Gauze packing as damage control for uncontrollable haemorrhage in severe thoracic trauma

Damage control surgery for life-threatening blunt chest trauma

A 31-year-old male sustained life-threatening chest contusions and recovered after damage control surgery. The patient was in an unwitnessed accident where his motorcycle was struck by a car. Upon admission, blood pressure was 69/58 mmHg, heart rate was 126 bpm, and oxygen saturation was 85%. Chest computed tomography revealed fractures to right ribs 1-9 and left ribs 1-7, lung contusions, multiple lung lacerations, and right hemopneumothorax. Upon presentation to the intensive care unit, hemostasis was achieved by suturing a deeply lacerated lung and applying gauze packing. The patient was placed on veno-veno type extracorporeal membrane oxygenation using both femoral veins after surgery until the 5th hospital day. The gauze was removed during the second operation on the 6th day. The third operation on the 13th hospital day was an open reduction of ribs 3-7 on the right. The patient was discharged on the 47th day without complications.

Pack the chest: Damage control strategy for management in thoracic trauma

BACKGROUND

Damage control surgery aims to control hemorrhage and contamination in the operating room (OR) with definitive management of injuries delayed until normal physiology is restored in the intensive care unit (ICU). There are limited studies evaluating the use of damage control thoracotomy (DCT) in trauma, and the best method of temporary closure is unclear.

METHODS

A retrospective review of trauma patients at two level I trauma centers who underwent a thoracotomy operation was performed. Subjects who underwent a thoracotomy after 24 h, age less than 16, expired in the trauma bay, or in the OR prior to ICU admission were excluded. One-way ANOVA and Kruskal-Wallis test were used to compare continuous and categorical variables between DCT and definitive thoracotomy (DT) patients.

RESULTS

207 trauma patients underwent thoracotomy, 76 met our inclusion criteria. DCT was performed in 30 patients (39%), 46 (61 %) underwent DT operation. Techniques for temporizing the chest varied from skin closure with suture (8), adhesive dressing (5), towel clamps (2), or negative pressure devices (12). Compared to definitive closure, DCT had more derangements in HR, pH, (110 vs. 95, p = 0.04; 7.05 vs 7.24, p < 0.001), and injury severity score (41 vs 25, p < 0.001), and required more blood transfusions (40 vs 6, p < 0.001). Eleven (36.7 %) DCT patients survived to discharge compared to 38 patients (95.0 %) in the DT group. DCT showed significantly higher differences in cardiac arrest and unplanned returns to the OR rates. No differences were observed in ventilator days, or ICU length of stay.

CONCLUSIONS

DCT is a viable option for management of patients in extremis following thoracic trauma. DCT was associated with higher mortality rates, likely due to differences in injury and physiologic derangement. Despite this, DCT was associated with similar rates of complications, ICU stay, and ventilator days.

Outcome of Emergency Pulmonary Lobectomy under ECMO Support in Patients with COVID-19

BACKGROUND

 Not much is known about the results of nonelective anatomical lung resections in coronavirus disease 2019 (COVID-19) patients put on extracorporeal membrane oxygenation (ECMO). The aim of this study was to analyze the outcome of lobectomy under ECMO support in patients with acute respiratory failure due to severe COVID-19.

METHODS

 All COVID-19 patients undergoing anatomical lung resection with ECMO support at a German university hospital were included into a prospective database. Study period was April 1, 2020, to April 30, 2021 (first, second, and third waves in Germany).

RESULTS

 A total of nine patients (median age 61 years, interquartile range 10 years) were included. There was virtually no preexisting comorbidity (median Charlson score of comorbidity 0.2). The mean interval between first positive COVID-19 test and surgery was 21.9 days. Clinical symptoms at the time of surgery were sepsis (nine of nine), respiratory failure (nine of nine), acute renal failure (five of nine), pleural empyema (five of nine), lung artery embolism (four of nine), and pneumothorax (two of nine). Mean intensive care unit (ICU) and ECMO days before surgery were 15.4 and 6, respectively. Indications for surgery were bacterial superinfection with lung abscess formation and progressive septic shock (seven of nine) and abscess formation with massive pulmonary hemorrhage into the abscess cavity (two of nine). All patients were under venovenous ECMO with femoral-jugular configuration. Operative procedures were lobectomy (eight) and pneumonectomy (one). Weaning from ECMO was successful in four of nine. In-hospital mortality was five of nine. Mean total ECMO days were 10.3 ± 6.2 and mean total ICU days were 27.7 ± 9.9. Mean length of stay was 28.7 ± 8.8 days.

