Unstable Penetrating Chest Trauma
Annotation for Point I
If superior mediastinal hematoma is encountered, the root of the great vessels, the ascending aorta, and arch can be exposed by extending the pericardial incision superiorly in the midline. This often allows for proximal intrapericardial control before inadvertentlydecompressingthehematoma.25 If, on entering the chest, major apical bleeding is encountered, packing the apex and holding hand pressure can temporize the bleeding. Ascending arch injuries can be controlled digitally, but caval occlusion can be helpful as well.25,26 Distal exposure of the great vessels can be obtained by simple supraclavicular or lateral neck extensions. Repair can be performed by simple suture, end-to-end reconstruction, interposition graft, or bypass graft. Temporary shunts may be used if available and if there is enough exposure. In the persistently unstable patient, this is usually not practical, and the proximal and distal exposure is not sufﬁcient. Ligation is generally limited to the left subclavian artery and in patients with devastating injuries who manifest coagulopathy.