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Penetrating Chest Trauma Author: Rohit Shahani, MD, MS, MCh; Chief Editor: Jeffrey C Milliken, MD more...

Updated: Dec 13, 2013

BackgroundThoracic injuries account for 20-25% of deaths due to trauma and contribute to 25-50% of the remaining deaths.Approximately 16,000 deaths per year in the United States alone are attributable to chest trauma.[1] Therefore,thoracic injuries are a contributing factor in up to 75% of all trauma-related deaths. The increased prevalence ofpenetrating chest injury (associated with the "drug war" in the United States) and improved prehospital andperioperative care have resulted in an increasing number of critically injured but potentially salvageable patientspresenting to trauma centers. Recently, the classic "trimodal" temporal distribution of trauma deaths has beenquestioned, even though it has been widely taught in the design of trauma systems.[2]

For more information, visit Medscape’s Trauma Resource Center.

History of the ProcedureOne of the earliest writings of thoracic injury was noted in the Edwin Smith Surgical Papyrus, written in 3000 BCE.Galen reported attempts to treat gladiators with chest injuries with open packing. In 1635, Labeza de Vaca firstdescribed operative removal of an arrowhead from the chest wall of a Native American. In 1814, Larrey (Napoleon'smilitary surgeon) reported various injuries to the subclavian vessels. Rehn performed the first successful humancardiorrhaphy in Germany in 1896. Hill performed the first cardiorrhaphy in the United States in 1902 and initiatedthe modern treatment of the wounded heart.

Penetrating trauma to the thoracic vessels was not extensively reported until the 20th century because of theabsence of survivors. In 1934, Alfred Blalock was the first American surgeon to successfully repair an aortic injury.Guidelines for treating thoracic trauma were not established until World War II.

Additional experience in the treatment of penetrating trauma to the thorax was gained in later military experiences,including the conflicts in Korea and Vietnam, and, to a lesser degree, in US actions in Grenada, Panama, theBalkans, Somalia, and the Persian Gulf. Other large international experiences have derived from the FalklandIsland conflict, various Middle Eastern engagements, and multiple conflicts in the African states.

Significant experience has also been gained from large US metropolitan areas as a result of assaults involvingfirearms and handheld weapons and impalements resulting from falls or leaps from elevations. Researchers fromHouston, Tex; Los Angeles, Calif; Atlanta, Ga; Detroit, Mich; and Denver, Colo, have been particularly productive intheir treatments of thoracic penetrating trauma. The number of trauma patients in these large metropolitan areasrose so rapidly in the 1970s and 1980s that the military sent its medical personnel to train caregivers at thesecenters.[3, 4]

With the advancement of wartime medical care and access to The Joint Theater Trauma Registry (JTTR), thoracicinjury patterns have changed dramatically. As a result of advances in body armor and the establishment of excellentmedical care at the battlefield, mortal thoracic wounds seem to have decreased, allowing patients who would havepreviously died to live long enough to receive treatment.[5]

ProblemAny entry wound below the nipples (front) and the inferior scapular angles (dorsum) should be considered an entrypoint for a course that may have carried the missile into the abdominal cavity. Missiles from gunshot wounds(GSWs) can penetrate all body regions regardless of the point of entry. Any patient with a gunshot entry wound forwhich a corresponding exit wound cannot be identified should be considered to have a retained projectile, whichcould embolize to the central or distal vasculature. A patient with combined intrathoracic and intra-abdominalwounds has a markedly greater chance of dying.

For information on treating penetrating abdominal wounds, see the article Abdominal Stab Wound Exploration.

Etiology

Mechanism of injury

The mechanism of injury may be categorized as low, medium, or high velocity. Low-velocity injuries includeimpalement (eg, knife wounds), which disrupts only the structures penetrated. Medium-velocity injuries include bulletwounds from most types of handguns and air-powered pellet guns and are characterized by much less primarytissue destruction than wounds caused by high-velocity forces. High-velocity injuries include bullet wounds caused byrifles and wounds resulting from military weapons.

Shotgun injuries, despite being caused by medium-velocity projectiles, are sometimes included within managementdiscussions for high-velocity projectile injuries. This inclusion is reasonable because of the kinetic energy transmittedto the surrounding tissue and subsequent cavitation, as described by the following equation in which KE is kineticenergy, M is mass, and V is velocity:

KE = ½ MV2

The 3 major subcategories of ballistics are internal, external, and terminal. Internal ballistics describe thecharacteristics of the projectile within the gun barrel. External ballistics examines the factors that affect the projectileduring its path to the target, including wind resistance and gravity. Terminal ballistics evaluates the projectile as itstrikes its target.

