challenging in the face of coagulopathy and hemodynamic instability. Dam­age control surgery involves an abbreviated operation with planned re-exploration and has become a main­stay in the treatment of severe abdominal trauma with coagulopathy.1 The use of damage control techniques has been demonstrated to improve survival rates for the severely injured trauma patient. A common element to the application of damage control surgery is the use of surgical packing to control nonsurgical hemorrhage. The timely application of these techniques in treating the critically injured patient has shown to be related to patient survival.2 Patient characteristics that would predict the need to use damage control techniques in­clude: hypothermia (34°C or less), Acidosis (pH 7.2 or less), serum bicarbonate 15mEq/L or less, transfusion 4000 mL or greater blood or 5000 mL or greater blood and blood products, intraoperative volume replace­ment 12,000 mL or greater, and clinical evidence of

Presented at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Savannah, GA, February 22-25, 2014.

Address correspondence and reprint requests to Michael J. Mackowski, M.D., Assistant Department of Surgery, University of Louisville, 550 South Jackson Street, Louisville, KY 40202. E-mail: mjmack02@louisville.edu.

coagulopathy.3 Similarly, a majority of the factors that Asensio and colleagues4 have described as indications for damage control surgery are also associated with increased mortality in the trauma patient population. Improvements in postoperative resuscitation with goal- directed therapy toward correction of coagulopathy and restoration of normal physiology have contributed to the improved survival of the patient requiring damage control.5

Damage control principles have been applied to other surgical subspecialties and are also used when caring for patients with intra-abdominal hypertension. Bleeding after cardiac surgery can be a problem for even the most skilled surgeon. Packing the chest with gauze or laparotomy sponges followed by temporary closure and resuscitation with reversal of coagulopathy is acceptable in the setting of elective cardiac pro­cedures. Surgical packing of the mediastinum has been described by Bouboulis6 in the setting of coagulo- pathic hemorrhage after elective cardiac surgery with acceptable results. Application of this technique for hemorrhage control lends itself well in the setting of surgery for thoracic trauma. With the relative paucity of literature available regarding the application of damage control for thoracic trauma, the goal of this retrospective case series is to describe our experience with the use of damage control techniques for patients requiring thoracic surgery for trauma.

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No. 9 DAMAGE CONTROL FOR THORACIC TRAUMA Mackowski et al. 911

Methods

We reviewed all patients entered into our trauma database at University of Louisville, a Level I trauma center in Louisville, Kentucky. We identified patients who underwent either a thoracotomy or sternotomy for thoracic trauma and were treated with damage control principles over a 2-year period (January 2010 to Jan­uary 2013). Charts were retrospectively reviewed for injury characteristics, Injury Severity Score (ISS), surgery performed, duration of packing, length of stay (LOS), ventilator days, transfusion requirements, and mortality.

Techniques for performing damage control involved placement of surgical packs to control coagulopathic hemorrhage. For patients requiring thoracotomy, packs were placed between the lung parenchyma and parietal pleura to control hemorrhage from both the paren­chyma itself and from the chest wall. Similarly, for patients requiring sternotomy, mediastinal packs were placed until hemorrhage was controlled. No packs were placed in direct contact with the heart or major vasculature. A temporary wound closure was per­formed in a manner similar to that of temporary ab­dominal closure with the placement of sterile surgical towels and chest tubes, used to create negative pres­sure, followed by coverage with Ioban (3M™) dressing. Negative pressure was then applied to the temporary closure with continuous wall suction while patients were undergoing resuscitation in the intensive care unit.

Results

Twenty-five patients underwent damage control surgery in the chest with packing, temporary closure with a vacuum dressing (Table 1). Planned re-explo- ration occurred after correction of coagulopathy and hemodynamic stabilization. Injuries sustained in­cluded eight blunt injuries and 17 penetrating injuries. Eighteen patients underwent anterolateral thoracoto­mies and the remainder sternotomies. The mean LOS in the thoracotomy group was 20.6 days (range, 1 to 50 days) with a mean duration of temporary packing of 1.4 days (range, 1 to 3 days). There was a consistent duration of temporary packing of 1 day for the entire sternotomy group with a mean LOS of 19.5 days (range, 2 to 49 days) (Figs. 1 and 2). The patients in the thoracotomy required a mean of 13 ventilator days with a mean of 14.3 in the sternotomy group (Fig. 1). The mean transfusion requirement was 109 total products for the thoracotomy group with a mean ISS of 34.2. A total of 55.8 total products were transfused with a mean ISS of 25.8 in the sternotomy group (Fig. 3). The rationale for use of damage control

techniques were coagulopathic bleeding in the ster­notomy group and either coagulopathic bleeding or hemodynamic instability in the thoracotomy group.

