Surgical Approach for Penetrating Anterior Chest Wounds
For penetrating anterior chest wounds, median sternotomy is the preferred surgical approach in hemodynamically stable patients, while anterolateral thoracotomy should be reserved for unstable patients requiring immediate intervention.
Approach Selection Based on Hemodynamic Status
Unstable Patients
- Anterolateral left thoracotomy is the initial approach of choice for patients with cardiac arrest or impending cardiac arrest from penetrating anterior chest wounds 1
- This approach allows rapid access to the heart, pericardium, and descending aorta for immediate control of hemorrhage 1
- If necessary, the anterolateral approach can be extended to a clamshell incision for improved exposure of both hemithoraces 1
- Emergency department thoracotomy has a reported survival rate of only 15% compared to 90% for sternotomy in more stable patients 2
Stable Patients
- Median sternotomy provides superior exposure for cardiac repair in hemodynamically stable patients with penetrating anterior chest trauma 2, 3
- It offers excellent access to the heart, great vessels, and anterior mediastinum without dividing major muscle groups 4
- Median sternotomy allows for better visualization and repair of injuries to multiple cardiac chambers, which occur in approximately 23% of penetrating cardiac trauma cases 2, 3
- This approach has a significantly higher survival rate (90%) compared to emergency thoracotomy (15%) 2
Anatomical Considerations
- For injuries in the "cardiac box" (area defined by the sternal notch superiorly, xiphoid process inferiorly, and nipples laterally), special attention should be given to potential cardiac involvement 1
- Upper chest injuries typically require thoracotomy (83% of operations), while lower chest injuries more commonly require laparotomy (81% of operations) 5
- Pulmonary injuries associated with cardiac trauma can be effectively managed through a median sternotomy approach 2, 4
Diagnostic Evaluation
- CT chest with IV contrast is the imaging modality of choice for characterizing penetrating thoracic injuries in stable patients 1
- It offers a high negative predictive value (up to 99%) in triaging hemodynamically stable patients 1
- Ultrasound examination can confirm the diagnosis of penetrating cardiac injury and detect pericardial tamponade 1
- Initial chest radiographs can identify pneumothorax, hemothorax, and mediastinal injuries requiring immediate intervention 1
Indications for Immediate Thoracotomy
- Pericardial tamponade with Beck's triad (hypotension, muffled heart sounds, distended neck veins) 1, 6
- Initial thoracostomy blood loss greater than 800 cc 6
- Blood pressure on admission less than 90 mmHg 6
- Progressive massive hemorrhage that cannot be controlled with chest tube drainage 1
- Radiographic evidence of retained hemothorax 6
Surgical Management
- For penetrating cardiac injuries, early diagnosis and surgical repair provide the best chance of survival 1, 3
- Damage control thoracotomy should be performed for severe pulmonary lacerations when thoracic closed drainage cannot relieve dyspnea or leads to continuous hemorrhage 1, 7
- In cases of penetrating trauma to thoracic great vessels with progressive hemorrhage, urgent thoracotomy should be performed to repair damaged vessels 1
- Non-operative management has become standard care for many cases without active bleeding or perforation, reducing morbidity and mortality 7
Common Pitfalls and Considerations
- Delayed surgical intervention significantly increases mortality in cases of hollow viscus perforation 7
- Non-therapeutic thoracotomy increases hospital length of stay and carries significant risk of complications 7
- Thoracotomy may require extension across the sternum for improved cardiac exposure or access to the contralateral hemithorax in approximately 20% of cases 2
- Careful consideration of the location of the entrance wound is critical - 70% of cardiac injuries occur with wounds in the upper mediastinum 6