Thoracic packing for uncontrolled bleeding in penetrating thoracic injuries.

Abstract: We present a series of three patients who suffered penetrating thoracic injury, and in whom thoracic packing was used as a life-saving procedure. Survival among these patients paralleled the severity and extent of the original injuries. Restriction of cardiac filling and lung expansion are potential deterrents from using this technique; however, its use seems to be a valid adjunct, especially in the setting of chest wall bleeding coming from the intercostal arteries. Damage control surgery in pentrating thoracic trauma, including thoracic packing, is a sound alternative when uncontrollable bleeding, hypothermia and coagulopathy compromises the survival of a patient.

Key Words: bleeding, packing, penetrating, thoracic, trauma

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Packing as a component of damage-control in the practice of trauma surgery has become a well-accepted strategy for controlling hemorrhage. This approach has been widely used in abdominal trauma, with successful control of hemorrhage reported in 46 to 66% of cases. (1-3) One of the most useful strategies in damage control surgery for abdominal trauma is intra-abdominal packing of diffusely bleeding surfaces. This technique allows the surgeon to bring the patient to the intensive care unit and provide a more physiologic and controlled resuscitation.

Unlike its accepted use in abdominal trauma, packing in thoracic trauma has been traditionally discouraged because of concerns about the potential compromise to cardiac filling and lung expansion. Specific reports in this regard are lacking, and reference in the literature is limited to the individual comments of practicing surgeons, without any in-depth analysis of this alternative as an option in thoracic trauma. We report a single-institution experience of three cases of thoracic damage control involving thoracic packing, and comment about the outcomes and complications of each particular case.

Case Reports

Case 1

A 23-year-old man arrived in the emergency department after sustaining multiple gunshot wounds to the chest. Bilateral chest tubes were placed, which produced massive bleeding and loss of pulses. An emergency thoracotomy was performed, revealing profuse bleeding from the chest wall and lung parenchyma, as well as an intact heart and pulmonary hilum. Further exploration in the operating suite revealed multiple lung injuries and bleeding from the posterior chest wall. Parenchymal injuries were oversewn, but chest wall bleeding was only partially controlled. Because the right chest tube continued draining copious blood, laparotomy pads were packed in the left chest and the right hemithorax was explored, evacuating residual hemothorax and oversewing multiple pulmonary injuries.

At this point, bleeding from the left chest persisted, and hypothermia, acidosis, and coagulopathy made hemorrhage uncontrollable. The left chest was packed with gauze rolls and the skin and muscle closed en masse with a running nylon suture. Estimated blood loss was 5 L. Fifteen units of packed red blood cells were transfused. The patient was stabilized in the surgical intensive care unit (SICU), and during the following 9 hours, 900 mL of blood drained through the right chest tube. The patient remained hemodynamically stable. Physiologic parameters that were measured in the immediate postoperative period until the removal of the thoracic packing were as follows:

Central venous pressure: 5 to 10 cm [H.sub.2]O.
Peak respiratory pressure: 35 to 40 cm [H.sub.2]O.
Positive end-expiratory pressure (PEEP): 8 to 15 cm [H.sub.2]O; PEEP had
to be increased as high as 15 cm [H.sub.2]O to provide adequate
oxygenation in the immediate postoperative recovery.
FI[O.sub.2] requirement: weaned to 40% with adequate oxygenation in the
first 24 hours after the initial surgery.
Arterial blood gasses:
  pH progressively increased from 7.14 to normal.
  Carbon dioxide (C[O.sub.2]) remained in the 40- to 50-mm Hg range
  without need of a significant increase in the respiratory rate.

Twenty-four hours later, the patient was returned to the operating room, where the packing was removed and 600 mL of hematoma was evacuated. There was no active bleeding evident from any of the areas previously packed. A chest tube was left in place and the thorax was definitively closed. The postoperative course was complicated by persistent fever and a fluid collection in the left costophrenic angle. Computed tomography-guided drainage evacuated 170 mL of clear fluid with negative microbial cultures. The patient was discharged on postoperative day 12 without any serious complications.

