Triage and Outcome of Patients with Mediastinal Penetrating Trauma

Dangerous passage: the utility and accuracy of modern chest computed tomography in penetrating thoracic injuries with potential transmediastinal trajectory

AIM

The aim of this study is to evaluate utility and reliability of chest CT as a standalone screening modality for stable patients with thoracic GSWs and potential transmediastinal trajectories.

METHODS

All patients with thoracic GSWs over a 5-year period were identified. Unstable patients requiring immediate surgery were excluded and the remaining underwent chest CT with intravenous contrast. Sensitivity and specificity for clinically significant injuries were tested against an aggregate gold standard of discharge diagnosis including imaging, operative and clinical findings.

RESULTS

A total of 216 patients met inclusion criteria and underwent chest CT. After imaging, 65 (30.1%) had indication for immediate surgery, of which 10 (4.6%) underwent a thoracic procedure for chest injuries while 151 (69.9%) were selected for nonoperative management (NOM). 11 (5.1%) required a delayed thoracic operation, none due to injuries missed on CT. The remaining 140 (64.8%) underwent successful NOM. Up to 195 (90.3%) patients had successful NOM of thoracic injuries. Only 9.2% required additional imaging, all negative. CT identified a cardiac injury in one case and a vascular injury in two cases, all confirmed by surgery, while one thoracic IVC injury missed on CT was found intraoperatively. 2 patients had CT suspicious for esophageal injury, ruled out by following investigations. There was one death in the total cohort, none in the NOM group.

CONCLUSIONS

Modern high-quality CT provides highly accurate and reliable screening modality for penetrating chest and mediastinal injuries and can be used as a standalone study in most patients or to guide further tests. Chest CT facilitated successful NOM.

Impact of Postoperative Imaging Following Emergency Surgery for Penetrating Ballistic Thoracic Trauma

INTRODUCTION

Patients undergoing emergent surgical procedures after penetrating trauma can benefit from postoperative imaging studies to identify potential missed injuries or indications to additional surgery. Aim of this study is to describe postoperative imaging findings in patients who underwent emergent operation for thoracic gunshot wounds (GSWs) and the subsequent need for further surgery, diagnostic evaluations or consults.

METHODS

Patients who survived to receive imaging evaluation after emergency surgery for penetrating chest trauma in a level I trauma center between 2017 and 2021 were included. Results of postoperative diagnostic evaluation were screened to determine their impact on the subsequent management.

RESULTS

Overall, 125 patients admitted with a thoracic GSW underwent an emergent surgical procedure and 29 survived to receive postoperative imaging and were included. Postoperative CT-scan was performed in 26 (89.6%) patients, echocardiography in 8 (27.5%). Other tests included esophagoscopy (1) and bronchoscopy (1). Impact on management of abnormal imaging included a new indication to surgery or additional procedures in 7 cases and need for additional imaging or consults in other 8 cases. Bone fractures and lung injuries were more often diagnosed on postoperative CT-scan. In 3 patients, abnormal echocardiographic findings led to a second cardiac operation.

CONCLUSION

Following emergency surgery for penetrating trauma, completion of injury assessment with CT-scan can lead to identification of missed or additional injuries, while other imaging is indicated according to operative findings. In this study, 24.1% had additional surgical pathology identified by postoperative imaging while others had findings requiring additional studies or specialist consult evaluations.

Imaging of penetrating vascular trauma of the body and extremities secondary to ballistic and stab wounds

In the United States, gunshot wounds (GSWs) have become a critical public health concern with substantial annual morbidity, disability, and mortality. Vascular injuries associated with GSW may pose a clinical challenge to the physicians in the emergency department. Patients demonstrating hard signs require immediate intervention, whereas patients with soft signs can undergo further diagnostic testing for better injury delineation. Although digital subtraction angiography is the gold standard modality to assess vascular injuries, non-invasive techniques such as Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography have evolved as appropriate alternatives. This article discusses penetrating bodily vascular injuries, specifically ballistic and stab wounds, and the corresponding radiological presentations.