Our criteria for re-exploration and definitive chest wall closure consisted of resolution of hemodynamic instability and correction of coagulopathy. We were able to close the chest in 17 (68%) of our patients with our average duration of packing of 1.3 days for the entire group. Two of these 17 patients died later in their hospital stay with their deaths attributed to events unrelated to packing: acute cardiopulmonary collapse from suspected pulmonary embolism and anoxic brain injury. All other patients who were not closed died secondary to cardiac failure from uncontrollable hemorrhage within the first hospital day.

Complications in the thoracotomy group included respiratory failure for six patients with three eventually requiring tracheostomy. Five patients developed ventilator- associated pneumonia (all of which had a prolonged ventilator course). One patient developed empyema requiring chest tube drainage and one patient de­veloped a superficial wound infection that was man­aged with opening of the wound. In the sternotomy group, two patients required prolonged mechanical ventilation for respiratory failure and one for acute respiratory distress syndrome (ARDS) with all three requiring tracheostomy. All sternotomy patients re­quiring tracheostomy developed ventilator-associated pneumonia; and one also developed a catheter-associated urinary tract infection. The overall mortality rate was 40 per cent, 35 per cent in the thoracotomy group and 50 per cent in the sternotomy group. Mortality was 53 per cent in patients with penetrating trauma and 38 per cent in blunt trauma. The causes of death for patients in the thoracotomy group were cardiac failure secondary to uncontrolled hemorrhage, which occurred within 24 hours of the injury and acute cardiopulmonary collapse from suspected pulmonary embolism on hospital Day 22. In the sternotomy group, the causes of death for patients were cardiac failure secondary to uncontrolled hemorrhage, which occurred within 24 hours of the injury, hypoxic arrest secondary to severe ARDS occurring on hospital Day 7 and anoxic brain injury occurring on hospital Day 2. Readmission was not required for any patient who survived to discharge to date.

Discussion

The efficacy and complications for damage control techniques in the abdomen have been well established in the current body of literature. Less is true for damage control surgery in the chest. Rotondo7 de­scribed these techniques for both abdominal trauma and thoracic injuries. The bony envelope of the chest

912 THE AMERICAN SURGEON September 2014 Vol. 80

Table 1. Patient Characteristics for Both Thoracotomy and Sternotomy GroupsThoracotomy Sternotomy Overall

GenderMale 16 7 23 (92%)Female 2 0 2 (8%)

Average age (years) [rangel 42 [23-53] 39 [22-61] 40 [22-611Mechanism

Penetrating 10 7 17 (68%)Blunt 8 0 8 (32%)

Average ISS [range] 34.2 [9-59] 25.8 [18-36] 30.4 [9-59]

ISS, Injury Severity Score.

30CO

Thoracotomy Sternotomy Thoracotomy Sternotomy Thoracotomy Sternotomy

V ent Days ICU LOS H osp ita l LOS

Fig. 1. Duration of mechanical ventilation, intensive care unit length of stay, hospital length of stay. Mean [standard error of mean].

poses some challenges to the placement of packs for control of nonsurgical hemorrhage. Adequate exposure is a key component when performing these techniques in the chest. Likewise, an abbreviated operation with the focus on hemorrhage control is a critical step that must be taken early in the operative course. Estab­lished techniques for dealing with lung injury are nonanatomic wedge resection, lobectomy, or even total pneumonectomy.7 Packing the chest, like the abdo­men, places the patient at risk for complications. Aside from the risk of infectious complications, the patient may be placed at risk for inadequate ventilation or oxygenation as a result of constraints on lung volume; and overpacking the mediastinum may cause cardiac tamponade. The trauma surgeon should be cognizant that the lungs are a lower pressure hemodynamic system, and so far fewer packs are necessary to achieve control of coagulopathic hemorrhage from lung pa­renchyma in comparison to other solid organs.

There have been several case series in the literature describing the application of damage control tech­niques for thoracic trauma. The reported mortality in these series ranges from 23 to 69 per cent, depending on the mechanism of injury.8-12 Our reported mortality falls within this range. O’Connor,12 in the largest series to date, reported the lowest mortality rate of 23 per cent with an in-hospital mortality rate of 16 per cent

excluding patients who died on extracorporeal membrane oxygenation. Compared with patients in our pop­ulation, there was a similar mean ISS; however, our patients were older and more severely injured because two of our thoracotomy group patients presented with an ISS of at least 50.12 Stab wounds were absent from our patient group compared with O’Connor’s, and the presence of these lower energy injuries may explain the improved mortality in their results.13 Our patients also differed from this population in that no clamshell

wCO

Fig. 2. Duration of thoracic packing. Mean [standard error of mean].

