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/11/12 Penetrating Chest Trauma

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As noted by Inci and colleagues in a 1998 study of 755 patients with thoracic injuries, penetrating chest trauma (PCT) comprises a broad spectrum of injuries and severity.[6] The injuries an

listed as follows: [6]

Hemothorax- 190

Hemopneumothorax - 184

Pneumothorax- 144

Diaphragmatic rupture- 121

Open hemopneumothorax - 95

Pulmonary contusion - 50

Open pneumothorax - 24

Rib fracture

Fewer than 2 fractures - 16

More than 2 fractures - 13

Subcutaneous emphysema- 14

Bilateral pneumothorax - 9

Open bilateral hemopneumothorax - 13Pneumomediastinum - 6

Thoracic wall lacerations - 4

Bilateral hemopneumothorax - 3

Open bilateral pneumothorax - 3

Sternal fracture - 3

Bilateral diaphragmatic rupture - 2

The clinical consequences depend on the mechanism of the injury, the location of the injury, associated injuries, and underlying illnesses. Organs at risk, in addition to the intrathoracic con

retroperitoneal space, and the neck.

Presentation

Initial management

As always in trauma, management begins with establishing ABCs. Indications for emergency endotracheal intubation include apnea, profound shock, and inadequate ventilation. Chest radi

clinical s igns of a tension pneumothorax, and immediate chest decompression is accomplished with either a large-bore needle at the second intercostal space or, more definitively, with a t

must be appropriately covered to permit adequate ventilation and to prevent the iatrogenic development of a tension pneumothorax.

Damage control operation appears to be the new mantra in the advanced care of penetrating thoracic trauma. Damage control requires modification of the ABCs of trauma, in that resuscitatisimultaneously in the immediate time after the unstable patient's presentation. Quickly and solely controlling hemorrhage and contamination to expedite reestablishing a survivable physiolo

Additionally, aggressive correction of the acidosis, coagulopathy, and hypothermia occurs in the ICU.[7]

Volume replenishment is the cornerstone of treating hemorrhagic shock but can also cause significant compromise of other organ systems. Continuous infusions of even blood or normoton

edema, frank acute respiratory distress syndrome (ARDS) or a tremendous increase in lung water ("soggy lungs"), and cardiac compromise. Newer approaches, described in both military a

of hypertonic solutions in an effort to minimize these complications.

Alternatively, several groups have championed the concept of "scoop and run" when treating injuries in the field.[8] With the development of modern (civilian) emergency medical services, th

Rapid assessment to identify life-threatening injuries along with key interventions, namely management of the airway and control of hemorrhage, and avoidance of massive volume increases

appropriate facility is the current standard of care. This is in contrast t o the concept of "s tay and play," during which trained personnel make major triage and treatment decisions in the field

If the patient has persistently low systemic pressure, a source of ongoing blood loss or some other mechanisms to explain the hypotension (eg, cardiac tamponade, tension pneumothorax

some data suggest that continued volume resuscitation before surgical control of bleeding may worsen both the bleeding process and final outcome.

Fluid collections in either hemothorax should be treated with percutaneous thoracostomy tubes. See the image below and the article Hemothorax.

Upright posteroanter ior chest rediograph of patient w ith right-sided hemothorax.

Indications

Thoracotomy

Thoracotomy may be indicated for acute or chronic conditions. Acute indications inc lude the following:

Cardiac tamponade

Acute hemodynamic deterioration/cardiac arrest in the trauma center

Penetrating truncal trauma (resusc itative thoracotomy)

Vascular injury at the thoracic outletLoss of chest wall substance (traumatic thoracotomy)

Massive air leak

Endoscopic or radiographic evidence of significant tracheal or bronchial injury

Endoscopic or radiographic evidence of esophageal injury

Radiographic evidence of great vessel injury

Mediastinal passage of a penetrating object

Significant missile embolism to the heart or pulmonary artery

Transcardiac placement of an inferior vena caval shunt for hepatic vascular wounds

Patients who arrive in cardiac arrest or who arrest shortly after arrival may be candidates for emergency resuscitative thoracotomy. A right chest tube must be placed simultaneously. The u

has been reported to result in survival rates of 9-57% for patients with penetrating cardiac injuries and survival rates of 0-66% for patients with noncardiac thoracic injuries, but overall surviva