Transmediastinal Gunshot Wound in a Pregnant Patient with Stable Hemodynamics

Transmediastinal gunshot wounds (TGWs) may lead to life-threatening injuries of vital organs such as large vessels, the esophagus, and lungs. Although they are not commonly encountered in pregnant women, additional caution should be given to these patients. Physical examination for the diagnosis and the choice of treatment modality contain controversial points in hemodynamically stable patients, and resuscitation has excessive importance due to physiological changes in pregnancy. We present a hemodynamically stable 26-week pregnant woman brought to the emergency department for TGW. She had a 1-cm diameter of bullet entrance hole on the right anterior 4^th intercostal space, 2 cm lateral to the sternum, and a 3-cm diameter exit hole on the right posterior 12^th intercostal space on the midscapular line. With our conservative approach, she had an uncomplicated pregnancy period, and gave birth to a healthy baby at term.

A rare chest X-ray sign in the diagnosis of an intracardiac bullet: case report

Background

Gunshot injuries to the heart are often seen in cardiac surgical practice. Victims are usually investigated with various types of imaging modalities, including simple chest X-ray (CXR) which is a primary imaging modality that can easily locate a bullet and is useful in monitoring before surgical intervention as bullets may migrate.

Case presentation

A 32-year-old man was admitted as an emergency in a primary hospital after being injured by a gunshot to the chest. The bullet entry was over the back of the left shoulder with no exit point seen. The chest X-ray showed left pleural effusion and a retained intrathoracic bullet. A chest drain was inserted and drained 2200 ml of blood. Computed tomography (CT) scan showed an intracardiac bullet associated with left lower lobe contusion and left-sided hemothorax. He was urgently transferred to theater for exploration via left thoracotomy. The bullet could not be found so the inlet point in the left ventricle was sutured. After stabilizing the patient, he was referred to a specialized cardiac center for further management.

The patient arrived at our center 2 days after the injury, fully conscious and hemodynamically stable. On arrival, chest X-rays were obtained to rule out possible migration of the bullet and revealed that the retained bullet was still within the cardiac silhouette. The X-ray appearance of the bullet showed a characteristically double contour, strongly suggesting that the bullet had lodged in the heart muscle and was moving with each heartbeat.

The patient was transferred to the theater for median sternotomy. The aorta, superior vena cava, and inferior vena cava were cannulated, and cardiopulmonary bypass was initiated. The aorta was cross-clamped and the cardioplegia was given. Palpation of the still heart readily identified the bullet within the interventricular septum. The left ventricle was opened 1 cm from the left anterior descending artery just on top of the bullet. The bullet was successfully retrieved. The bullet was transfixing the septum causing a small ventricular septal defect which was closed using a Teflon patch and the ventricle was repaired.

Conclusion

The double contour appearance of the bullet indicates that the bullet is moving and strongly suggests an intramyocardial position.

Delayed presentation of cardiac injury four weeks after stabbing

Penetrating trauma to the heart has a high associated mortality due to significant hemorrhage, coronary artery injury, and cardiac tamponade. Such sequelae progress rapidly, often leading to death before reaching hospital. We report a case of delayed presentation following a stab injury to the right ventricle. This case highlights the mechanisms that may facilitate a delayed presentation and the importance of appropriate investigation when suspicion of cardiac injury is high.

Usefulness of routine computed tomography in the evaluation of penetrating war injuries to the chest

OBJECTIVES

This review was conducted to compare the contributions of chest X-ray (CXR) and computed tomography (CT) towards detecting intrathoracic damage in patients with penetrating war injuries to the chest and to determine whether identification of additional injuries by chest CT will have an impact on the choice of therapeutic interventions and clinical outcomes.

METHODS

We reviewed records of 449 patients (374 men, mean age 29.3 ± 14.8 years) who were admitted to our hospital with penetrating war injuries to the chest over a 7-year period. Collected data included mechanisms of injury, associated injuries, results of CXRs and chest CTs, methods of management, in-hospital stays, complications and mortalities.

RESULTS

Immediate screening CXRs were obtained in all patients not requiring emergent thoracotomies, of which 91.4% showed positive signs of injury. Chest CTs were performed at the discretion of the physicians in 49.4% of patients, and CXR-positive findings were confirmed in all cases, while revealing additional injuries in 11% of patients. Chest CT findings led to additional closed chest drainage in 5.6% of patients but had no impact on treatment strategy in 94.4% of scanned patients. Follow-up CXRs showed new positive findings in 22 patients, leading to additional closed chest drainage in 3 patients and delayed open thoracotomies in 7 other patients.

