Penetrating Chest Trauma

Introduction

This is a recommended algorithm of the Western Trauma Association for the acute management of penetrating chest injury. Because of the paucity of recent prospective randomized trials on the evaluation and management of penetrating chest injury, the current algorithms and recommendations are based on available published cohort, observational and retrospective studies, and the expert opinion of the Western Trauma Association members. The two algorithms should be reviewed in the following sequence: Figure 1 for the management and damagecontrol strategies in the unstable patient and Figure 2 for the management and definitive repair strategies in the stable patient. Figure 1 will discuss damage-control techniques; Figure 2 will focus on more definitive repairs. Because of the variety of possible mechanisms, presentation, injury sites, and operative approaches,we recognize that therewill be variability in decision making, local resources, institutional consensus, and patientspecific factors that may require deviation from the algorithms presented. The algorithms and accompanying text represent our consensus for a safe and reasonable approach in these complex cases and attempts to incorporate historically validated approaches with the advent of newer imaging, interventional, resuscitative, operative, and selective/expectant management approaches.

Historical Perspective

The precise incidence of penetrating chest injury, varies depending on the urban environment and the nature of the review. Overall, penetrating chest injuries account for 1% to 13% of trauma admissions, and acute exploration is required in 5% to 15% of cases; exploration is required in 15% to 30% of patients who are unstable or in whom active hemorrhage is suspected. Among patients managed by tube thoracostomy alone, complications including retained hemothorax, empyema, persistent air leak, and/or occult diaphragmatic injuries range from 25% to 30%.^1-6 In civilian practice, this low incidence has been generally attributed to ‘‘low-kinetic energy’’ mechanisms. In zones of conflict, among properly outfitted soldiers, body armor also results in a lower requirement for operation and incidence of complications.^1,5,6 The reported incidence of specific injuries also varies, depending on site and characterization of the patient population. Demetriades⁷ reported an overall incidence of great vessel injury of 5.3% following gunshot wounds and 2% after stab wounds to the chest.Rhee et al.⁸ described an overall incidence of penetrating cardiac injuries as 1 per 210 admissions. Sixty-five percent of the patients admitted to the University of Louisville with peristernal penetrating injuries sustained a cardiac injury.⁹In patients requiring urgent (nonYemergency department) thoracotomy, cardiac injuries are found in approximately 16% to 52% following stab wounds and 10% to 37% following gunshot wounds, and lung injuries are found in 30% to 59% of stab wounds and 65% to 86% of gunshot wounds.^10-12 It is clear that mortality is significantly impacted by preadmission hypotension, the ability to perform aggressive resuscitation and operative intervention, and appropriate imaging in stable patients.^13,14 Focusing on blood products rather than crystalloids and in some settings ‘‘hypotensive’’ resuscitation seems to have a survival benefit.⁶

Anatomy

The simplest anatomic classification is based on the likelihood of specific organ injury. Classically, penetrating injuries between the nipple lines anteriorly or the scapula posteriorly have the potential for cardiac or great vessel injury. The ‘‘danger zone’’ has been described as the region between the epigastrium to the sternal notch and laterally within 3 cm of the sternum.^9,15 Injuries below the level of the tip of the scapula posteriorly or the inframammary crease/nipple anteriorly have the potential to traverse the diaphragm, particularly left lower thoracic injuries.¹ As many as 20% of patients with penetrating injuries will have associated abdominal injuries.¹⁴ Unfortunately, particularly with gunshot wounds, any region of the chest may be affected, and these anatomic relationships should only be considered as generalizations.

Presentation

The presentation and management of a patient of penetrating trauma depends on three interrelated factors: stability, mechanism, and location of the wound. For the purposes of this discussion, stability requires that the airway be secure (with or without intubation), that the patient is both oxygenating and ventilating at an acceptable level, and that continued hemodynamic stability is documented. Patients with evidence of shock or impending collapse (systolic blood pressure < 90 mm Hg and/or persistent tachycardia > 120 beats per minute, not explained by pain or anxiety and/or persistent hypoxemia) should be managed by airway control combined with aggressive blood product resuscitation. In essence, a stable patient is one in whom there is time to consider different diagnostic and therapeutic options; the unstable patient is one in whom the approach is predicated on getting to the operating room as soon as possible with minimal delay for extraneous testing. This excludes the agonal patient. Clearly, there are times when the scenarios overlap (e.g., transmediastinal gunshot wound with suspicion of tamponade), and the pathways described are not mutually exclusive.

Techniques

There are a number of different approaches that can be used involving variations in incision, airway management, and positioning. The choice is dictated by stability, mechanism, and surgeon preference/experience. A brief review of these is presented in Table 1. In an unstable patient, the optimal positioning is supine in the crucifix position, with the patient draped to include the neck, supraclavicular area, entire thorax, abdomen, and proximal thighs. A single-lumen tube is the optimal initial airway tool in chest trauma. The tube can be advanced into the left main stem bronchus to isolate the right lung, or an endobronchial blocker can be placed to isolate the left. Advancing a single-lumen tube into the right often causes obstruction of the right upper lobe bronchus. This rapid isolation can be particularly useful in patients with massive unilateral air leak and/or hemorrhage. A double-lumen tube can be used in stable patients who require lung isolation or in centers that are facile with emergent placement. In patients who present in severe shock and/or require massive volume resuscitation, it may not be possible to ‘‘switch out’’ the double-lumen tube at the end of the case because of tenuous oxygenation/ventilation status. When possible, antibiotics with gram-positive coverage should be administered, although there has been conflicting data regarding the efficacy of ‘‘prophylactic’’ antibiotics.^16,17 Ideally, this should be administered before tube thoracostomy, but practically, it happens soon after. There are various recommendations regarding duration, but in general, duration of greater than 24 hours is not recommended.¹⁸

Table 1

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