de Lesquen Henri, Avaro Jean-Philippe, Gust Lucile, Ford Robert Michael, Beranger Fabien, Natale Claudia, Bonnet Pierre-Mathieu, D'Journo Xavier-Benoît
Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France.
Interact Cardiovasc Thorac Surg. 2015 Mar;20(3):399-408. doi: 10.1093/icvts/ivu397. Epub 2014 Dec 4.
This review aims to answer the most common questions in routine surgical practice during the first 48 h of blunt chest trauma (BCT) management. Two authors identified relevant manuscripts published since January 1994 to January 2014. Using preferred reporting items for systematic reviews and meta-analyses statement, they focused on the surgical management of BCT, excluded both child and vascular injuries and selected 80 studies. Tension pneumothorax should be promptly diagnosed and treated by needle decompression closely followed with chest tube insertion (Grade D). All traumatic pneumothoraces are considered for chest tube insertion. However, observation is possible for selected patients with small unilateral pneumothoraces without respiratory disease or need for positive pressure ventilation (Grade C). Symptomatic traumatic haemothoraces or haemothoraces >500 ml should be treated by chest tube insertion (Grade D). Occult pneumothoraces and occult haemothoraces are managed by observation with daily chest X-rays (Grades B and C). Periprocedural antibiotics are used to prevent chest-tube-related infectious complications (Grade B). No sign of life at the initial assessment and cardiopulmonary resuscitation duration >10 min are considered as contraindications of Emergency Department Thoracotomy (Grade C). Damage Control Thoracotomy is performed for either massive air leakage or refractive shock or ongoing bleeding enhanced by chest tube output >1500 ml initially or >200 ml/h for 3 h (Grade D). In the case of haemodynamically stable patients, early video-assisted thoracic surgery is performed for retained haemothoraces (Grade B). Fixation of flail chest can be considered if mechanical ventilation for 48 h is probably required (Grade B). Fixation of sternal fractures is performed for displaced fractures with overlap or comminution, intractable pain or respiratory insufficiency (Grade D). Lung herniation, traumatic diaphragmatic rupture and pericardial rupture are life-threatening situations requiring prompt diagnosis and surgical advice. (Grades C and D). Tracheobronchial repair is mandatory in cases of tracheal tear >2 cm, oesophageal prolapse, mediastinitis or massive air leakage (Grade C). These evidence-based surgical indications for BCT management should support protocols for chest trauma management.
本综述旨在解答钝性胸部创伤（BCT）处理最初48小时内常规外科实践中最常见的问题。两位作者检索了1994年1月至2014年1月发表的相关手稿。按照系统评价和Meta分析的首选报告项目声明，他们聚焦于BCT的外科处理，排除儿童和血管损伤，选取了80项研究。张力性气胸应立即诊断，并通过针穿刺减压迅速处理，随后紧密跟进胸腔闭式引流管置入（D级）。所有创伤性气胸均考虑行胸腔闭式引流管置入。然而，对于部分无呼吸系统疾病或无需正压通气的单侧小量气胸患者，可进行观察（C级）。有症状的创伤性血胸或血胸量>500ml应通过胸腔闭式引流管置入进行治疗（D级）。隐匿性气胸和隐匿性血胸通过每日胸部X线观察进行处理（B级和C级）。围手术期使用抗生素预防与胸腔闭式引流管相关的感染并发症（B级）。初始评估时无生命体征且心肺复苏持续时间>10分钟被视为急诊开胸手术的禁忌证（C级）。对于大量漏气、难治性休克或胸腔闭式引流管初始引流量>1500ml或3小时内每小时引流量>200ml导致的持续性出血，应进行损伤控制开胸手术（D级）。对于血流动力学稳定的患者，对于残留血胸应早期行电视辅助胸腔手术（B级）。如果可能需要机械通气48小时，则可考虑固定连枷胸（B级）。对于有移位、重叠或粉碎、顽固性疼痛或呼吸功能不全的胸骨骨折，应进行固定（D级）。肺疝、创伤性膈肌破裂和心包破裂是危及生命的情况，需要立即诊断并寻求手术建议（C级和D级）。对于气管撕裂>2cm、食管脱垂、纵隔炎或大量漏气的情况，必须进行气管支气管修复（C级）。这些基于证据的BCT处理外科指征应支持胸部创伤处理方案。