Case 2

A 22-year-old man who was found unresponsive and apneic subsequent to receiving a stab wound to the chest was immediately intubated in the field. On arrival to the emergency department, he was in pulseless electrical activity, and an emergency left thoracotomy was performed. Cardiac tamponade was evident on opening the chest, and pericardiotomy drained 750 mL of clotted blood. A small penetrating injury to the right ventricle was noted. Resuscitation was carried out with occlusion of the ventricular injury, intracardiac epinephrine, and cardioversion. The ventricular laceration was repaired in the emergency department and the patient was taken to the operating room for further exploration. During this procedure, a lung wedge resection was performed for a parenchymal laceration. The thoracotomy incision was closed, a chest tube was left in place, and the patient was taken to the SICU.

Over the following 6 hours, the patient developed tachycardia and the chest tube drained 1,500 mL of blood. The patient was returned to the operating room, where bleeding from the raw pleural surface was evident. Hemostasis was attempted, and the left internal mammary artery was ligated. In view of persistent hypothermia and coagulopathy, and after a total transfusion of 10 units of blood, decortication and packing of the chest wall with three laparotomy pads was performed to control bleeding. The skin and muscle were closed en masse with nylon suture. The patient remained hemodynamically stable, and peak airway pressures remained between 45 and 50 cm [H.sub.2]O. Twenty-four hours later, the patient was returned to the operating room, where serosanguinous fluid and old blood were found inside the chest after removal of the thoracic packing. Physiologic parameters that were measured in the immediate postoperative period until the removal of the thoracic packing were as follows:

Central venous pressure: 10 to 14 cm [H.sub.2]O.
Peak pressures: 45 to 50 cm [H.sub.2]O.
PEEP: 5 cm [H.sub.2]O.
FI[O.sub.2] requirement: weaned to 40% with adequate oxygenation in the
first 24 hours after the initial surgery.
Arterial blood gasses:
  pH progressively increased from 7.05 to normal.
  C[O.sub.2] remained in the 44- to 49-mm Hg range without need of a
  significant increase in the respiratory rate.

Eight days after the initial surgery, the patient underwent thoracoscopic drainage of a retained hemothorax and decortication with extensive lysis of adhesions between the lung and chest wall. The chest tubes were finally removed and the patient was subsequently discharged home with no further bleeding.

Case 3

A 17-year-old male subject suffered a single gunshot wound to the right chest, with entrance under the right clavicle in the midclavicular line and no exit wound. Systolic blood pressure at arrival in the emergency department was 70 mm Hg, and there was a large amount of bleeding from the wound. A chest tube was placed in the emergency room, which drained only a small amount of blood, and a chest radiograph showed only scattered lead in the right upper chest.

Because of continuous bleeding, the patient was taken to the operating room, and a right thoracotomy was performed. Massive bleeding was encountered on opening of the chest, and an extended clamshell incision was made for better visualization. A wedge resection was initially performed on the right upper lung in an effort to control blood loss. This was followed by a complete right pneumonectomy after identifying a major right hilar injury. A subclavian vein injury was also identified and ligation of the vein was performed. At this point, estimated blood loss was 14 L. Obvious coagulopathy, hypothermia, and hypotension developed. The right chest was completely packed with laparotomy pads and the skin and muscle closed en masse. Physiologic parameters that were measured in the immediate postoperative period were as follows:

Central venous pressure: 3 to 5 cm [H.sub.2]O.
Peak pressures: 50 to 55 cm [H.sub.2]O.
PEEP: 10 cm [H.sub.2]O.
FI[O.sub.2] requirement: weaned to 60% with adequate oxygenation.
Arterial blood gasses:
  pH revealing persistent metabolic acidosis, below 7.2 at all times.
  C[O.sub.2] remained in the 35- to 40-mm Hg range without need of a
  significant increase in the respiratory rate.

In the SICU, the patient remained hypotensive, requiring vasopressor support and multiple transfusions of blood products. The patient died 3 hours later with persistent blood loss from the chest cavity.

