Unstable Penetrating Chest Trauma
Annotation for Point K
Lung injuries that are bleeding massively may also require rapid hilar control. Tractotomy is preferred to expose the depth of a bleeding wound, permits ligation of injured pulmonary vessels, and is particularly appropriate as a damage-control technique.30,31 In general, the lesser the parenchymal resection, the better the outcome.3 Deep parenchymal tracts should not bemanaged by oversewing the entry and exit sites. Thiswill lead to intraparenchymal hemorrhage, respiratory failure, and airembolism. It is far better to leave the tract open. Biologic gluesmay be tried if it is clear that there is no open communication with major airways or vasculature. The technique (anatomic vs. stapled) is determined by the experience of the surgeon and comfort level, but what works quickest is generally associated with improved outcomes. Air embolism results in acute instability and can manifest with cardiac (arrhythmia, arrest) and/or neurologic (sudden stroke) complications. It may occur with intubation and positivepressure ventilation or at thoracotomy when the lung injury is decompressed. Cardiac air embolism may be evident as air is usually seen in the coronary arteries. Management includes clamping the airway to the affected parenchyma or hilar control. In patients who are acutely decompensating, crossclamping the aorta (to increase coronary perfusion pressure), cardiac massage, and venting the left ventricle are required.19,32 Rarely, cardiopulmonary bypass may be an option in patients without contraindications. Neurologic air embolism is similarly addressed by controlling the site of lung injury, maintaining cerebral perfusion pressure, and hyperbaric oxygenation in select patients.