Penetrating Thoracic Trauma

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How often do patients with penetrating chest wounds need an operation?

Most penetrating injuries seen in civilian practice are from knives and low-energy handguns. Consequently, although injuries to the chest wall and lung are common, the vast majority can be treated with tube thoracostomy alone. Formal thoracotomy or median sternotomy is required in <15% of isolated penetrating chest injuries.

2

What are the indications for emergency department thoracotomy after penetrating chest wounds?

Patients who arrive within 15 minutes of circulatory collapse (or arrest after arrival) can benefit from an emergency department thoracotomy (EDT). Unlike blunt injury, a treatable cause is more commonly found after penetrating injury (e.g., pericardial tamponade). EDT results in a survival of 25% in this setting. If the patient arrests in the emergency department with an isolated stab wound to the chest, survival exceeds 50%.

3

When should resuscitative endovascular balloon occlusion of the aorta (REBOA) be used in chest trauma?

Never. REBOA can only occlude the aorta. EDT can accomplish this task, while also addressing interventions to improve perfusion including (1) relief of cardiac tamponade, (2) internal cardiac massage, (3) direct hemorrhage control of vital structures in the chest, and (4) control of acute air embolism with hilar clamp and selective air aspiration of the heart.

4

What is the “6-hour rule” for chest injuries?

An upright chest radiograph with no evidence of pneumothorax after 6 hours makes a delayed pneumothorax or occult injury to an intrathoracic organ very unlikely. The 6-hour rule identifies patients who can be safely discharged.

5

How much blood in the pleural space can be reliably detected by chest radiograph?

250 mL or more.

6

If a stable patient with a penetrating chest wound has continued bleeding from a chest tube, when should a thoracotomy be done?

A good rule of thumb is that immediate return of over 1500 mL of blood or ongoing bleeding in excess of 250 mL/h for 3 consecutive hours should prompt operation. All unstable patients warrant an immediate operation.

7

What is a “clam shell” thoracotomy?

Bilateral anterolateral thoracotomies with extension across the sternum. This procedure allows rapid access to pleural spaces, pulmonary hila, and the mediastinum.

8

What is an open pneumothorax?

A defect in the chest wall that is open to the pleural space. In penetrating chest injuries, it most often is the result of a close-range shotgun blast.

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