Discussion

This report presents three cases of penetrating thoracic trauma where damage control surgery involving packing of the chest cavity was used as a means of controlling bleeding. Even though the nature of each of these cases is different, all of them ultimately developed profuse bleeding secondary to hypothermia, coagulopathy, and acidosis, requiring substantial replacement of blood products. Clinical presentation, outcome, and intraoperative findings are summarized in Table 1 for each of the cases.

Thoracic packing has been described in the literature as a means of controlling bleeding after heart surgery (4) and, in a few instances, after elective lung resections. (5) Major hemorrhage after pleurectomy or pulmonary resection occasionally presents as diffuse bleeding from raw chest wall surfaces. In these situations, thoracic packing has been reported as a bleeding-control strategy. (5,6)

There are no data in the literature that specifically review the outcome of cases of damage-control surgery in the setting of thoracic trauma. The only references made to this technique are as general recommendations based on the experience of practicing surgeons, (5,7) or as a citation of individual cases as part of a larger series. (2,8)

Wall and Soltero (7) mention that packing is often attempted as a last resort in the cold, coagulopathic patient with multiple chest wall injuries and diffuse bleeding. They infer that this strategy may be most useful to control generalized oozing at the extremes of the chest, in the apexes and upper mediastinum, or down in the sulcus away from the heart and hilum of the lung. Newer techniques include the use of collagen, thrombin, and fibrin glue, which can be combined with the packing itself to provide better hemostasis.

Hirshberg et al (2) reported an institutional experience of planned reoperation for trauma in 124 patients, where they refer to packing as the most frequently used technique to control bleeding, being used in the thorax in two of the patients in this series. One year later, a review article (8) about planned reoperation for severe trauma from Hirshberg and Mattox makes reference to thoracic packing as an occasionally necessary technique in the management of uncontrollable bleeding in the pleural cavity.

Aside from the references cited above, there are no additional studies focusing on the use of thoracic packing in the setting of trauma. Furthermore, there are no reports in the literature to describe in detail the situations or outcome involved with its application.

The primary reason thoracic packing has traditionally been discouraged is the potential for restriction of cardiac filling and lung expansion due to the physical space the packing occupies in the chest cavity, which could also raise ventilator pressures and increase the risk of barotrauma. In our three patients, two survived the packing of the chest with adequate hemostatic control of the injury. In both of these patients, the bleeding was coming from the chest wall, with the intercostal arteries being the most likely source. In the first case, the packing was placed in the posterior chest wall with gauze rolls, and in the second case, three laparotomy pads were placed in the lateral chest wall. Closure in all three cases was performed with a single running suture including the skin and muscle layer.

During the postoperative period, none of the three patients developed significantly elevated airway pressures, and it appears that arterial oxygenation was not seriously compromised as a result of thoracic packing since all three showed above-normal arterial oxygenation on an inspired oxygen fraction of 40%. This finding, consistent with a good tolerance to the physical presence of the packing, may in part be explained by the adequate respiratory reserve of these young patients.

Hemodynamic physiologic measurements in the immediate postoperative period were assessed by means of central venous and arterial indwelling catheters. Swan-Ganz catheters were not placed because their use had not provided any additional relevant information.

Respiratory dynamic was assessed by monitoring arterial blood gasses and peak airway inspiratory pressures. The latter was used as an indicator of the intrathoracic pressure because of the potential of the thoracic packing to raise this parameter and produce barotrauma. In the event that peak pressures increased, the tidal volume had to be decreased; these changes were tolerated by the patients, as indicated by adequate oxygenation and C[O.sub.2] levels.

Even though thoracic packing might be a reasonable means of controlling thoracic bleeding, it is our personal bias to try to remove it as soon as the physiologic condition of the patient allows. If this method is going to work in a specific patient, it will be evident in the first 24 hours; otherwise, persistent bleeding will be noted. Leaving the packing for a longer period of time may significantly increase infectious complications in the setting of a foreign body and a significant amount of remaining intrathoracic clot.

The lowest core temperatures recorded after the patients arrived in the emergency room were 34[degrees]C, 34[degrees]C, and 31.9[degrees]C, respectively. Jurkovich et al (9) analyzed the impact of hypothermia in trauma victims and concluded that a core temperature of less than 32.0[degrees]C was associated with a 100% mortality rate. Outcomes in our series correlate with this finding, with the single fatality occuring in the only patient whose lowest core temperature was below 32[degrees]C.