CONCLUSIONS

CXRs continue as the primary diagnostic modality in the assessment of patients with penetrating war injuries to the chest. Chest CTs can be omitted in most patients, thus reducing CT imaging case-load substantially, while most clinically significant chest injuries remain sufficiently recognized.

Posterior Thoracic Stab Wounds: Evaluating the Value of Commonly Used Radiologic Modalities

This study was performed to assess our institution's experience with stab injuries to the posterior mediastinal box. We examine the value of performing CT of the chest and esophagram in conjunction with a chest X-ray (CXR) over performing CXR(s) alone in evaluating this group of patients. We performed a retrospective study covering a 10-year period consisting of patients with stab wounds to the posterior mediastinal box. Age, gender, and injury severity score as demographic data points were collected. CXR, CT, and esophagram results; identified injuries; and subsequent interventions were analyzed. Of 78 patients who met the inclusion criteria, a total of 55 patients underwent esophagram, one had a false-positive result, and zero had their course altered by the study. Sixty-six patients underwent CT imaging, and there were nine missed findings on initial CXR. Five of these were clinically insignificant and the remaining four were managed with a chest tube alone. There were no tracheobronchial, esophageal, cardiac, or great vessel injuries. Hemodynamically stable, asymptomatic patients with stab wounds to the posterior mediastinal box do not require routine CT and esophagram in the absence of CXR and cardiac ultrasonographic abnormalities.

A systematic review of 3251 emergency department thoracotomies: is it time for a national database?

PURPOSE

Emergency department thoracotomy (EDT) is a potentially life-saving procedure, performed on patients suffering traumatic cardiac arrest. Multiple indications have been reported, but overall survival remains unclear for each indication. The objective of this systematic review is to determine overall survival, survival stratified by indication, and survival stratified by geographical location for patients undergoing EDT across the world.

METHODS

Articles published between 2000 and 2016 were identified which detailed outcomes from EDT. All articles referring to pre-hospital, delayed, or operating room thoracotomy were excluded. Pooled odds ratios (OR) were calculated comparing differing indications.

RESULTS

Thirty-seven articles, containing 3251 patients who underwent EDT, were identified. There were 277 (8.5%) survivors. OR demonstrate improved survival for; penetrating vs blunt trauma (OR 2.10; p 0.0028); stab vs gun-shot (OR 5.45; p < 0.0001); signs of life (SOL) on admission vs no SOL (OR 5.36; p < 0.0001); and SOL in the field vs no SOL (OR 19.39; p < 0.0001). Equivalence of survival was demonstrated between cardiothoracic vs non-cardiothoracic injury (OR 1.038; p 1.000). Survival was worse for USA vs non-USA cohorts (OR 1.59; p 0.0012).

CONCLUSIONS

Penetrating injury remains a robust indication for EDT. Non-cardiothoracic cause of cardiac arrest should not preclude EDT. In the absence of on scene SOL, survival following EDT is extremely unlikely. Survival is significantly higher in the non-USA publications; reasons for this are highly complex. A UK multicentre prospective study which collects standardised data on all EDTs could provide robust evidence for better patient stratification.

Pediatric Trauma Care in Low Resource Settings: Challenges, Opportunities, and Solutions

Trauma constitutes a significant cause of death and disability globally. The vast majority -about 95%, of the 5.8 million deaths each year, occur in low-and-middle-income countries (LMICs) 3-6. This includes almost 1 million children. The resource-adapted introduction of trauma care protocols, regionalized care and the growth specialized centers for trauma care within each LMIC are key to improved outcomes and the lowering of trauma-related morbidity and mortality globally. Resource limitations in LMICs make it necessary to develop injury prevention strategies and optimize the use of locally available resources when injury prevention measures fail. This will lead to the achievement of the best possible outcomes for critically ill and injured children. A commitment by the governments in LMICs working alone or in collaboration with international non-governmental organizations (NGOs) to provide adequate healthcare to their citizens is also crucial to improved survival after major trauma. The increase in global conflicts also has significantly deleterious effects on children, and governments and international organizations like the United Nations have a significant role to play in reducing these. This review details the evaluation and management of traumatic injuries in pediatric patients and gives some recommendations for improvements to trauma care in LMICs.

Radiologic findings of thoracic trauma

Introduction

Chest trauma may be blunt or penetrating and the chest is the third most common trauma region. It is a significant cause of mortality. Multidetector computed tomography (MDCT) has been an increasingly used method to evaluate chest trauma because of its high success in detecting tissue and organ injuries. Herein, we aimed to present MDCT findings in patients with blunt and penetrating chest trauma admitted to our department.

