Unusually low mortality of penetrating wounds of the chest. Twelve years' experience

Within a 12-year period ending in March 1984, 1109 patients with penetrating thoracic injuries were treated at King-Drew Medical Center located in south central Los Angeles. The average age of the patients was 28.1 years. There were 607 stab wounds and 502 gunshot wounds. Antibiotic prophylaxis was prescribed only for the 428 patients who had laparotomy, thoracotomy, and pulmonary contusion with hemoptysis. Of the 1109 patients, 105 had cardiac injuries. All patients with cardiac trauma underwent thoracotomy, and the mortality rate was 18.1%. Specifically, the mortality rate of gunshot wound of the heart 24.5% and that of stab wound of the heart, 11.5%. In contrast, of the 1004 patients without cardiac injuries, only 115 required thoracotomy and the mortality rate in this group was 0.8% (8/1004). The mortality rate was 69.6% in patients who had a thoracotomy in the emergency room but only 2.8% in patients who had a thoracotomy in the operating room within the first 24 hours after admission. In the 242 patients who had associated abdominal injuries, the mortality rate was 2.1% (5/242), as compared with 2.5% (22/867) for those who had isolated chest injuries. In the entire group, the incidence of complications was 5.1%, of which 1.8% were infectious complications. The presence of associated abdominal injuries did not influence the outcome. The mortality rate in noncardiac thoracic injuries is very low compared with that of cardiac injury. Because of the complexity of the injury, gunshot wound of the heart has the highest mortality rate.     

Penetrating injuries of the subclavian artery

BACKGROUND: Penetrating injuries of the subclavian artery occurs infrequently but represent a surgical challenge. We reviewed our experience with penetrating injury of the subclavian artery and identify factors that influenced morbidity and mortality. METHODS: A retrospective review was performed on 54 consecutive patients who sustained penetrating injury to the subclavian artery during a 10-year period. RESULTS: The causes of injuries were gunshot wounds in 46 patients (85%), stab wounds in 5 patients (9%), and shotgun wounds in 3 patients (6%). The overall mortality was 39%. Operative management of the subclavian artery injury included primary repair in 38 patients, interposition grafting in 13 patients, and ligation in 3 patients. The most common associated injury was subclavian vein (44%) followed by brachial plexus (31%). Predictors of survivability include mechanism of penetrating injuries, hemodynamic status of patients on arrival, and three or more associated injuries involving other structures. Associated brachial plexus injury accounts for the majority of long-term morbidity in survivors. CONCLUSIONS: Penetrating injuries of the subclavian artery are associated with high morbidity and mortality. Multiple concomitant injuries, unstable vital signs upon presentation, and gun shot injuries greatly increase mortality.     

Prediction of injury caused by penetrating wounds to the abdomen, flank, and back

Controversy about the appropriate evaluation of penetrating abdominal, flank, and back injuries prompted this retrospective review of 311 patients at an urban level 1 trauma center over 5 years. Seventy-five (24%) patients sustained gunshot wounds to the abdomen. All patients with gunshot wounds underwent exploratory laparotomy; results of 67 laparotomies (89%) were positive. Of 236 patients sustaining stab wounds (140 abdominal wounds, 51 flank wounds, 26 back wounds, and 19 wounds to multiple sites), 147 were treated according to a selective protocol, based on results of physical examination, wound exploration, peritoneal lavage, and ancillary diagnostic studies. No injuries were found at celiotomy in three (2%) of these 147 patients. One false-negative result of evaluation of a flank wound occurred. Significant injuries were found in 13 patients (68%) with stab wounds to multiple sites, 61 patients (44%) with abdominal stab wounds, 15 patients (29%) with flank stab wounds, and four patients (15%) with back stab wounds. Mandatory exploration of gunshot wounds is justified. Physical findings of intra-abdominal injury or positive results of peritoneal lavage identify stab wound victims likely to benefit from surgical exploration. A policy of mandatory observation or routine celiotomy for treatment of stab wounds is not justified.     