CONCLUSION

 Emergency surgery under ECMO support seems to open up a perspective for surgical source control in COVID-19 patients with bacterial superinfection and localized pulmonary abscess.

Case Report and Minireview of the Literature on Blunt Azygos Injury

Azygos vein injury seems to be an uncommon cause of hemothorax and hemomediastinum; however, this injury is potentially fatal. We report a fatal case of blunt azygos injury and a PubMed search was undertaken to identify English articles from 1989 to 2022 using the key words "azygos", "injury" and "blunt". We found 28 articles about blunt azygos injury and 39 patients including the present case (average 41.2 years [range: 18-81 years]; male, n=20; female, n=19). The other variables were as follows: right hemothorax (n=32); unstable circulation on arrival (n=32); and survival (n=19; unknown, n=2). These cases were divided into two groups based on the outcome: the survival group and the fatal group. There were no significant differences with regard to the year of the report, age, sex, rate of right rib fracture, rate of preoperative computed tomography (CT) examination, rate of associated injury, and rate of operation. The rate of shock on arrival in the survival group was significantly lower than that in the fatal group. The rate of azygos arch injury in the survival group was significantly greater than that in the fatal group. The emergency physician must consider azygos vein injury as a possible cause of right hemothorax when a patient with blunt chest trauma presents persistent hypotension.

Intra-Abdominal Gauze Packing for Uncontrolled Hemorrhage in Non-Trauma Patients

Purpose: The outcomes of non-trauma patients requiring intra-abdominal gauze packing for the management of uncontrollable hemorrhage following surgery, and the evaluation of survival risk factors were examined. Methods: Data from patients who underwent intra-abdominal gauze packing to control bleeding during abdominal surgery between September 2012 and March 2019 were retrospectively reviewed. Results: A total of 28 patients were included in the study population analysis. There were 9 patients who died during hospitalization. One patient died as a result of uncontrolled bleeding. In spite of gauze packing, 2 patients who had increasing blood transfusion requirements (> 4 packs/4 hours) were found to have arterial bleeding. Univariate analysis for hospital death showed that immunocompromised status, emergency surgery, a thrombocytopenic state prior to initial surgery, and a longer duration until gauze removal had a negative association with survival outcomes. Among these factors, only time to gauze removal > 36 hours was identified as an independent risk factor for survival outcome in the multivariate analysis. Conclusions: Gauze packing could be considered as an effective method for the management of uncontrolled hemorrhage, in non-trauma patients. In cases of persistent bleeding after gauze packing, arterial bleeding should be suspected. Gauze removal after > 36 hours may indicate a poor survival outcome.

[Koblenz algorithm for open abdomen management]

The issue of laparostomy treatment is still controversial, since there are insufficient evidence-based data. German military surgeons have developed and implemented the «Koblenz algorithm» of laparostomy treatment into everyday practice. The algorithm was developed at the Bundeswehr Central Hospital in Koblenz (Germany). Today, approximately 50% of German civilian hospitals use the «Koblenz algorithm». The database for laparostomy treatment was created on the basis of international platform European Registry of Abdominal wall Hernias (EuraHS) in May 2015. These data will be valuable for further multipla-center studies. This manuscript is devoted to analysis of clinical effectiveness of the «Koblenz algorithm» in the treatment of patients with laparostomy. Searching of Russian, English and German studies devoted to «Koblenz algorithm» in the treatment of patients with laparostomy was carried out in the eLIBRARY, Elektronische Zeitschriftenbibliothek, the Cochrane Library and the PubMed databases. The authors comprehensively described «Koblenz algorithm». Mortality in the group of VAC - therapy was 57% (31/54), in case of «Koblenz algorithm» - 33% (33/100). Between-group differences were significant (OR 0.36, 95% CI 0.18-0.72, p=0.003). However, an efficacy of «Koblenz algorithm» should be confirmed in further multiple-center studies including national evidence-based trials.

