Loss of the Chest Wall

Abstract

High-velocity bullets, close-range shotgun blasts, explosions, secondary projectiles, and impalements can cause significant chest wall destruction. The majority of patients with these devastating injuries require urgent endotracheal intubation and positive pressure ventilation. Prior to transport from the scene, a brief attempt to clamp arterial and venous bleeding from the intercostal vessels or chest wall musculature is advised to prevent exsanguination. A nonocclusive dressing allowing egress of air from the pleural space is placed to protect the wound from further contamination and to prevent a tension pneumothorax. Upon arrival to a hospital with a qualified surgeon, operative intervention commences with definitive control of hemorrhage and proceeds to wound debridement and cleansing. Damage control principles and a staged operation strategy apply. At the first operation, the wound is packed with gauze, an occlusive dressing with closed suction is fashioned, and a pleural tube is placed under water seal and suction. Surgical reconstruction at serial operations depends on the extent of chest wall tissue loss. Small defects can be closed with secondary rib and skin approximation but larger defects will need a biologic tissue patch and potentially a muscle flap rotation with a skin graft.