The amount of tissue damage is directly related to the amount of energy exchange between the penetrating objectand the body part. The density of the tissue involved and the frontal area of the penetrating object are the importantfactors determining the rate of energy loss.

The energy exchange produces a permanent cavity inside the tissue. Part of this cavity is a result of the crushing ofthe tissue as the projectile passes through. The expansion of the tissue particles away from the pathway of the

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bullet creates a temporary cavity. Because this cavity is temporary, one must realize that it was once present inorder to understand the full extent of injury.

Penetrations from blast fragments or from fragmentation weapons can be particularly destructive because of theirextremely high velocities. Weapons designed specifically for antipersonnel effects (eg, mines, grenades) cangenerate fragments with initial velocities of 4500 ft/s, a far greater speed than even most rifle bullets. Thetremendous energy imparted to tissue from fragments with such velocity causes extensive disruptive and thermaltissue damage. Weaponry of the 21st century consists mostly of improvised explosive devices (IEDs). These devicesare homemade bombs and they create a deadly triad of penetrating, blast, and burn wounds. Of the thoracic traumathat is seen in the current Global War on Terror, 40% is penetrating chest trauma.

PathophysiologyAs 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 and number of patients (some with >1injury) is listed as follows:[6]

Hemothorax - 190Hemopneumothorax - 184Pneumothorax - 144Diaphragmatic rupture - 121Open hemopneumothorax - 95Pulmonary contusion - 50Open pneumothorax - 24Rib fracture

Fewer than 2 fractures - 16More than 2 fractures - 13

Subcutaneous emphysema - 14Bilateral pneumothorax - 9Open bilateral hemopneumothorax - 13Pneumomediastinum - 6Thoracic wall lacerations - 4Bilateral hemopneumothorax - 3Open bilateral pneumothorax - 3Sternal fracture - 3Bilateral diaphragmatic rupture - 2

The clinical consequences depend on the mechanism of the injury, the location of the injury, associated injuries, andunderlying illnesses. Organs at risk, in addition to the intrathoracic contents, include the intraperitoneal viscera, theretroperitoneal space, and the neck.

Presentation

Initial management

As always in trauma, management begins with establishing ABCs. Indications for emergency endotrachealintubation include apnea, profound shock, and inadequate ventilation. Chest radiography is not indicated in patientswith clinical signs of a tension pneumothorax, and immediate chest decompression is accomplished with either alarge-bore needle at the second intercostal space or, more definitively, with a tube thoracostomy. A sucking chestwound must be appropriately covered to permit adequate ventilation and to prevent the iatrogenic development of atension 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 resuscitative and diagnostic techniques areused simultaneously in the immediate time after the unstable patient's presentation. Quickly and solely controllinghemorrhage and contamination to expedite reestablishing a survivable physiology is the essence of thoracic damagecontrol. 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 compromiseof other organ systems. Continuous infusions of even blood or normotonic fluids cause significant peripheral tissueedema, frank acute respiratory distress syndrome (ARDS) or a tremendous increase in lung water ("soggy lungs"),and cardiac compromise. Newer approaches, described in both military and civilian literature, are emphasizing theuse 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, the field care of injured patients hasimproved. Rapid assessment to identify life-threatening injuries along with key interventions, namely managementof the airway and control of hemorrhage, and avoidance of massive volume increases before rapid transport to theclosest appropriate facility is the current standard of care. This is in contrast to the concept of "stay 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 toexplain the hypotension (eg, cardiac tamponade, tension pneumothorax) should be preferentially sought.Additionally, some data suggest that continued volume resuscitation before surgical control of bleeding may worsenboth the bleeding process and final outcome.

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

Upright posteroanterior chest rediograph of patient with right-sided hemothorax.