Shock, Not Blood Pressure or Shock Index, Determines the Need for Thoracic Damage Control Following Penetrating Trauma

BACKGROUND

Damage control laparotomy has increased survival for critically injured patient with penetrating abdominal trauma. There has been a slower adoption of a damage control strategy for thoracic trauma despite the considerable mortality associated with emergent thoracotomy for patients in profound shock. We postulated admission physiology, not blood pressure or shock index, would identify patients who would benefit from thoracic damage control.

STUDY DESIGN

Retrospective trauma registry review from 2002 to 2017 at a busy, urban trauma center. Three hundred one patients with penetrating thoracic trauma operated on within 6 h of admission were identified. Of those 66 (21.9%) required thoracic damage control and comprise the study population.

RESULTS

Compared with the non-damage control group, the 66 damage control patients had significantly higher Injury Severity Score, chest Abbreviated Injury Scale, lactate and base deficit, and lower pH and temperature. In addition, the damage control thoracic surgery group had significantly more gunshot wounds, transfusions, concomitant laparotomies, vasoactive infusions, and shorter time to the operating room. Notably, however, there were no significant differences in admission systolic blood pressure or shock index between the groups. Once normal physiology was restored, chest closure was performed 1.7 (0.7) days after the index operation. Mortality for thoracic damage was 15.2%, significantly higher than the 4.3% in the non-damage control group. Over two-thirds of damage control deaths occurred prior to chest closure.

CONCLUSIONS

Mortality in this series of severely injured, profoundly physiologically altered patients undergoing thoracic damage control is substantially lower than previously reported. Rather than relying on blood pressure and shock index, early recognition of shock identifies patients in whom thoracic damage control is beneficial.

Damage Control Thoracotomy: A Systematic Review of Techniques and Outcomes

BACKGROUND

Damage control surgery is the practice of delaying definitive management of traumatic injuries by controlling hemorrhage in the operating room and restoring normal physiology in the intensive care unit prior to definitive therapy. Presently, damage control or "abbreviated" laparotomy is used extensively for abdominal trauma in an unstable patient. The application of a damage control approach in thoracic trauma is less established and there is a paucity of literature supporting or refuting this practice. We aimed to systematically review the current data on damage control thoracotomy (DCT), to identify gaps in the literature and techniques in temporary closure.

METHODS

An electronic literature search of Pubmed, MEDLINE, and the Cochrane Database of Collected Reviews from 1972-2018 was performed using the keywords "thoracic," "damage control," and "thoracotomy." Studies were included if they reported the use of DCT following thoracic trauma and included survival as an outcome.

RESULTS

Of 723 studies, seven met inclusion criteria for a total of a 130 DCT operations. Gauze packing with temporary closure of the skin with suture was the most frequently reported form of closure. The overall survival rate for the seven studies was 67%. Survival rates ranged from 42-77%. Average injury severity score was 30, and 64% of injuries were penetrating in nature. The most common complications included infections (57%; pneumonia, empyema, wound infection, bacteremia), respiratory failure (21%), ARDS (8%), and renal failure (18%).

CONCLUSION

DCT may be associated with improved survival in the critically injured patient population. Delaying definitive operation by temporarily closing the thorax in order to allow time to restore normal physiology may be considered as a strategy in the unstable thoracic trauma patient population. The impact an open chest has on respiratory physiology remains inconclusive as well as best mechanisms of temporary closure. Multi-center studies are required to elucidate these important questions.

The tenets of intrathoracic packing during damage control thoracic surgery for trauma patients: a systematic review

PURPOSE

Although Damage Control Thoracic Surgery (DCTS) has become a provocative alternative to treat patients with chest injuries who are critically ill and physiologically depleted, the management approaches of chest-packing and the measurement of clinically relevant outcomes are not well established. In this paper, we systematically reviewed the available knowledge and evidence about intra-thoracic packing during DCTS for trauma patients. We furthermore inform on the management approaches, surgical strategies, and mortality associated with this intervention.

METHODS

We identified articles in MEDLINE and SCOPUS. We reviewed all studies that included trauma patients with chest injuries and managed with intrathoracic packing during DCTS. Studies were eligible if the use of intrathoracic packing in trauma populations was reported.

