Hilar control in penetrating chest trauma: a simplified approach to an underutilized maneuver

In both urban and military settings, penetrating thoracic injuries remain a significant source of trauma-related mortality, and many patients require resuscitative thoracotomy. Existing literature emphasizes relief of pericardial tamponade and aortic clamp application as the key therapeutic maneuvers. The purpose of this report is to revisit pulmonary hilar clamping and highlight its application for hemorrhage control, air embolism prevention, and other benefits in the setting of massive hemothorax.

Records from an urban, American College of Surgeons verified level I trauma center were evaluated over a six-month period. Patients who underwent early pulmonary hilar clamping were identified.

Twenty-four patients with trauma presented during the study period required thoracotomy. Of these, three (13%) underwent early pulmonary hilar clamping for massive hemothorax. Trauma mechanism was penetrating in each instance. Injuries included pulmonary lobe destruction, subclavian artery disruption, and internal thoracic artery transection. These cases illustrate the utility of early pulmonary hilar clamping for hemorrhage control, prevention of air embolization, and improved exposure.

To decrease morbidity and mortality at our institution, a method of pulmonary hilar control has evolved using an organized, "hand-over-hand" approach that controls hemorrhage, prevents fatal air embolism, protects against blood spillage into contralateral airways, and facilitates pulmonary surgery. Several features distinguish our approach from those previously reported.