Eur J Cardiothorac Surg 2008;33:1153-1154. doi:10.1016/j.ejcts.2008.03.025
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Successful emergency resuscitative thoracotomy and thoracoscopy in an injured patient with impending death
Moheb A. Rashida,b,*
a Department of Surgery, Lillehammer Hospital, Lillehammer, Norway
b Scandinavian Cardiovascular Surgery Center, Gothenburg, Sweden
Received 10 January 2008;
received in revised form 4 March 2008;
accepted 8 March 2008.
* Corresponding author. Address: Scandinavian Cardiovascular Surgery Center, Gothenburg or Hagforsgatan 71, 416 75 Gothenburg, Sweden. Tel.: +46 31 256 985/46 708 350 680; fax: +46 31 899072. (Email: mohebrashid{at}yahoo.se).
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Abstract
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A 23-year-old man was bilaterally stabbed with knife creating 10 cm wide wounds similar to minithoracotomy incisions. Initially, the patient had no cardiac or respiratory activity. Emergency resuscitative thoracotomy was hastily performed on the right side. An Immediate manual occlusion of the pulmonary hilum was done as damage control. A pneumonorrhaphy was performed and the bleeding was completely stopped. The patient was stabilized and to avoid another thoracotomy on the left side due to massive blood loss, video-assisted thoracoscopic surgery (VATS) was performed. The wound was explored, the hemothorax was evacuated, and a superficial non-bleeding parenchymal pulmonary laceration was discovered. The postoperative course was uneventful and the patient was discharged home 10 days later, and returned to his physically demanding work after 5 weeks. It is concluded that VATS can be cautiously performed on the less severely injured side in patients with bilateral thoracic penetrating trauma in extremis following successful emergency resuscitative thoracotomy.
Key Words: Emergency surgery • Resuscitation • Thoracotomy • Thoracoscopy/VATS • Lung
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1. Introduction
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Emergency resuscitative thoracotomy can be defined as a thoracotomy performed immediately on the scene, in the emergency room/department (ERT/EDT) or in the operating room (OR) as an integral part of the initial resuscitation. The American College of Surgeons Committee on Trauma carried out a review of the literature (1966–1999) and found a survival rate of 7.8% (11.2% for penetrating injuries and 1.6% for blunt lesions) [1] in trauma victims that would otherwise have 100% mortality. To the best of the author's knowledge, this is the first reported survival of an injured patient in extremis following bilateral extensive knife stabs and who underwent ERT on the right side combined with VATS on the left side.
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2. Case report
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A 23-year-old man was stabbed with knife creating 10 cm wide wound on the precordium and a similar one on the back of the right side of the chest (Fig. 1
). The patient had no cardiac or respiratory activity after arrival to the hospital. In transit to the OR, bilateral chest tubes were inserted and about 2 l of blood was drained immediately from the right chest tube, with significant bleeding from the left side. ERT was hastily performed on the right side, which depicted a massive hemothorax. Immediate manual occlusion of the pulmonary hilum was done as damage control, while evacuating the blood and searching for the bleeding lesion. A 5 cm wide and 6 cm long lesion was found in the right lower lobe very close to the hilum (Fig. 2
). Slow release of the hand compressing the hilum showed that the bleeding was markedly decreased. A pneumonorrhaphy was performed and the bleeding was completely stopped. The patient was stabilized and to avoid another thoracotomy on the left side due to the significant bleeding, VATS was performed. The lesion on the left side (15 cm long extended from the second intercostal space downwards and medially to the pericardium) was explored, hemothorax was evacuated, a non-bleeding superficial parenchymal pulmonary laceration was discovered, and clotted blood on the diaphragm was evacuated. The diaphragm, pericardium, and heart were intact. The postoperative course was uneventful and the patient was discharged home 10 days later. He returned to his physically demanding work and was doing well during a follow-up 5 weeks postoperatively.
