Shock, Not Blood Pressure or Shock Index, Determines the Need for Thoracic Damage Control Following Penetrating Trauma

Abstract

Background: Damage control laparotomy has increased survival for critically injured patient with penetrating abdominal trauma. There has been a slower adoption of a damage control strategy for thoracic trauma despite the considerable mortality associated with emergent thoracotomy for patients in profound shock. We postulated admission physiology, not blood pressure or shock index, would identify patients who would benefit from thoracic damage control. Study Design: Retrospective trauma registry review from 2002 to 2017 at a busy, urban trauma center. Three hundred one patients with penetrating thoracic trauma operated on within 6 h of admission were identified. Of those 66 (21.9%) required thoracic damage control and comprise the study population. Results: Compared with the non-damage control group, the 66 damage control patients had significantly higher Injury Severity Score, chest Abbreviated Injury Scale, lactate and base deficit, and lower pH and temperature. In addition, the damage control thoracic surgery group had significantly more gunshot wounds, transfusions, concomitant laparotomies, vasoactive infusions, and shorter time to the operating room. Notably, however, there were no significant differences in admission systolic blood pressure or shock index between the groups. Once normal physiology was restored, chest closure was performed 1.7 (0.7) days after the index operation. Mortality for thoracic damage was 15.2%, significantly higher than the 4.3% in the non-damage control group. Over two-thirds of damage control deaths occurred prior to chest closure. Conclusions: Mortality in this series of severely injured, profoundly physiologically altered patients undergoing thoracic damage control is substantially lower than previously reported. Rather than relying on blood pressure and shock index, early recognition of shock identifies patients in whom thoracic damage control is beneficial.

Damage control surgery in lung trauma

“…A sub-analysis of patients with thoracic trauma who underwent emergency thoracotomy in Cali-Colombia reported that 72% of patients managed by damage control thoracotomy presented lung trauma, compared to those who did not required damage control thoracotomy, only 56% presented with lung trauma 16 . Similar to the case series from Baltimore-United states, were 86% of patients who require damage control thoracotomy presented with lung injuries 15 .…”

“…Early identification of whether a patient benefits from damage control surgery, or not, enables activation of resuscitation protocols and redirects surgical effort towards a damage control thoracotomy. Two groups have researched the variables that differentiate patients who require thoracic damage control 15 , 16 . They have reported the following conditions that relates to a damage control approach: neurological status upon admission, resuscitative thoracotomy, need of a concomitant laparotomy, severe lung injury, mayor vascular injury, tracheobronchial injury, massive hemothorax, hypothermia, acidosis and coagulopathy.…”

“…The reported experience of managing lung damage control with anatomical lung resection is limited. Some case series have reported a pneumonectomy or lobectomy rate of 32% O’Connor and 26% Deane for Baltimore-United States 13 , 15 , 20% García and 15% Chica for Cali-Colombia 14 , 16 . This last group has reported a rate greater than 3% of patients with lung resections without the need damage control thoracotomy 16 .…”

“…Research aimed to identify variables associated with the risk of damage control thoracotomy have found that alterations in arterial pH, lactate levels, base deficit, preoperative hypothermia 15 , preoperative neurological status with alteration of consciousness, magnitude of hemothorax, need of aortic occlusion, central lung injury, mayor vascular injury, tracheobronchial injury or multiple bleeding sites are associated with the decision of a damage control surgical strategy 16 . ( Table 1 )…”

“…Pneumorrhaphy or wedge lung resection with a linear stapler after clamping injured lung tissue with a Satinsky forceps is rarely used during a damage control thoracotomy 14 , 15 . Nevertheless, they can be suitable for definite management of small peripheral injuries in patients with multiple bleeding sites.…”