It is relevant to mention that the two cases with successful outcomes involved a limited surgical approach, mainly focused in the ligation of bleeders and resection of small areas of lung. In both of these cases, damage control was adopted early in the course of the operation and did not involve major parenchymal resections or more complicated procedures. In the third case, the injuries involved a greater degree of severity, leading to a more aggressive surgical repair, initially with a lung wedge resection that subsequently required total pneumonectomy and ligation of the subclavian vein. The severity of the injury, which involved the subclavian vein and the pulmonary hilum, predicted a poor outcome for the patient.

In several studies, (10,11) it has been reported that there is a higher mortality in penetrating chest injuries that require lung resection, and that this mortality correlates with the extent of resection, with mortality in total pneumonectomy reported to be between 50 and 100%. In our small series, this observation was found to be accurate, because the fatality occurred in the patient with hilar injury requiring total pneumonectomy.

There are several additional therapeutic methods not used in the cases reported, but which may also be considered in similar situations of diffuse, uncontrollable bleeding. Thoracic cavity irrigation with hot saline is one of these options. It has been described that the use of saline irrigation at temperatures of 40[degrees]C to 45[degrees]C could potentially be beneficial. However, the rationale behind this strategy rests on its usefulness as a means of raising the body core temperature, and not as a directly hemostatic agent.

Argon beam cautery is another adjunct that could be used, if it were readily available in emergent care facilities. Studies have not addressed its use in the thoracic trauma setting; however, experimental data in animal models of pulmonary resection show adequate control of bleeding, with a lower incidence of postoperative air leaks and tissue damage when compared with standard electrocautery and suture closure. Its main disadvantage is the feasibility of having the unit readily available in the trauma setting, where the expediency of bleeding control is of utmost importance. (12)

Topical hemostatic agents have recently been popularized as adjuncts for bleeding control, mainly in solid organs, raw surface bleeding, and vascular anastomotic leaks. There are three major sealant adjuncts commercially available: fibrin sealant (Tisseel VH; Baxter Healthcare Corp., Deerfield, IL), hemostatic sealant (FloSeal; Baxter), and Surgical sealant (CoSeal; Baxter). Their uses are described as follows:

* Fibrin sealant: A mixture of fibrinogen and thrombin that, when combined, creates net-like matrices that firmly adhere to surrounding connective tissue. This combination is available for topical application, spray, and as dry fibrin sealant dressings.

* FloSeal: A mixture of a gelatin matrix and thrombin that is proven to control bleeding of various types, from capillary oozing to arterial spurting, and is effective on wet, actively bleeding tissue. It is available for topical application.

* CoSeal: Two polyethylene glycol polymers that, when mixed, chemically bond together to form CoSeal surgical sealant. Mostly recommended for sealing vascular reconstructions. It is available for topical application.

In cases such as those described above, spray applicators and dry dressings of fibrin sealants would be the most suitable of these options to obtain hemostatic efficacy, because of the large bleeding area involved. Theoretically, these two products, in addition to thoracic packing, could facilitate hemostasis in the trauma setting. The remaining products mentioned are more appropriate for very localized areas of bleeding.

Conclusion

Thoracic packing is a useful alternative as a damage-control surgery technique in cases of continuing exsanguination in thoracic trauma. We believe outcomes can be improved if this technique is performed early in the course of the operation in order to prevent massive exsanguination and irreversible shock. As reported in the trauma patient population, hypothermia is an ominous sign and correlates with mortality. Major lung resections or repairs should be avoided if possible because it seems to affect outcome negatively. The literature is limited regarding this technique of damage control, and additional case studies are required to arrive at more definite conclusions.