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Fig. 1. A 10 cm wide knife stab is shown (arrow) perforating the seventh interspace posteriorly (similar to a minithoracotomy incision).
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Fig. 2. A 5 cm wide and 6 cm long lesion (arrow) was found in the right lower lobe very close to the hilum is shown following release of the manual compression of the hilum and prior to pneumonorrhaphy.
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3. Discussion
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Our Scandinavian experience in cardiothoracic trauma has shown 100% success in ERT performed for lung injuries [2], 80% survival for heart injuries [3] and 87.5% survival for thoracic aortic ruptures [4] without neurological complications. ERT is seldom done on the right side even in the largest published studies [1]. However, the incision should be decided by the nature of the lesion. In our case, the lesion was found perforating the right seventh intercostal space posteriorly (Fig. 1) and showed much more external bleeding than the left-sided lesion. The quickly performed chest X-ray taken immediately after admission to the hospital, showed a total right-sided hemothorax. Therefore a right-sided ERT was undertaken.
The management of minor and severe lung lesions is considered as a relatively straightforward maneuver using simple oversewing and lobectomy/pneumonectomy, respectively while the treatment of deep lobar lesions is still controversial. A sudden right heart failure as a result of the aggressive volume resuscitation and the sudden halving of the pulmonary circuit is a major threat in such cases after pulmonary hilar cross clamping or pneumonectomy with up to 100% mortality [1], therefore a manual compression was tried first and was successful. There were no signs of air embolism. The wound was irrigated with saline and showed no major bleeding; therefore a simple oversewing was quickly done with hemostasis.
Tractotomy is a procedure defined by dividing the lung tissue bridging the wound tract between clamps or with linear staples with selective ligation of point bleeders and air leaks with figure-of-eight 4-0 Prolene as a damage control [5] and even as a definitive repair under more stable conditions. This lesion was suitable also for tractotomy at least as a damage control. However, we managed the case using a simple oversewing, and avoided the problems of tractotomy like air leaks, diffuse bleeding and devitalized tissues along the tracts.
VATS has been used mostly in elective trauma cases such as evacuation of clotted hemothorax, examining the pericardium, lung parenchyma, diaphragm and the internal side of the chest wall for any lesion of the intercostal or internal mammary vessels. However, the role of VATS in cases with ERT has not been evaluated. VATS was performed under difficult circumstances including a patient with impending death who just underwent ERT, and the patient was bilaterally ventilated. Therefore, inspection was done intermittently during expiration phases and the lung was collapsed more using a sucker that was introduced through the chest tube incision to compress the lung tissues. It is concluded that VATS can be cautiously performed on the less severely injured side in patients with bilateral thoracic penetrating trauma in extremis following successful ERT.
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Acknowledgments
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The author acknowledges the great assistance of Dr Eirik Aunan, Dr Erik Medby, and all personnel who contributed to the survival of this patient.
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References
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- American College of Surgeons – Committee on Trauma (Working Group, Ad Hoc Subcommittee on Outcomes). Practice management guidelines for emergency department thoracotomy. J Am Coll Surg 2001;193(3):303–9.
- Rashid MA, Wikström T, Örtenwall P. Outcome of lung trauma. Eur J Surg 2000;166:22-28.[CrossRef][Medline]
- Rashid MA, Wikström T, Örtenwall P. Cardiac injuries: a ten-year experience. Eur J Surg 2000;166:18-21.[CrossRef][Medline]
- Rashid MA, Lund J. Trauma to the heart and thoracic aorta: the Copenhagen experience. Interac Cardiovasc Thorac Surg 2003;2:53-57.[Abstract/Free Full Text]
- Wall Jr. MJ, Hirsberg A, Mattox KL. Pulmonary tractotomy with selective vascular ligation for penetrating injuries of the lung. Am J Surg 1994;168:665-669.[CrossRef][Medline]
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Abstract
1. Introduction
