Surgical management of chest injuries in patients with multiple and/or severe trauma- a systematic review and clinical practice guideline update

Purpose: Our aim was to update evidence-based and consensus-based recommendations for the surgical and interventional management of blunt or penetrating injuries to the chest in patients with multiple and/or severe injuries on the basis of current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

Methods: MEDLINE and Embase were systematically searched to May and June 2021 respectively for the update and new questions. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies and comparative registry studies were included if they compared interventions for the surgical management of injuries to the chest in patients with multiple and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality, length of stay, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

Results: One study was identified. This study compared wedge resection, lobectomy and pneumonectomy in the management of patients with severe chest trauma that required some form of lung resection. Based on the updated evidence and expert consensus, one recommendation was modified and two additional good practice points were developed. All achieved strong consensus. The recommendation on the amount of blood loss that is used as an indication for surgical intervention in patients with chest injuries was modified to reflect new findings in trauma care and patient stabilisation. The new good clinical practice points (GPPs) on the use of video-assisted thoracoscopic surgery (VATS) in patients with initial circulatory stability are also in line with current practice in patient care.

Conclusion: As has been shown in recent decades, the treatment of chest trauma has become less and less invasive for the patient as diagnostic and technical possibilities have expanded. Examples include interventional stenting of aortic injuries, video-assisted thoracoscopy and parenchyma-sparing treatment of lung injuries. These less invasive treatment concepts reduce morbidity and mortality in the primary surgical phase following a chest trauma.