Penetrating cardiac injuries

Our objective was to determine the influence of several clinical factors on the survival of patients with penetrating wounds to the heart. A retrospective review of 80 consecutive penetrating cardiac injuries treated in a Level II urban trauma center from 1980 through 1994 were examined. Thirty-six patients (45%) had gunshot wounds (including 1 shotgun wound), and 44 (55%) had stab wounds. Intervention consisted of emergency room (ER) or operating room thoracotomy. We measured the effect of several clinical factors on morbidity and patient survival. Survival rate was 17 of 36 (47%) in gunshot injuries and 35 of 44 (80%) in stab injuries, with an overall survival rate of 52 of 80 patients (65%). The average age was 24 years (range, 9-53), and there were 3 female patients. Twelve patients (15%) had multiple cardiac injuries, and 63 (79%) had other associated injuries. Fourteen patients (17%) presented with no blood pressure, and 55 (69%) were hypotensive on admission. ER thoracotomy was performed on 7 of 52 survivors (13%) and 24 of 28 nonsurvivors (86%). Survival after ER thoracotomy was 7 of 31 patients (22%). A selective approach is recommended, because ER thoracotomy has a limited role in penetrating cardiac injury. A high index of suspicion, prompt resuscitation, and immediate definitive surgical management resulted in a high survival rate for these frequently lethal injuries.     

Penetrating Cardiac Injuries: Recent Experience in South Africa

Background Penetrating cardiac injury is a dramatic and lethal form of trauma. The majority of patients will die before reaching medical care, but for those who arrive at hospital alive, the diagnostic acumen and rapid surgical intervention of physicians and surgeons can lead to successful outcomes. Materials and Methods A structured diagnostic and management approach is used in our trauma unit to deal with penetrating cardiac injury. A retrospective study of 117 patients with penetrating trauma to the heart was conducted over 32 months; the purpose of this study was to describe our protocol and review overall outcome with this type of injury. Demographic details, mechanism of injury, and mode of presentation were recorded. Mortality and morbidity data were collated and echocardiographic follow-up was performed. Results There were 109 male patients, mean age 29 years (range: 15–54 years) and 8 female patients, mean age 35 years (range: 23–56 years). Most patients (96/117) had sustained stab wounds, and the associated mortality was 15.6%. Twenty-one patients had sustained gunshot wounds (GSW), with a mortality of 81%. Gunshot wounds were significantly more likely to result in death (P ≤ 0.0001). Five patients sustained multiple cardiac wounds, and three of them died. The risk of death was not different between patients sustaining single or multiple cardiac wounds (P = 0.11). Eleven patients had thoracoabdominal injury, and 3/11 (27%) died; all of those that died had sustained GSW. The risk of death was not different between patients sustaining thoracoabdominal wounds and those with isolated thoracic injury (P = 1.0). Among the 51 patients with stab wounds who presented with cardiac tamponade, the mortality was only 8%. Compared to the other patients with stab wounds, cardiac tamponade conferred a significant survival advantage (P = 0.02). Conclusions A high index of suspicion for penetrating cardiac injury and an understanding of the modes of presentation can lead to rapid diagnosis even by inexperienced junior staff. Such a structured approach to patients with penetrating trauma to the chest leads to early definitive management and acceptable results.     

Abdominal wound injuries: diagnosis and treatment. Report of 79 cases

INTRODUCTION. - Traditionally, penetrating abdominal wounds justify routine laparotomy. However, this policy can be adapted to mechanism of injury (stab or firearm) and accuracy of imaging procedures if they eliminate visceral injury thus allowing close follow up. PATIENTS AND METHODS: Retrospective study of 79 patients (May 1995-May 2002) with a penetrating abdominal wound: (47 (59%) stab wounds and 32 (41 %) firearm wounds). Correlation between imaging and surgical findings, treatment, post-operative course were studied. RESULTS: Sixty-eight patients were operated on from the outset, and 11 underwent close follow-up. Of the 11 patients who had follow-up, (9 after stab wound and 2 after firearm wound), two had to be operated (1 in each group). Correlation between imaging and surgical findings was good in 34 (72%) patients after stab wound and in 21 (80%) after firearm wound; the mean number of visceral injuries was 1 and 3 respectively. Six patients (8%) died (mortality: 2% and 16% respectively), 12 (15%) had postoperative complications. CONCLUSION: Penetrating abdominal stab wounds can be treated by close follow-up if imaging excludes visceral injury. Firearm wounds still justify routine laparotomy due to both multiplicity of visceral injuries and bad prognosis.     