RESULTS

We identified 14 studies with a total of 211 patients. Overall, intrathoracic packing was used in 131 trauma patients. Packing was most commonly used to arrest persistent coagulopathic bleeding or oozing either from raw surfaces or repaired structures and in conjunction with other operative techniques. Pneumonectomy was a deadly intervention; however, one study reported survivors when pneumonectomy was deferred.

CONCLUSION

Packing is a feasible, reliable and potentially effective complementary method for hemorrhage control. Therefore, we recommend that packing can be used liberally as a complement to rapid lung-sparing techniques.

A clinical series of packing the wound tract for arresting traumatic hemorrhage from injuries of the lung parenchyma as a feasible damage control technique

Background

Tractotomy has become the standard of care for transfixing through-and-through lung injuries as it can be performed quickly with little blood loss and a low risk of complications. However, packing with laparotomy pads could be a feasible alternative to tractotomy on selected patients. We describe a series of four patients with lung trauma in which packing of the pulmonary wound tract was used as the primary and unique surgical strategy for arresting hemorrhage from injuries of the lung parenchyma.

Methods

Packing of the traumatic tract is achieved by gently pulling a laparotomy pad with a Rochester clamp and adjusting it to the cavity to stop the bleeding. The pack is removed in a subsequent surgery by moistening and tractioning it softly to avoid additional damage. The operation is completed by manual compression of the wounded lobe. We present a case series of our experience with this approach.

Results

From 2012 to 2016, we treated four patients with the described method. The mechanism was penetrating in all them. The clinical condition was of exsanguinations with multiple sources of hemorrhage. There were three patients with peripheral injuries to the lung and one with a central injury to the pulmonary parenchyma. Bleeding was stopped in all the cases. Three patients survived. A patient had recurrent pneumothorax which was resolved with a second chest tube.

Conclusion

Packing of the traumatic tract allowed rapid and safe treatment of transfixing through-and-through pulmonary wounds in exsanguinating patients under damage control from several bleeding sources.

Chinese expert consensus on echelons treatment of thoracic injury in modern warfare

The emergency treatment of thoracic injuries varies of general conditions and modern warfare. However, there are no unified battlefield treatment guidelines for thoracic injuries in the Chinese People's Liberation Army (PLA). An expert consensus has been reached based on the epidemiology of thoracic injuries and the concept of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since there are no differences in the specialized treatment for thoracic injuries between general conditions and modern warfare, first aid, emergency treatment, and early treatment of thoracic injuries are introduced separately in three levels in this consensus. At Level I facilities, tension pneumothorax and open pneumothorax are recommended for initial assessment during the first aid stage. Re-evaluation and further treatment for hemothorax, flail chest, and pericardial tamponade are recommended at Level II facilities. At Level III facilities, simple surgical operations such as emergency thoracotomy and debridement surgery for open pneumothorax are recommended. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

Delayed Cardiac Rupture Induced by Traumatic Myocardial Infarction: Consequence of a 45-Magnum Blast Injury; A Comprehensive Case Review

A penetrating chest trauma, a myocardial contusion or a myocardial infarction can lead to a cardiac rupture, which is linked to an extreme high death rate. Only few cases with delayed perforation of the myocardium have been reported in literature. We report about a penetrating gunshot injury, which led to a myocardial contusion with secondary delayed rupture of the left ventricle and the left inferior lobe of the lung. The leakage of the lesion in the left ventricle could be sealed sufficiently with fibrin-coated collagen fleeces after adapting stitches with Prolene 2-0. For additional stabilization of the vulnerable myocardium area, a bovine patch has been placed on the damaged ventricle. Fibrin fleeces are used successfully in cardiac surgery, as in our case, to seal the leakage of the lesion in the left ventricle. The implantation of a bovine patch in the pericardium could prevent a cardiac compartment syndrome with a fatal pericardial tamponade. To prohibit a thoracic compartment syndrome a modified Bogota bag could be sewed in for temporarily closure of the chest. In most cases penetrating cardiac injuries can be treated without heart-lung-machines. An immediate transfer to a cardio-surgical center is, due to the acute situation, not possible. If a surgeon with thoraco-surgical expertise is present a transfer is not absolutely necessary.