Methods

A total of 240 patients admitted to the emergency department of our hospital between April 2012 and July 2013 with a diagnosis of chest trauma who underwent MDCT evaluations were included. Most of the patients were male (83.3%) and victims of a blunt chest trauma. The images were analyzed with respect to the presence of fractures of bony structures, hemothorax, pneumothorax, mediastinal organ injury, and pulmonary and vascular injuries.

Results

MDCT images of the 240 patients yielded a prevalence of 41.7% rib fractures, 11.2% scapular fractures, and 7.5% clavicle fractures. The prevalence of thoracic vertebral fracture was 13.8% and that of sternal fracture was 3.8%. The prevalence of hemothorax, pneumothorax, pneumomediastinum, and subcutaneous emphysema was 34.6%, 62.1%, 9.6%, and 35.4%, respectively. The prevalence of rib, clavicle, and thoracic vertebral fractures and pulmonary contusion was higher in the blunt trauma group, whereas the prevalence of hemothorax, subcutaneous emphysema, diaphragmatic injury, and other vascular lacerations was significantly higher in the penetrating trauma group than in the blunt trauma group (p<0.05).

Conclusion

MDCT images may yield a high prevalence of fracture of bony structures, soft tissue lacerations, and vascular lesions, which should be well understood by radiologists dealing with trauma.

Intracardiac foreign body resulting from a transmediastinal gunshot mimics an extracardiac foreign body: An image presentation

A transmediastinal gunshot wound (TMGW) is one of the most severe traumatic injuries, with a high mortality rate. Prompt diagnosis and emergency surgical intervention with or without cardiopulmonary bypass are usually required to save lives. We report a particular case of TMGW in which the computed tomography imaging findings indicated an extracardiac foreign body. However, intraoperative findings revealed an intracardiac foreign body, and urgent cardiopulmonary bypass was performed to remove the foreign body. We suggest that cardiopulmonary bypass should be on standby during an exploratory sternotomy for TMGW, when the trajectory of the bullet hints at a cardiac-penetrating injury according to imaging studies and the location of the bullet remains unaffected by the patient's postural changes.

Pediatric thoracic trauma: Current trends

Pediatric thoracic trauma is relatively uncommon but results in disproportionately high levels of morbidity and mortality when compared with other traumatic injuries. These injuries are often more devastating due to differences in children׳s anatomy and physiology relative to adult patients. A high index of suspicion is of utmost importance at the time of presentation because many significant thoracic injuries will have no external signs of injury. With proper recognition and management of these injuries, there is an associated improved long-term outcome. This article reviews the current literature and discusses the initial evaluation, current management practices, and future directions in pediatric thoracic trauma.

An unusual case of impalement injury

Impalement injuries result when a hard elongated object penetrates the body cavity or any body part and remains in place. A rare and unusual case of impalement by a bamboo stick in the thoracic cavity through the oropharynx is described. Injury resulted when a man tried to pole-vault with a bamboo stick, which slipped and entered his mouth. Impalement injury through the natural orifice of the oropharynx is discussed, along with the mechanism of the trauma and subsequent death.

Multidetector CT for Penetrating Torso Trauma: State of the Art

The use of computed tomography (CT) for hemodynamically stable victims of penetrating torso trauma continues to increase but remains less singular to the work-up than in blunt trauma. Research in this area has focused on the incremental benefits of CT within the context of evolving diagnostic algorithms and in conjunction with techniques such as laparoscopy, endoscopy, and angiographic intervention. This review centers on the current state of multidetector CT as a triage tool for penetrating torso trauma and the primacy of trajectory evaluation in diagnosis, while emphasizing diagnostic challenges that have lingered despite tremendous technological advances since CT was first used in this setting 3 decades ago. As treatment strategies have also changed considerably over the years in parallel with advances in CT, current management implications of organ-specific injuries depicted at multidetector CT are also discussed.