Emergency Department thoracotomy in children--a critical analysis

Recent clinical reviews have helped to clarify the role of Emergency Department (E.D.) thoracotomy in critically injured adults. However, guidelines in the pediatric population remain ill defined. The purpose of this report is to examine the yield of E.D. thoracotomy in patients less than or equal to 18 years of age to allow for a more cost-effective application of this heroic measure. From an 11-year experience of 689 consecutive E.D. thoracotomies, 83 patients (12%) were less than or equal to 18 years old. Mechanism of injury was blunt trauma in 57%, gunshot wound in 30%, and stab wound in 13%. Mean age was 15 years and 71% were male. Survival by injury mechanism was 9% (1/11) for stab wound, 4% (1/25) for gunshot wound, and 2% (1/47) for blunt trauma. Sixty-nine patients presented to the E.D. without vital signs and only one, a 16-year-old with stab wounds to the chest and abdomen, survived. In contrast, two (14%) among 14 patients presenting with vital signs were salvaged. As in adults, outcome was largely determined by injury mechanism and physiologic status on E.D. presentation. Blunt trauma, the predominant mechanism of lethal injuries in children, had a dismal outcome, with only 2% salvage and no survivors when vital signs were absent. This study demonstrates a similar outcome for E.D. thoracotomy in children compared to adults, and supports a selective policy of liberal use in penetrating injury irrespective of physiologic status but limited in those arriving lifeless following blunt trauma.     

Cardiac injuries--a clinical and autopsy profile

One hundred two patients sustaining cardiac injuries over a 4-year period were analysed to highlight the natural history of the cardiac injuries. There were 45 blunt, 36 stab, and 21 gunshot injuries. The injury involved the ventricle in 85, atrium in seven, pulmonary artery in five cases, and resulted in crush injury to the heart in the remaining five cases. Thirty-three patients (32.3%) died on the scene and 58 (56.9%) died during the transportation. Only 11 patients (10.8%) reached the hospital alive, and ten of these patients survived following thoracotomy and repair of the cardiac injury. The factors influencing the natural course of cardiac injury were analysed: 2.2% of patients with blunt cardiac trauma reached the hospital alive compared to 19.4% with stab and 14.3% with gunshot injuries; ventricular injuries had a greater prehospital mortality compared to atrial or pulmonary artery injuries; 11.3% of patients sustaining injury to right ventricle reached the hospital alive compared to 3% of those with left ventricular injuries. These data emphasize the need for rapid transport, immediate recognition, and aggressive surgical management, to make a favourable impact on the natural history of cardiac injuries.     

Gall bladder injuries as part of the spectrum of civilian abdominal trauma in South Africa

BACKGROUND: Trauma to the gall bladder is rare, but when missed or improperly managed it may be associated with significant morbidity. The aim of the present study was to review the management and outcomes of gall bladder trauma in a trauma centre. METHODS: Forty-three patients with gall bladder injury due to abdominal trauma were reviewed over a 3-year period. Surgical management, associated injuries, morbidity and mortality rates were determined. RESULTS: Among 1242 patients undergoing laparotomy for acute trauma, 43 patients (3.46%) with gall bladder injuries were identified. Forty patients sustained penetrating injuries (37 with gunshot wounds and three with stab wounds), and three patients suffered from blunt trauma. All patients with gall bladder injury underwent abdominal exploration because of associated intra-abdominal injuries. Thirty-six patients were treated with cholecystectomy, four patients underwent primary suture repair of the gall bladder perforation, while three patients with gall bladder injury were treated without any surgical intervention at laparotomy. No complications could be attributed to the gall bladder trauma or surgery. CONCLUSION: Cholecystectomy is the preferred procedure of choice for gall bladder injuries and is associated with no morbidity.     

