Thoracoabdominal Wound
A 32-year-old male is brought to the ER after sustaining a gunshot wound to the right thoraco-abdomen. He is hemodynamically stable.
What are the initial steps of evaluation and management? Imaging?
Secondary survey to rule out other wounds. FAST exam. CXR.
What injuries must be considered with these wounds and imaging patterns?
Chest (heart, lungs, etc.), abdomen (solid organs or hollow viscus), and diaphragm.
He underwent exploratory laparotomy. He was found to have a right diaphragm defect, which was repaired primarily. There was a transhepatic GSW and hepatorrhaphy was performed with chromic suture. A blast injury to the anterior gastro-esophageal junction was buttressed with an anterior Dor fundoplication.
Management of Thoracoabdominal Wounds
The thoraco-abdomen is between the nipples and the costal margin. Organs in the chest and abdomen can be injured, and the diaphragm is also at risk.
Liver Trauma
Management depends on how it is diagnosed and the patient's hemodynamic stability and physical exam.
Diagnosed pre-operatively on CT scan + no concern for the need for operative intervention for concurrent injury→ non-operative management if the patient is hemodynamically stable without peritonitis. Embolization should be considered in adults with active arterial extravasation on CT. Operative intervention is indicated for hemodynamic instability, ongoing transfusion requirement, and/ or change in the abdominal exam.
Diagnosed intra-operatively→ management depends on the severity and presence of bleeding, presence of concomitant injuries. Hemorrhage control is the immediate concern. Manual pressure and packing (sandwich lap pads above and below) first. If this is ineffective, use the Pringle maneuver (hepatic inflow control)→ if bleeding stops, it was either hepatic artery or portal venous in origin. If bleeding continues, hepatic vein or IVC are likely injured.
Minimal bleeding can be controlled with cautery, hemostatic agents, omental packing, or argon beam coagulation. Moderate bleeding from a laceration from often be controlled with suture hepatorrhaphy. More significant bleeding may require non-anatomic resection or vessel ligation.
Topical hemostatic agents
Absorbable hemostatics
Oxidized regenerated cellulose- Surgicel, Surgicel Fibrillar (sheet), Surgicel NuKnit
Polysaccharide- Arista
Porcine collagen (gelatin matrix)- sponge, film, or powder. Brands- Gelfoam, Gelfilm, Surgifoam.
Bovine collagen (microfibrillar)- sponge, sheet, powder. Brands- Avitene, Ultrafoam.
Sealants with thrombin or fibrin
Thrombin, reconstituted (Recothrom)
Thrombin + collagen + chondroitin sulfate (Hemoblast)
Thrombin + bovine gelatin (Floseal)
Thrombin + porcine gelatin (Surgiflo)
Thrombin + fibrinogen + aprotinin + plasminogen (Tisseel)
Thrombin + fibrinogen + albumin (Evicel)
QuikClot- kaolin
HemCon- chitosan
If there is a trans-hepatic wound, tamponade can be created by threading a red rubber catheter through a Penrose drain, placing this into the wound, and then filling the Penrose with saline.
Stabina S, Kaminskis A, Pupelis G. Start of Polytrauma Management in University Hospital: First Experience with Liver Trauma. Acta Chirurgica Latviensis. 2014;14(1):20-25.