Let us endeavor to live so that when we come to die, even the undertaker
will be sorry.
--Mark Twain

Table 1. Thoracic packing experience

      Mechanism  Intraoperative
Case  of injury  injuries                  Operative procedure

1     Multiple   Multiple parenchymal      Oversewing of bilateral
        gunshot    injuries in both lungs    parenchymal lung injuries
        wounds   Uncontrollable bleeding   Kerlix rolls in posterior
        to the     from the posterior        left chest
        chest      left chest
2     Stab       Penetrating injury to     Repair of ventricular
        wound      right ventricle (first    laceration (first surgery)
        to the     surgery)
        chest    Laceration of the left    Left upper lobe wedge
                    upper lobe (first        resection (first surgery)
                    surgery)
                 Bleeding from raw         Ligation of internal mammary
                    pleural surfaces         artery (during reoperation)
                    (during reoperation)
                                           Three laparotomy pads in
                                             lateral aspect of chest
                                             wall (during reoperation)
3     Gunshot    Right upper lung injury   Initial right upper lobe
        wound    Right hilar injury          resection with subsequent
        to       Subclavian vein injury      right pneumonectomy
        right                              Right subclavian vein
        chest                                ligation
                                           Right chest entirely packed
                                             with laparotomy pads

      Lowest        Blood
      temperature   transfused  Lowest  Outcome/
Case  ([degrees]C)  (U)         pH      complications
1     34            15          6.8     Left pleural fluid collection
2     34             6          7.05    Retained hemothorax
3     31.6          14          6.9     Postoperative death

Accepted September 30, 2003.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9707-0637

References

1. Burch JM, Ortiz VB, Richardson RJ, et al. Abbreviated laparotomy and planned reoperation for critically injured patients. Ann Surg 1992;215:476-482.

2. Hirshberg A, Wall MJ Jr, Mattox KL. Planned reoperation for trauma: a two year experience with 124 consecutive patients. J Trauma 1994;37:365-369.

3. Morris JA Jr, Eddy VA, Blinman TA, et al. The staged celiotomy for trauma: issues in unpacking and reconstruction. Ann Surg 1993;217:576-586.

4. 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;57:856-861.

5. Urschel JD, Bertsch DJ, Takita H. Thoracic packing for postoperative hemorrhage. J Cardiovasc Surg 1997;38:673-675.

6. Petterfy A, Hence A. Haemorrhagic complications of pulmonary resection: a retrospective review of 1428 resections with 113 haemorrhagic episodes. Scand J Thorac Cardiovasc Surg 1983;17:283-287.

7. Wall MJ Jr, Soltero E. Damage control for thoracic injuries. Surg Clin North Am 1997;77:863-878.

8. Hirshberg A, Mattox KL. Planned reoperation for severe trauma. Ann Surg 1995;222:3-8.

9. Jurkovich GJ, Greiser WB, Luterman A, et al. Hypothermia in trauma victims: an ominous predictor of survival. J Trauma 1987;27:1019-1024.

10. Wall MJ, Villavicencio RT, Miller CC III, et al. Pulmonary tractotomy as an abbreviated thoracotomy technique. J Trauma 1998;45:1015-1023.

11. Tominaga GT, Waxman K, Scannell G, et al. Emergency thoracotomy with lung resection following trauma. Am Surg 1993;59:834-837.

12. Steg PG, Gal D, Rongione AJ, et al. Effect of argon laser irradiation on rabbit aortic smooth muscle: evidence for endothelium independent contraction and relaxation. Cardiovasc Res 1988;22:747-753.

RELATED ARTICLE: Key Points

* Damage-control surgery is often required in the setting of penetrating thoracic injuries.

* Despite concerns about restriction of cardiac filling and lung expansion, thoracic packing is a reasonable option to be used as a means of damage control surgery.

* Topical hemostatic agents, argon beam cautery, and irrigation with hot saline are some other potentially useful adjuncts in damage control surgery of the thorax.

Manuel Caceres, MD, Kennan J. Buechter, MD, Areti Tillou, MD, Jennifer A. Shih, BS, Donald Liu, MD, and Glenn Steeb, MD

From the Department of Surgery, Louisiana State University Medical Center, New Orleans, LA, and the Department of Surgery, University of Chicago Printzker School of Medicine, Chicago, IL.

Reprint requests to Manuel Caceres, MD, Department of Surgery, Louisiana State University School of Medicine, 1542 Tulane Avenue, New Orleans, LA 70112. Email: [e-mail]