Pericardial tamponade: a critical determinant for survival following penetrating cardiac wounds

Previous studies have emphasized injury mechanism, wound site, and presenting vital signs as critical determinants for survival following penetrating cardiac injury. Our experience suggests pericardial tamponade is another crucial factor and is the basis for this study. Prognostic features were reviewed in 100 consecutive, unselected patients with acute cardiac injuries. Mechanism was stab wound in 57, and gunshot injury in 43. Location included right ventricle in 55, left ventricle in 49, right atrium in 16, and left atrium in seven. Overall salvage was 31%,; 27 (47%) of 57 stab wounds, four (9%) of 43 gunshot wounds, 22 (49%) of 45 right, and nine (23%) of 39 left heart wounds. The presence or absence of pericardial tamponade was documented in 77 patients. Patients with tamponade had a survival of 73% (24/33) compared to 11% (5/44) in those without its protective effect. The presence of tamponade improved survival (p less than 0.05) following stab injuries (77% vs. 29%), gunshot wounds (57% vs. none), right heart wounds (79% vs. 28%), left heart injuries (71% vs. 12%), and overall in patients arriving with vital signs (96% vs. 50%). Multivariant discriminant analysis by logistic regression demonstrated cardiac tamponade was a critical independent factor in patient survival, and suggested that it may be more influential than presenting vital signs in determining outcome.     

Penetrating pancreatic injuries, 1978-1983

During the review period, 41 trauma service patients were found to have penetrating pancreatic injuries. The cause of injury was a gunshot wound in 25 patients, stab wound in 13 patients, and shotgun wound in 3 patients. All patients had at least one other intra-abdominal organ injured, and 19 (46%) were admitted in shock. The pancreatic injury was managed by resection in 21 patients, drainage in 19 patients, and diverticulization in 1 patient. Complications related to the pancreatic injury developed in 11 (52%) treated by resection. By comparison pancreatic complications were seen in only three (16%) patients managed with drainage (P = 0.04). The mortality rate for resection was 19 per cent compared to 11 per cent for drainage (N.S.). Differences in morbidity observed could not be clearly accounted for by severity of injury. Based on these data, the authors recommend drainage for the majority of penetrating pancreatic injuries and suggest resection be reserved for injuries requiring debridement for hemostasis.     

Eviszeration von Darm nach Stichverletzung des Abdomens

Study aim

The aim of the study was an estimation of the incidence and clinical aspects of emergency room (ER) parameters of penetrating abdominal injury patients with bowel evisceration.

Study design and methods

The study involved a retrospective cohort analysis of ER data from the Chris Hani Baragwanath Academic Hospitals, Soweto, Johannesburg, South Africa between September 2000 to May 2005.

Results

Out of 9,010 ER patients, 4,390 suffered penetrating injuries with 8 out of 71 eviscerations due to a single gunshot wound, 60 out of 71 eviscerations due to single stab wounds and 3 further patients suffered multiple injuries. The ER mortality was 1 out of 71(1.6 %) with an average ER mortality of 4.2 %. The only death seen was a single abdominal gunshot wound with vascular injury. The causative mortality due to abdominal stab wounds with evisceration of the bowels was therefore zero. The heart rate in patients with abdominal stab wounds with and without bowel evisceration showed no significant difference, thus mesentery tearing or vagal overstimulation could not be seen, neither with bradycardia nor hypotension.

Conclusion

Evisceration itself is not a cause for increased mortality or cardiovascular instability seen in the ER. There is ample time for diagnostic procedures before laparotomy is performed.     

Demography of penetrating cardiac trauma.

All cases of penetrating cardiac trauma in 1985 and 1986 in Jefferson County, Alabama, where patients dying of penetrating trauma received autopsies, were retrospectively reviewed. All hospitals in the county plus the single coroner's office provided the records of the 72 patients comprising this study. Incidents occurred most often in the home or residence (70%) by a known assailant (83%) due to domestic/social disputes (73%). Frequency was greatest in the evening hours (73% between 6:00 PM and 3:00 AM), on weekends in spring and summer. Victims tended to be male (86%), black (72%), married (46%), blue collar workers (62%). There were 41 (57%) gunshot wounds, 3 (4%) shotgun wounds, and 28 (39%) stab wounds with an associated mortality rate of 97%, 100%, and 68%, respectively. Prehospital mortality rate (dead at the scene) was 54.2% (39/72), and death on arrival was 26.4% (19/72), for a combined pretreatment mortality rate of 80.6%. All patients who arrived with no vital signs died. Mortality appeared to be related to mechanism of injury, age, race, sex, vital signs on arrival, number and specific cardiac chambers injured, associated major vascular injury, hematocrit, and mode of transportation. Mortality was not related to caliber of weapon, ethanol level, transport time, time from arrival to operation, or transfusion requirements. There were only ten survivors (1 gunshot wound and 9 stab wounds), all of whom had ventricular injuries and no associated major vascular injuries. The ten survivors represented a 71.4% (10/14) salvage rate for those victims arriving with vital signs. Complications occurred in three patients. Hospitalization averaged 7.3 days in the survivors. Penetrating cardiac trauma remains a serious, socially linked disease with a high rate of mortality. Rapid transport, aggressive resuscitation and cardiorrhaphy remain the best treatment.     