The proportion of patients with PCT who can be treated without operation has been reported to vary from 29-94%. [9]

Chronic indications for thoracotomy include the following:

Nonevacuated clotted hemothorax

Chronic traumatic diaphragmatic hernia

Traumatic cardiac septal or valvular lesion
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Chronic traumatic thoracic aortic pseudoaneurysm

Nonclosing thoracic duct fistula

Chronic (or neglected) posttraumatic empyema

Infected intrapulmonary hematoma (eg, traumatic lung abscess)

Missed t racheal or bronchial injury

Tracheoesophageal fistula

Innominate artery/tracheal fistula

Traumatic arterial/venous fistula

Another indication for acute thoracostomy is often based on chest tube output. Immediate evacuation of 1500 mL of blood is a sufficient indication; however, the trend in output is more imp

of more than 250 mL/h, thoracotomy is probably indicated.

Thoracoscopy

The role of video-assisted thoracoscopic surgery in the management of penetrating chest trauma is expanding rapidly. Initially promoted for the management of retained hemothoraces and t

and thoracic surgeons are now using thoracoscopy for treatment of chest wall bleeding, diagnosis of transmediastinal injuries, pericardial window, and persistent pneumothoraces.[10] The mthoracoscopic surgery is hemodynamic instability.

Relevant Anatomy

The anatomy of the thoracic cage is well-known and encompasses the area beneath the clavicles and superior to the diaphragm, bound laterally by the rib cage, anteriorly by the sternum a

bodies. Entry into the thorax may be made by sternotomy; thoracotomy (incising between selected ribs, most commonly the fourth and fifth) on either the right or left side; or a clamshell in

incisions t raversing the sternum to join the two. Additional modifications of each of these approaches are not discussed in detail here.

Particular care must be exercised laterally near the sternum, where the internal thoracic (mammary) artery lies 2-4 cm on either side. Similarly, remember that immediately inferior to each

nerve, from which voluminous bleeding can occur. Patients have required reexploration for injuries to these various vessels and have exsanguinated as a result of missed injuries to these ves

Anteriorly, injuries to the heart should be presumed to have occurred if entry points are present anywhere between the 2 midclavicular lines. On occasion, significant injury to the heart has

margins, as in gunshot or missile injuries.

Exceptionally long penetrating instruments and weapons (eg, arrows, swords, lances) can also directly penetrate the heart from a distant entry point. Similarly, injuries to any of the intratho

penetrating devices; consider the possibility of injuries to the diaphragm, great vessels, or posterior mediastinal structures in these cases.

The right atrium and right ventricle are the anterior portions of the heart; these areas are the primary sites involved in penetrating injuries of the heart.

Contraindications

Contraindications to various explorations and techniques are discussed in their respective sections.

Contributor Information and DisclosuresAuthor

Rohit Shahani, MD, MS, MCh Consulting Staff, Department of Cardiothoracic Surgery, Health Quest Medical Practice and Vassar Brothers Medical Center

Rohit Shahani, MD, MS, MCh is a member of the following medical soc ieties:American College of Cardiology,American College of Surgeons,American Medical Association, and Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jan David Galla, MD, PhD Assis tant Professor, Department of Cardiothoracic Surgery, Mount Sinai Medical Center

Jan David Galla, MD, PhD is a member of the following medical societies: Aerospace Medical Association,American Association for the Advancement of Science,American College of Ca

American Heart Association,American Medical Association, Civil Aviation Medical Association, International Society for Heart and Lung Transplantation, and Society of Thoracic Surgeons


Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assis tant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Daniel S Schwartz, MD, FACS Assis tant Clinical Professor of Cardiothoracic Surgery, Mount Sinai School of Medicine; Chief of Thoracic Surgery, Huntington Hospital

Daniel S Schwartz, MD, FACS is a member of the following medical soc ieties:American College of Chest Physic ians,American College of Surgeons, Society of Thoracic Surgeons, and W


Paolo Zamboni, MD Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies:American Venous Forumand New York Academy of Sciences


Chief Editor

Jeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California, Irvine,

Jeffrey C Milliken, MD is a member of the following medical societies:Alpha Omega Alpha,American Association for Thoracic Surgery,American College of Cardiology,American College

Surgeons,American Heart Association,American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Ka

Southwest Oncology Group, and Western Surgical Association


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