No. 9 DAMAGE CONTROL FOR THORACIC TRAUMA Mackowski et at. 913

cn

Thoracotomy SternotomyFig. 3. Transfusion requirements for total length of stay. Mean

[standard error of mean],

thoracotomies were used, and the main injury sus­tained was laceration to the pulmonary parenchyma.

Our average duration of packing was approxi­mately 1.5 days less than those reported in other series.8- 9> 12 These differences may be accounted for by the use of packing with temporary closure in the setting of hemodynamic instability as was performed in our series. Additionally, all of our procedures were performed in an operating room setting. This may portend a better outcome for patients because we may be selecting out those who are less likely to survive transfer to the operating room. This increase in survival of patients who have their emergency thoracic procedure performed in an operating room setting has also been previously described by Karmy- Jones.13

The majority of the complications patients had in our case series was respiratory failure requiring a pro­longed ventilatory course with the development of ventilator-associated pneumonia. All of the patients in our series received postoperative antibiotic pro­phylaxis that extended through the duration of their temporary packing. All of our patients did require massive transfusion, and this is associated with an increased risk of bacterial infections.14 Bouboulis described the average duration of packing in the setting of sternal wound infection and dehiscence in that series was 33 hours, and the only patient to develop a surgical site infection in our series had packs in place for 48 hours. One of the patients in our series developed empyema; this has been seen in other series as well.12 This may be attributed to our relatively shorter duration of packing compared with the other series in the literature, and further in­vestigation will be needed to see if duration of packing becomes an independent predictor of in­fectious complications.

Conclusion

As the body of evidence regarding the safety and efficacy of the application of damage control techniques grows, its use is going to be applied to other injuries. It already has a well-respected role in the setting of ab­dominal and orthopedic trauma. The adaptation of damage control techniques to the thoracic body com­partment will require ongoing study. The results in this study, among others, show promise that the use of an abbreviated initial operation followed by packing, temporary closure of the chest, and goal-directed re­suscitation before definitive chest wall closure can be safely used with accepted outcomes.

REFERENCES

1. Rotondo MF, Schwab CW, McGonigal MD, et al. ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993;35:375-82.

2. Garrison JR, Richardson JD, Hilakos AS, et al. Predicting the need to pack early for severe intra-abdominal hemorrhage. J Trauma Inj Infect Crit Care 1996;40:923-9.

3. Asensio JA, Petrone P, Roldan G, et al. Has evolution in awareness of guidelines for institution of damage control improved outcome in the management of the posttraumatic open abdomen? Arch Surg 2004;139:209-14.

4. Ordonez CA, Badiel M, Sanchez Al, et al. Improving mor­tality predictions in trauma patients undergoing damage control. Am Surg 2011;77:778-82.

5. Duchesne JC, Barbeau JM, Islam TM, et al. Damage control resuscitation: from emergency department to the operating room. Am Surg 2011;77:201-6.

6. Bouboulis N, Rivas LF, Kuo J, et al. Packing the chest: a useful technique for intractable bleeding after open heart oper­ation. Ann Thorac Surg 1994;57:856-60.

7. Rotondo MF, Bard MR. Damage control surgery for thoracic injuries. Injury 2004;35:649-54.

8. Vargo DJ, Battistella FD. Abbreviated thoracotomy and temporary chest closure: an application of damage control after thoracic trauma. Arch Surg 2001 ;136:21—4.

9. Moriwaki Y, Toyoda H, Harunari N, et al. Gauze packing as damage control for uncontrollable haemorrhage in severe thoracic trauma. Ann R Coll Surg Engl 2013;95:20-5.

10. Caceres M, Buechter KJ, Tillou A, et al. Thoracic packing for uncontrolled bleeding in penetrating thoracic injuries. South Med J 2004;97:637-11.

11. Lang JL, Gonzalez RP, Aldy KN, et al. Does temporary chest wall closure with or without chest packing improve survival for trauma patients in shock after emergent thoracotomy? J Trauma 2011;70:705-9.

12. O’Connor J, DuBose J, Scalea T, Cowley RA. Damage control thoracic surgery: management and outcomes. Presented at the 73rd Annual Meeting of AAST and Clinical Congress of Acute Care Surgery.

13. Karmy-Jones R, Nathens A, Jurkovich GJ, et al. Urgent and emergent thoracotomy for penetrating chest trauma. J Trauma 2004;56:664-9.

14. Sihler KC, Napolitano LM. Complications of massive transfusion. Chest 2010;137:209-20.

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