Penetrating chest wounds: 24 years experience

Thoracic and thoracoabdominal penetrating wounds are frequently encountered in urban medical centers in the United States. This study was undertaken to determine the clinical characteristics and in hospital outcome of these injuries. This was a longitudinal, nonblinded study using the established standard of care of patients with penetrating chest trauma. It consists of an analysis of a consecutive series of 3049 patients treated at one trauma center between April 1972 and March 1996. There were 1347 stab wounds and 1702 gunshot wounds. Antibiotic prophylaxis was administered to patients who underwent laparotomy or thoracotomy or who had lung contusion with hemoptysis (41.6%, 1296/3049). Of 3049 patients, 196 had cardiac injuries. All of them underwent thoracotomy, and the mortality was 21.9%. In contrast, among 2853 patients without cardiac injuries, only 257 (9%) required thoracotomy; the mortality in this group was 1.5%. Patients with thoracoabdominal injuries (899/3049) had a mortality of 4.3% compared to 2.1% among those who had isolated chest injuries. The overall mortality was 2.8%. Of 1702 patients with gunshot wounds, 85 (5%) sustained transaxial injuries, with an overall mortality of 36.5%. The complication rate among the survivors was 6% with only 2.5% being infectious. We conclude that the mortality for noncardiac penetrating injuries of the chest is low. The presence of associated abdominal injuries increases the mortality twofold. More than one-third of the patients with transaxial wounds die. Gunshot wounds of the heart result in higher mortality than stab wounds to the heart. The infection rate is low.     

Cardiac injuries: a ten-year experience.

OBJECTIVE: To present our experience of cardiac injuries treated at one Swedish emergency department in the 10 years 1988-97. DESIGN: Retrospective study. SETTING: Teaching hospital. SUBJECTS: 11 patients (9 men and 2 women, mean age 33 years, range 19-54); in 7 they were penetrating injuries and in 4 blunt. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: The mechanisms of injury were stab wound (n = 7), and car crash, fall, boat crash, and abuse (n = 1 each); drug or alcohol misuse played a part in all those with penetrating injuries. The penetrating wounds involved the left ventricle (n = 3), the right ventricle (n = 2), and the pericardium (n = 2). All 5 patients with ventricular wounds presented with cardiac tamponade, in 1 of whom it was fatal (he bled to death during emergency thoracotomy). The main complications were anoxic brain damage and postpericardiotomy syndrome (1 each). There was no case of myocardial concussion. CONCLUSION: Our data reflect the Swedish experience of heart trauma: there are few cases, alcohol and drug misuse is the principal risk factor, and there were no gunshot wounds.     

穿透性心脏损伤急诊室剖胸五例穿透性心脏损伤急诊室剖胸五例

目的探讨在急诊室剖胸对危急心脏穿透伤的疗效。方法在急诊室紧急开胸５例，４例濒于死亡，１例已无生命体征；火器伤２例，锐器伤３例；心脏压塞型２例，失血休克型３例。结果全组死亡３例，存活２例（２／５）；火器伤２例均无存活（０／２），锐器伤２例存活（２／３）；压塞型１例存活（１／２），失血休克型１例存活（１／３）。结论急诊室剖胸是救治危急心脏穿透伤的有效手段，濒于死亡的心脏穿透伤特别是锐器伤部分可能获救     

