Central lung injuries: a need for early vascular control

During a 7-year period (1980-1987), 161 patients underwent emergency thoracotomy for penetrating lung injuries. Of these, 25 (15%) had injuries involving central pulmonary (hilar) vascular structures. Anterolateral thoracotomies were performed in 14 patients because of unstable vital signs (ten) or cardiac arrest (four), and only two (14%) of these patients survived. In seven of these patients the incision was extended into a bilateral thoracotomy to provide better exposure for continued severe bleeding, and all seven died. Of 11 relatively stable patients having a posterolateral incision (ten) or a median sternotomy (one), only two (18%) died. Of 18 patients in whom the initial procedure was hilar clamping, ten (63%) survived. In seven patients an attempt was made to control the bleeding before hilar clamping and only one (14%) survived. In six patients, resection of a lobe (five) or a segment (one) was used to achieve hemostasis with five (83%) survivors. Eight of the 14 deaths were clearly due to blood loss, which was treated with an average of 19.5 units of blood. However, in six of the earlier deaths with much less blood loss, air emboli may have been a factor, but was unproven. Early vascular control at the hilum for central lung injuries seems to be needed not only to stop the bleeding but also to prevent systemic air emboli.