Selective packing for uncontrollable traumatic thoracic wall bleeding preserving cardiopulmonary function

BACKGROUND

Uncontrollable chest wall bleeding secondary to thoracic trauma has been a challenging problem faced by surgeons. Thoracic packing has been described as a good alternative although most thoracic surgeons avoid it because of the potential deleterious effects on cardiopulmonary function.

METHODS

We describe a selective gauze packing technique of the thoracic wall preserving cardiopulmonary function in 3 patients with uncontrollable bleeding, where gauze packs were placed on bleeding areas holding them in a "sandwich-like" arrangement between the skin and the pleura and tightly fixed with coated wire stitches using internal and external-thoracic Ventrofil® devices.

RESULTS

Successful hemostasis and cardio-respiratory stability were achieved in all cases after selective packing. X-ray showed acceptable lung expansion and no heart compression.

CONCLUSIONS

This selective packing technique is simple, feasible and highly effective in managing uncontrollable post-traumatic or even post-operative chest wall hemorrhages when the life of patients is in danger.

Damage-control neurosurgery: Packing to halt relentless intracranial bleeding

BACKGROUND

The objective of this study was to review the efficacy of intracranial packing as a means of tamponade for life-threatening intraoperative hemorrhage that was refractory to more common techniques for achieving hemostasis.

METHODS

Neuroimaging and hospital records were reviewed for the seven adult patients who had experienced life-threateningly severe hemorrhage during intracranial surgery and in whom packing was used to control the bleeding. All packing was left in place at the time of closure and was removed when the patient's condition was considered safe for a second operation.

RESULTS

Hemorrhage was successfully halted in all seven patients, and all survived their operations. Six were discharged from the hospital, but one patient with severe parenchymal injury from trauma and multiple medical comorbidities died on postoperative Day 2 after supportive care was withdrawn. Four had an improved Glasgow Outcome Scale (GOS) score at the time of last follow-up, and two of these improved from dependent to independent living. There were no postoperative intracranial or wound infections.

CONCLUSION

Intracranial packing to tamponade severe intracranial hemorrhage can be a lifesaving neurosurgical maneuver.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: A content analysis and expert appropriateness rating study

BACKGROUND

The use of abbreviated or damage control (DC) interventions may improve outcomes in severely injured patients when appropriately indicated. We sought to determine which indications for DC interventions have been most commonly reported in the peer-reviewed literature to date and evaluate the opinions of experts regarding the appropriateness (expected benefit-to-harm ratio) of the reported indications for use in practice.

METHODS

Two investigators used an abbreviated grounded theory method to synthesize indications for 16 different DC interventions reported in peer-reviewed articles between 1983 and 2014 into a reduced number of named, content-characteristic codes representing unique indications. For each indication code, an international panel of trauma surgery experts (n = 9) then rated the appropriateness of conducting the DC intervention of interest in an adult civilian trauma patient.

RESULTS

The 424 indications identified in the literature were synthesized into 101 unique indications. The panel assessed 12 (70.6%) of the coded indications for the 7 different thoracic, 47 (78.3%) for the 7 different abdominal/pelvic, and 18 (75.0%) for the 2 different vascular interventions to be appropriate for use in practice. These included indications for rapid lung-sparing surgery (pneumonorrhaphy, pulmonary tractotomy, and pulmonary wedge resection) (n = 1); pulmonary tractotomy (n = 3); rapid, simultaneously stapled pneumonectomy (n = 1); therapeutic mediastinal and/or pleural space packing (n = 4); temporary thoracic closure (n = 3); therapeutic perihepatic packing (n = 28); staged pancreaticoduodenectomy (n = 2); temporary abdominal closure (n = 12); extraperitoneal pelvic packing (n = 5); balloon catheter tamponade (n = 6); and temporary intravascular shunting (n = 11).

CONCLUSION

This study identified a list of candidate appropriate indications for use of 12 different DC interventions that were suggested by authors of peer-reviewed articles and assessed by a panel of independent experts to be appropriate. These indications may be used to focus future research and (in the interim) guide surgical practice while studies are conducted to evaluate their impact on patient outcomes.

Damage Control for Thoracic Trauma

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.