Penetrating Thoracic Injury

This article discusses the role of radiology in evaluating patients with penetrating injuries to the chest. Penetrating injuries to the chest encompass ballistic and nonballistic injuries and can involve superficial soft tissues of the chest wall, lungs and pleura, diaphragm, and mediastinum. The mechanism of injury in ballistic and nonballistic trauma and the impact the injury trajectory has on imaging evaluation of penetrating injuries to the chest are discussed. The article presents the broad spectrum of imaging findings a radiologist encounters with penetrating injuries to the chest, with emphasis on injuries to the lungs and pleura, diaphragm, and mediastinum.

Mediastinal impalement with a fibreglass sheet

Mediastinal impalement injuries are uncommon and often fatal. There have been very few reported cases of survival following mediastinal impalement. Patients who present with these injuries always undergo operative intervention regardless of their underlying haemodynamic status or associated injuries. We herein present a case of mediastinal impalement injury, where a sheet of fibreglass had fractured the manubrium and entered the anterior mediastinum with no associated great vessel injury. The fibreglass sheet was removed via a partial sternotomy and the patient made an uneventful postoperative recovery.

Rescue extracorporeal membrane oxygenation in a young man with a stab wound in the chest

A 27-year-old man with haemorrhagic shock and acute cardiac tamponade due to a stab in the chest underwent successful resuscitation and surgical repair of the right ventricular perforation thanks to the use of extracorporeal membrane oxygenation (ECMO) in the emergency department. To the best of the authors' knowledge, this is the first report around the use of ECMO to rescue a victim of a penetrating cardiac trauma. The physicians who have portable ECMO device should be aware of this option when a life-threatening internal bleeding in haemodynamically unstable patients could be quickly controlled by surgery, even if performed in ill-suited settings.

Transmediastinal and transcardiac gunshot wound with hemodynamic stability

Cardiac injuries caused by knives and firearms are slightly increasing in our environment. We report the case of a 43-year-old male patient with a transmediastinal gunshot wound (TGSW) and a through-and-through cardiac wound who was hemodynamically stable upon his admission. He had an entrance wound below the left clavicle, with no exit wound, and decreased breath sounds in the right hemithorax. Chest X-ray showed the bullet in the right hemithorax and large right hemothorax. The ultrasound revealed pericardial effusion, and a chest tube produced 1500 cc. of blood, but he remained hemodynamically stable. Considering these findings, a median sternotomy was carried out, the through-and-through cardiac wounds were suture-repaired, lung laceration was sutured, and a pacemaker was placed in the right ventricle. The patient had uneventful recovery and was discharged home on the twelfth postoperative day. The management and prognosis of these patients are determined by the hemodynamic situation upon arrival to the Emergency Department (ED), as well as a prompt surgical repair if needed. Patients with a TGSW have been divided into three groups according to the SBP: group I, with SBP >100 mmHg; group II, with SBP 60–100 mmHg; and group III, with SBP <60 mmHg. The diagnostic workup and management should be tailored accordingly, and several series have confirmed high chances of success with conservative management when these patients are hemodynamically stable.

Transmediastinal gunshot wounds in a mature trauma centre: changing perspectives

BACKGROUND

Transmediastinal gunshot wounds are associated with a high mortality and frequently require operative intervention. The purpose of this study was to identify the diagnostic and therapeutic challenges of these injuries in a mature trauma system with decreasing prehospital time intervals.

METHODS

Patients admitted to a large urban Level 1 trauma centre between 1/2006 and 12/2010 sustaining a firearm injury to the torso were identified. Transmediastinal gunshot wounds were defined as missile tracts traversing the mediastinum identified on CT images, operative notes or autopsy reports.

RESULTS

Overall, 133 patients met study criteria. A total of 116 patients (87.2%) were haemodynamically unstable or had no vital signs on arrival to the Emergency Department. Ninety-seven (83.6%) of these patients required a resuscitative thoracotomy resulting in 8 survivors (6.0%). There were 17 haemodynamically stable patients (12.8%) identified, 14 of whom underwent CT scan evaluation. Six patients subsequently required operative intervention. Only 11 patients (8.3%) in the study population were successfully managed nonoperatively. The overall mortality was 78.9%, and for those who reached the hospital with vital signs, the mortality was 24.3%.

CONCLUSIONS

Transmediastinal gunshot wounds encountered in a mature trauma centre are highly lethal injuries requiring resuscitative thoracotomy in most instances. Changing perspectives in these injuries may reflect the effects of an evolving prehospital care.

