A 20-year-old woman is admitted to your service six hours after being shot by a high-velocity rifle through the right chest. Indications for operation include each of the following EXCEPT

A. copious bloody intratracheal secretions
B. immediate evacuation of 900 ml of blood and after insertion of a chest tube 50 ml hourly the next two hours
C. persistent hemothorax by chest radiograph after appropriate drainage
D. persistent large air leak
E. right hemothorax opacification on initial chest x-ray film




Answer B

High velocity missile injuries to the chest can result in copious bloody secretions which can be aspirated into the uninvolved lung. In the Vietnam experience patients with such injuries did better if managed by thoracotomy and resection of the involved lobe. The lobe was often infarcted because of associated vascular injury, it was a site for pulmonary shunting, and secondary infection was common. 

The initial chest film may direct emergency therapy. Complete opacification of a hemothorax usually represents tamponade, and decompression unmasks massive hemorrhage from a major vessel or vessels. Emergency thoracotomy is prudent. For lesser degrees of hemothorax a chest tube should be placed. Immediate evacuation of a less than a liter of blood is not an indication for thoracotomy. Ongoing significant bleeding is, however, another indication for operation. Bleeding at only 50 ml per hour does not warrant thoracotomy. 

Persistent hemothorax after drainage is an indication for surgical intervention. If left unresolved there is a high likelihood of empyema and a need for later decortication to obtain re-expansion of the lung. Persistent pleural opacification after drainage suggests clot and formal evacuation by a small thoracotomy is necessary.

Multiple rib fragments scattered within the lung parenchyma may be an indication for thoracotomy. These fragments can act as foreign bodies and there is a high likelihood that morbidity will result. Surgical exploration is not urgent and depends on stabilization and the condition of the patient. 

Large air leaks should prompt early bronchoscopy to rule out major airway injury. Conservative management is appropriate, but air leaks that do not resolve after several days suggest severe underlying lung laceration or destruction; therefore, thoracotomy, debridement, and conservative resection is appropriate before empyema develops.

Robison PD, Harman DL, Trinkle JK, Grover FL. Management of penetrating lung injuries in civilian practice. J Thorac Cardiovasc Surg 1988;95:184-90.
Recent reports of military thoracic injuries have advocated early thoracotomy and aggressive management of pulmonary injuries with resection as opposed to the more conservative and traditional treatment with chest tube thoracostomy. A retrospective study was therefore performed to determine the incidence of thoracotomy and lung resection in civilian injuries and to evaluate the effectiveness of treatment of these injuries. Between 1973 and 1985, in a series of 1,168 patients, there were 384 gunshot wounds and 784 stab wounds to the thorax. Two hundred eighty-three patients with a gunshot wound (74%) and 602 with a stab wound (77%) were treated with chest tubes alone. Sixty-eight patients (6% of the total) required operative repair of pulmonary hilar or parenchymal injury. Pulmonary resection was necessary in only 18 patients (nine with a gunshot wound and nine with a stab wound), and 10 patients had repair of hilar injuries (nine with a gunshot wound and one with a stab wound). Of patients requiring pulmonary resection, nine required wedge or segmental resection, six required lobectomy, and three patients required pneumonectomy. Mortality for all thoracic injuries was 2.3%: for those treated with chest tube alone, 0.7%; for pulmonary hilar injuries, 30%; for pulmonary parenchymal injuries, 8.6%; and for injuries necessitating lung resection, 28%. Most civilian lung injuries can be treated by tube thoracostomy alone. Although relatively few patients with primary pulmonary injury require thoracotomy, those that do are at significant risk and may require lung resection to control bleeding or hemoptysis or to remove destroyed or devitalized lung tissue. 

Stewart KC, Urschel JD, Nakai SS et al. Pulmonary resection for lung trauma. Ann Thorac Surg 1997;63:1587-8.
BACKGROUND: Pulmonary resection is rarely required for trauma, and its mortality is reportedly high. METHODS: A 10-year retrospective review of pulmonary resections for trauma was done. RESULTS: Of 2,455 patients with chest trauma, 183 (7.4%) underwent thoracotomy and 32 (1.3%) required pulmonary resection. Mean age was 28.4 years and mean injury severity score was 24.5. Mechanism of injury was stab wound in 14 patients, gunshot wound in 6, and blunt trauma in 12. Blunt trauma patients had a higher injury severity score (29.6) than penetrating trauma patients (21.4), but this was not significant (p < 0.07). Indications for thoracotomy were hemorrhage in 24 patients, airway disruption in 4, and other indications in 4. Operations consisted of wedge resection (19 patients), lobectomy (9), and pneumonectomy (4). Four (12.5%) patients (pneumonectomy, 2; lobectomy, 1; wedge, 1) died. Mortality for pneumonectomy was 50%, but this was not significantly higher than for lesser resections. Blunt trauma had a higher mortality (33%) than penetrating trauma (0%) (p < 0.02). Nonsurvivors had higher injury severity scores (44.2) than survivors (21.6) (p < 0.001). CONCLUSIONS: Pulmonary resection is infrequently required for lung injury. Overall mortality is lower than previously reported, but pneumonectomy has a high mortality. Blunt trauma has a higher mortality than penetrating trauma. Injury severity scores are higher for nonsurvivors than survivors; this shows the importance of associated injuries on outcome.