Penetrating chest trauma
Patients with penetrating chest injuries can present from asymptomatic with just small wounds to pulseless with life-threatening injuries. Cardiac injuries with a pericardial tamponade, exsanguinating hemorrhage or thoraco-abdominal injuries are typical life-threatening conditions. Most of these patients die pre-hospital. However, some of these deaths are preventable. The goal is to reduce morbidity and mortality. The key to a successful management is an immediate standardized assessment and clear treatment algorithms. Time is of paramount essence. Chest X-ray, focused sonography, and computed tomography are standard diagnostic tools. Cardiac tamponade, large hemo-, or pneumothoraces must be ruled out. Up to 80% of all patients with penetrating chest injuries can be managed non-operative, however a tube thoracostomy (18%) or sternotomy/thoracotomy (3%) are necessary in selected cases. A stable patient with a small pneumothorax/ hemothorax and no relevant additional findings can be assessed and treated non-operative. A large pneumo- or hemothorax must be drained with a chest tube. Patients with a low systolic blood pressure (<90 mmHg) despite 1 to 2 liters fluid usually need surgical evaluation and treatment. Typically, a hemodynamic unstable patient with a wound that involves the central “cardiac zone” requires a sternotomy. With wounds emerging more laterally, the trauma surgeon will perform an anterolateral thoracotomy. A patient in arrest needs to be evaluated for an emergency department thoracotomy (EDT).