How to mend a broken heart: a major stab wound of the left ventricle

A 28-year-old male admitted with a stab wound under his left nipple, underwent emergency surgery because of confusion, a decreasing blood pressure and increasing tachycardia. A median sternotomy incision was made and after establishing cardiopulmonary bypass, a 7 cm wound in the left ventricle and a smaller wound in the left atrium were repaired. An injured segment of lung was resected and the left anterior descending and circumflex arteries were grafted after weaning from cardiopulmonary bypass was initially unsuccessful. Although the patient suffered a stroke, probably due to prehospital hypoperfusion, he eventually recovered without major sequelae. In addition to the case report we present a literature review of the last 15 years pertaining the management of penetrating cardiac injury.

Chest computed tomography for penetrating thoracic trauma after normal screening chest roentgenogram

BACKGROUND

Chest computed tomography (CCT) is a method of screening for intrathoracic injuries in hemodynamically stable patients with penetrating thoracic trauma. The objective of this study was to examine the changes in utilization of CCT over time and evaluate its contribution to guiding therapeutic intervention.

METHODS

A level 1 trauma center registry was queried between 2006 and 2011. Patients undergoing CCT in the emergency department after penetrating thoracic trauma as well as patients undergoing thoracic operations for penetrating thoracic trauma were identified. Patient demographics, operative indications, use of CCT, injuries, and hospital admissions were analyzed.

RESULTS

In all, 617 patients had CCTs performed, of whom 61.1% (371 of 617) had a normal screening plain chest radiograph (CXR). In 14.0% (51 of 371) of these cases, the CCT revealed findings not detected on screening CXR. The majority of these injuries were occult pneumothoraces or hemothoraces (84.3%; 43 of 51), of which 27 (62.8%) underwent tube thoracostomy. In only 0.5% (2 of 371), did the results of CCT alone lead to an operative indication: exploration for hemopericardium. The use of CCT in our patients significantly increased overall (28.8% to 71.4%) as well as after a normal screening CXR (23.3% to 74.6%) over the study period.

CONCLUSIONS

The use of CCT for penetrating thoracic trauma increased 3.5-fold during the study period with a concurrent increase in findings of uncertain clinical significance. Patients with a normal screening CXR should be triaged with 3-hour delayed CXR, serial physical examinations, and focused assessment with sonography for trauma; and CCT should only be used selectively as a diagnostic modality.

[Knife injury to the thoracic aorta and spinal cord. Report on an"almost-mistake"]

We report the surgical treatment of a thoracic knife injury with lesions of the aorta and the myelon. An initially incomplete revision of the wound nearly resulted in a critical situation. Complete revision of a wound is obligatory in a penetrating injury, when a relevant structure is possibly injured.

Great vessel and cardiac trauma: diagnostic and management strategies

Blunt and penetrating trauma to the chest can result in great vessel or cardiac injury. Both the diagnosis and management of these thoracic injuries have evolved from more invasive to less invasive strategies paralleling the advent of sophisticated imaging tools and the development of endovascular therapies. Despite these advances, conventional open repair and reconstruction techniques remain important and are often the definitive means toward effective management of these severely injured patients. The following review outlines the historical perspective, diagnosis, and management of blunt thoracic aortic, blunt cardiac, and penetrating cardiac injuries.

Anesthetic management of thoracic trauma

PURPOSE OF REVIEW

Trauma remains a leading cause of death across all age groups. Thoracic injury is a contributing cause in approximately half of these. Despite being potentially life threatening, most thoracic trauma is managed nonoperatively or with an intercostal catheter. Only 10% of thoracic trauma patients will require emergency thoracotomy. Many more will undergo emergency or urgent surgical intervention for coexisting injuries. Thoracic injuries are dynamic. It is crucial for the anesthesiologist to continually reassess the patient, so that the manifestations of evolving injuries may be detected as early as possible and appropriate management decisions made. Up-to-date knowledge of injury patterns, mechanisms, pathophysiology, and operative and nonoperative management will facilitate optimal management of these patients.

RECENT FINDINGS

There is recent literature discussing the surgical, anesthetic and critical care management of a range of thoracic injuries resulting from either blunt or penetrating trauma.

SUMMARY

Initial resuscitation and surgical management of patients with thoracic trauma continue to evolve. Improvements in prehospital care and diagnostic techniques as well as development of minimally invasive interventions mean that the anesthesiologist may be required to provide care to unstable patients in an expanded range of scenarios and environments.