Penetrating chest injuries in the firearm era

BACKGROUND: firearm wounds of the chest are now common at our institution. The management algorithm for firearm wounds has not been evaluated for this mode of injury. METHODS: records of all patients with penetrating chest injuries admitted to an urban tertiary hospital over 1 year were retrieved and analysed. RESULTS: there were 473 stab and 116 firearm wounds. In comparison to stab injuries firearm wounds had significantly more normal X-rays (14 vs. 5%), fewer pneumothoraces (15 vs. 37%), and more contusions (43 vs. 2%). The frequency of haemothoraces (34 vs. 23%) and haemopneumothoraces (36 vs. 35%) was similar in both groups. Stabbing caused all the 18 cardiac injuries. Associated abdominal injuries occurred in 8% of stab and 34% of firearm injuries. Pneumothoraces due to firearms were uncommon and rarely required drainage. More pneumothoraces were treated nonoperatively among firearm injuries in contrast to stabbing injuries where the opposite applied. The management of haemothorax and haemopneumothorax was similar in both groups that fulfilled the criteria for drainage. The rate of ICU admission was higher and the hospital-stay longer following firearm injuries. Fifty-nine patients died (10% of the total), 33 (28%) from the firearm injuries and 26 (6%) from stab-wounds. Early deaths were 1 and 3% for stabs and firearms, respectively. CONCLUSIONS: patients with firearm injuries reaching hospital suffered three times higher mortality and a longer ICU and hospital stay than those with stab injuries. However, early mortality was similar for both modes of injury and validates the continued application of the stab wound derived management algorithm to all modes of injury.     

Management of penetrating lung injuries in civilian practice

Recent reports of military thoracic injuries have advocated early thoracotomy and aggressive management of pulmonary injuries with resection as opposed to the more conservative and traditional treatment with chest tube thoracostomy. A retrospective study was therefore performed to determine the incidence of thoracotomy and lung resection in civilian injuries and to evaluate the effectiveness of treatment of these injuries. Between 1973 and 1985, in a series of 1,168 patients, there were 384 gunshot wounds and 784 stab wounds to the thorax. Two hundred eighty-three patients with a gunshot wound (74%) and 602 with a stab wound (77%) were treated with chest tubes alone. Sixty-eight patients (6% of the total) required operative repair of pulmonary hilar or parenchymal injury. Pulmonary resection was necessary in only 18 patients (nine with a gunshot wound and nine with a stab wound), and 10 patients had repair of hilar injuries (nine with a gunshot wound and one with a stab wound). Of patients requiring pulmonary resection, nine required wedge or segmental resection, six required lobectomy, and three patients required pneumonectomy. Mortality for all thoracic injuries was 2.3%: for those treated with chest tube alone, 0.7%; for pulmonary hilar injuries, 30%; for pulmonary parenchymal injuries, 8.6%; and for injuries necessitating lung resection, 28%. Most civilian lung injuries can be treated by tube thoracostomy alone. Although relatively few patients with primary pulmonary injury require thoracotomy, those that do are at significant risk and may require lung resection to control bleeding or hemoptysis or to remove destroyed or devitalized lung tissue.     

The ultrasound screen for penetrating truncal trauma

A prospective blinded pilot study was performed at an urban level 1 trauma center to evaluate the efficacy of ultrasound in ruling out penetrating visceral truncal injury. For 8 months, 49 nonconsecutive patients who presented with truncal gunshot and stab wounds were evaluated by a 10-MHz ultrasound tranducer probe. The deepest muscle bundle and the fascia enveloping it was examined by ultrasound. These images were compared to the equivalent contralateral unaffected side of the patient. All the patients then underwent standard testing to evaluate for potential intracavitary injury. Forty-nine patients with a mean age of 28 years (SD, 8.8) were evaluated by ultrasound. A total of 58 injuries were evaluated of which 37 were stab wounds and 21 were gunshot wounds. Thoracoabdominal and back and flank injuries were the most commonly evaluated injuries. There were 20 true positives, 20 false positives, and 18 true negatives, each with approximately twice as many stab as gunshot wounds. There were no false negatives. The sensitivity and negative predictive value of ultrasound in determining clinically significant truncal visceral injury in penetrating truncal trauma is 100 per cent. The specificity and positive predictive value are both approximately 50 per cent. Ultrasonic examination of the injured abdominal wall layers in truncal penetrating trauma is an excellent screening tool. Simple comparative assessment with the unaffected contralateral side allows a highly sensitive method of decreasing the number of potentially morbid, time consuming, and expensive tests that are currently employed to rule out visceral injury.