Penetrating Chest Trauma

Incisions and Approaches

There are a number of different approaches that can be used involving variations in incision, airway management, and positioning. The choice is dictated by stability, mechanism, and surgeon preference/experience. A brief review of these is presented in Table 1. In an unstable patient, the optimal positioning is supine in the crucifix position, with the patient draped to include the neck, supraclavicular area, entire thorax, abdomen, and proximal thighs. A single-lumen tube is the optimal initial airway tool in chest trauma. The tube can be advanced into the left main stem bronchus to isolate the right lung, or an endobronchial blocker can be placed to isolate the left. Advancing a single-lumen tube into the right often causes obstruction of the right upper lobe bronchus. This rapid isolation can be particularly useful in patients with massive unilateral air leak and/or hemorrhage. A double-lumen tube can be used in stable patients who require lung isolation or in centers that are facile with emergent placement. In patients who present in severe shock and/or require massive volume resuscitation, it may not be possible to ‘‘switch out’’ the double-lumen tube at the end of the case because of tenuous oxygenation/ventilation status. When possible, antibiotics with gram-positive coverage should be administered, although there has been conflicting data regarding the efficacy of ‘‘prophylactic’’ antibiotics.^16,17 Ideally, this should be administered before tube thoracostomy, but practically, it happens soon after. There are various recommendations regarding duration, but in general, duration of greater than 24 hours is not recommended.¹⁸