What is the appropriate management for penetrating chest trauma?

Management of Penetrating Chest Trauma

For patients with penetrating chest trauma, immediate assessment of hemodynamic stability should guide management, with unstable patients requiring emergent surgical intervention and stable patients potentially managed with imaging-guided approaches.

Initial Assessment and Triage

Hemodynamic Status Evaluation

• Hemodynamic stability defined as systolic BP ≥90 mmHg and heart rate 50-110 beats/minute 1
• Immediate classification into:
  • Unstable: SBP <90 mmHg despite fluid resuscitation
  • Stable: SBP ≥90 mmHg with appropriate response to initial resuscitation

Immediate Actions for Unstable Patients

• Aggressive hemostatic resuscitation with blood products (enhanced plasma/PRBC ratios) 2
• Portable chest radiograph and FAST (Focused Assessment with Sonography for Trauma) 1
• FAST examination to detect:
  • Hemopericardium (cardiac injury)
  • Pneumothorax
  • Free intraperitoneal fluid 1
• Emergent thoracotomy for hemodynamically unstable patients with penetrating chest trauma 1

Management Algorithm Based on Hemodynamic Status

Unstable Patients (SBP <90 mmHg)

1. Immediate surgical intervention without delay for CT imaging 1, 2
2. Damage control approach with three components:
   • Abbreviated resuscitative thoracotomy/laparotomy for bleeding control
   • ICU treatment focused on core re-warming, correction of acid-base imbalance and coagulopathy
   • Definitive surgical repair once target parameters achieved 2
3. Monitor and treat the "lethal triad" (coagulopathy, acidosis, hypothermia) 2

Stable Patients (SBP ≥90 mmHg)

1. Bedside cardiac ultrasonography (BCU) - strongly recommended 1

   • Detects occult cardiac injury following penetrating chest trauma
   • Guides critical care physician to take immediate lifesaving actions
   • Note: False negatives can occur with cardiac injury decompressing into hemithorax through pericardial rent 1

2. CT Chest with IV contrast 1

   • Optimal for identifying trajectory of penetrating injuries
   • Helps determine optimal surgical approach if needed
   • Evaluates for:
     • Diaphragmatic injury
     • Thoracic injuries (pneumothorax, hemothorax)
     • Solid organ injuries
     • Vascular injuries
     • Hollow viscus injuries 2

3. Tube thoracostomy for hemothorax/pneumothorax

   • Consider continuous low-pressure suction to chest tubes (beyond water seal)
   • Helps with evacuation of blood, expansion of lung, and prevention of clotted hemothorax 3

Special Considerations

Cardiac Injuries

• Right ventricle is the most commonly injured heart chamber (48%) in penetrating trauma 4
• Pericardiocentesis should only be performed as a resuscitative measure in unstable patients prior to thoracotomy 4
• Cardiorrhaphy (cardiac repair) typically performed through left anterior lateral thoracotomy 4
• High index of suspicion with expeditious thoracotomy results in greatest salvage rate 4

Monitoring After Initial Management

• Serial hemoglobin/hematocrit measurements
• Repeat imaging if clinical deterioration occurs
• Monitor for signs of rebleeding 2
• Monitor intra-abdominal pressure in patients at risk of abdominal compartment syndrome 2

Common Pitfalls and Caveats

1. Delayed Recognition of Cardiac Injury: Penetrating cardiac injuries can present with normal hemodynamic parameters initially before rapid deterioration 1, 5

2. False-Negative FAST: A cardiac injury decompressing into the hemithorax through a pericardial rent may result in a large (usually left) hemothorax with a false-negative pericardial view 1

3. Delaying Surgery for Imaging: In hemodynamically unstable patients, delaying surgical intervention for imaging can increase mortality 1, 2

4. Inadequate Drainage Management: Failure to apply continuous low-pressure suction to chest tubes may lead to clotted hemothorax requiring additional surgical intervention 3

5. Missed Diaphragmatic Injuries: These can be difficult to detect (sensitivity 14-82%) but are important to identify as they may lead to herniation of abdominal contents 2