Unstable Penetrating Chest Trauma

Annotation for Point J

Central hilar injuries are managed first by hilar control.²⁷ This can take the form of ‘‘hilar twist,’’snare, or simple hand control, followed by clamping. The hilar twist requires division of the inferior pulmonary ligament, and results in severe hilar injury and obscures operative exposure. Therefore, it is really of historical interest. Clamping inferiorly also requires division of the inferior pulmonary ligament, while this is not needed if clamping from superior to inferior. This reduces the risk of fatal hemorrhage and air embolism.²⁸ Massive central injuries may require pneumonectomy. A central tractotomy can lead the surgeon to the injured area, permitting control and avoiding pneumonectomy. If performing a ‘‘stapled’’ pneumonectomy, fluid should be restricted when possible, and bronchial stump reinforcement should be performed acutely or, if the patient is too unstable, at a later date.²⁹ Themortality rate following trauma pneumonectomy ranges from 50% to 100%, and commonly, the cause is acute cor pulmonale. Once bleeding is controlled, fluids should be restricted.