Indications

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Thoracotomy

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

Cardiac tamponadeAcute hemodynamic deterioration/cardiac arrest in the trauma centerPenetrating truncal trauma (resuscitative thoracotomy)Vascular injury at the thoracic outletLoss of chest wall substance (traumatic thoracotomy)Massive air leakEndoscopic or radiographic evidence of significant tracheal or bronchial injuryEndoscopic or radiographic evidence of esophageal injuryRadiographic evidence of great vessel injuryMediastinal passage of a penetrating objectSignificant missile embolism to the heart or pulmonary arteryTranscardiac 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 resuscitativethoracotomy. A right chest tube must be placed simultaneously. The use of emergency resuscitative thoracotomyhas been reported to result in survival rates of 9-57% for patients with penetrating cardiac injuries and survival ratesof 0-66% for patients with noncardiac thoracic injuries, but overall survival rates are approximately 8%.[9]

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 hemothoraxChronic traumatic diaphragmatic herniaTraumatic cardiac septal or valvular lesionChronic traumatic thoracic aortic pseudoaneurysmNonclosing thoracic duct fistulaChronic (or neglected) posttraumatic empyemaInfected intrapulmonary hematoma (eg, traumatic lung abscess)Missed tracheal or bronchial injuryTracheoesophageal fistulaInnominate artery/tracheal fistulaTraumatic arterial/venous fistula

Another indication for acute thoracostomy is often based on chest tube output. Immediate evacuation of 1500 mL ofblood is a sufficient indication; however, the trend in output is more important. If bleeding persists with a steadytrend 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 expandingrapidly. Initially promoted for the management of retained hemothoraces and the diagnosis of diaphragmatic injury,trauma and thoracic surgeons are now using thoracoscopy for treatment of chest wall bleeding, diagnosis oftransmediastinal injuries, pericardial window, and persistent pneumothoraces.[10] The major contraindication tovideo-assisted thoracoscopic surgery is hemodynamic instability.

Relevant AnatomyThe anatomy of the thoracic cage is well-known and encompasses the area beneath the clavicles and superior tothe diaphragm, bound laterally by the rib cage, anteriorly by the sternum and ribs, and posteriorly by the rib andvertebral 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 incision, consisting of left andright thoracotomy incisions traversing the sternum to join the two. Additional modifications of each of theseapproaches are not discussed in detail here.

Particular care must be exercised laterally near the sternum, where the internal thoracic (mammary) artery lies 2-4cm on either side. Similarly, remember that immediately inferior to each rib body are the intercostal artery, vein, andnerve, from which voluminous bleeding can occur. Patients have required reexploration for injuries to these variousvessels and have exsanguinated as a result of missed injuries to these vessels.

Anteriorly, injuries to the heart should be presumed to have occurred if entry points are present anywhere betweenthe 2 midclavicular lines. On occasion, significant injury to the heart has occurred from entry points lateral to thesemargins, as in gunshot or missile injuries.

Exceptionally long penetrating instruments and weapons (eg, arrows, swords, lances) can also directly penetrate theheart from a distant entry point. Similarly, injuries to any of the intrathoracic structures can be effected with longpenetrating devices; consider the possibility of injuries to the diaphragm, great vessels, or posterior mediastinalstructures in these cases.

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

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

Contributor Information and DisclosuresAuthorRohit Shahani, MD, MS, MCh Consulting Staff, Department of Cardiothoracic Surgery, Health Quest MedicalPractice and Vassar Brothers Medical Center

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

Disclosure: Nothing to disclose.

Coauthor(s)Jan David Galla, MD, PhD Assistant Professor, Department of Cardiothoracic Surgery, Mount Sinai MedicalCenter

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

Disclosure: Nothing to disclose.

Specialty Editor BoardFrancisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical CenterCollege of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Daniel S Schwartz, MD, FACS Assistant Clinical Professor of Cardiothoracic Surgery, Mount Sinai School ofMedicine; Chief of Thoracic Surgery, Huntington Hospital

Daniel S Schwartz, MD, FACS is a member of the following medical societies: American College of ChestPhysicians, American College of Surgeons, Society of Thoracic Surgeons, and Western Thoracic SurgicalAssociation

Disclosure: Nothing to disclose.

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 Forum and New YorkAcademy of Sciences

Disclosure: Nothing to disclose.

Chief EditorJeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine MedicalCenter; Clinical Professor, Department of Surgery, University of California, Irvine, School of Medicine

Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, AmericanAssociation for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians,American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs,California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa,Society of Thoracic Surgeons, Southwest Oncology Group, and Western Surgical Association

Disclosure: Nothing to disclose.

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