Unusually low mortality of penetrating wounds of the chest

Ultramassive transfusion and adjunctive therapies in a case of blood bank depletion

Background

We present the case of a patient who presents with a high velocity thoracoabdominal gunshot wound requiring ultramassive transfusion who exhausted the county blood bank requiring adjunctive therapies to balanced blood product transfusion while additional blood products could be obtained.

Summary

Thoracoabdominal gunshot wounds carry a high mortality of 14-37 % because of the risk to produce cardiopulmonary, solid organ as well as major vascular injuries (Mandal and Oparah (1989) [1]). Ultramassive transfusion (>20 units of blood product transfusion) also carries high morbidity and mortality and management has generally centered on balanced transfusion (Matthay et al. (2021) [2]).

Conclusion

Balanced blood product transfusion reduces mortality for patients requiring ultramassive transfusion but when this is not possible utilization of adjuncts to blood products may temporize resuscitation until additional blood products can be obtained.

A case report of a bullet in the breast of a woman for four years without any complications

INTRODUCTION AND IMPORTANCE

A bullet stabilized in a breast for more than 4 years without causing any complication due to its presence is not a common case. Sometimes breast isolated injury could be seen without symptoms like pain, or palpable mass, or it could present with abscess formation and fistula. In addition, the bullet - if it's small - could mimic calcifications seen in malignancy when performing mammography.

CASE PRESENTATION

We report a case of a 46-year-old well-being female who came to resect a superficial gunshot she got in her left breast in one of the armed conflict areas in Syria. The bullet has been settled there for more than 4 years without causing any inflammation-related signs at the wound's site and without causing any symptoms or complications.

CLINICAL DISCUSSION

The tissue damage caused by the gunshot is associated with several factors such as the bullet caliber, speed, range of shooting, and energy flux. Frequently, gunshot injuries are most serious in friable solid organs like the liver and brain, whereas dense tissues such as bones and loose tissues like subcutaneous fat are more tolerant and resistant to that kind of insult. When a foreign body (bullet) enters the body without causing tremendous tissue damage and settles there for enough period of time we expect seeing signs of inflammation (heat, swelling, pain, tenderness, and redness).

CONCLUSION

Such cases must be taken into consideration and not be neglected without intervention due to the increased risk of many fearful complications including Squamous Cell Carcinoma.

An Unusual Case of Fatal Thoracoabdominal Gunshot Wound without Diaphragm Injury

In case of thoracoabdominal gunshot wounds (GSW), diaphragmatic lesions are common autopsy findings. In these cases, the bullet’s path involves both the thorax and the abdomen, so the diaphragm (the muscle that separates the two cavities) is frequently damaged. In the present report we illustrate a very unusual autopsy finding, came up after a man was shot twice and affected by a lethal thoracoabdominal gunshot wound. In particular, as expected based on CT scans, the corpse exhibited a thoracic-abdominal path and a retained bullet in the abdomen, but no diaphragmatic lesions or hemorrhagic infiltrations of this muscle have been detected during the autopsy. After a scrupulous examination and the section of all the organs, the intracorporeal projectile’s path was reconstructed, inferring that the thoracoabdominal transit of the bullet extraordinarily had occurred in correspondence of the diaphragmatic inferior vena cava’s ostium, thus exploiting a natural passage without damaging the diaphragmatic muscle.

Emergency Department Resuscitative Thoracotomy: Indications, surgical procedure and outcome. A narrative review

BACKGROUND

Emergency Department Thoracotomy (EDRT) after traumatic Cardio-pulmonary Arrest (CPR) can be used to salvage select critically injured patients. Indications of this surgical procedure are widely debated and changed during last decades. We provide the available literature about EDRT in the effort to provide a comprehensive synthesis about the procedure, likelihood of success and patient's outcome in the different clinical setting, accepted indications and technical details adopted during the procedure for different trauma injuries.

METHODS

Literature from 1975 to 2020 was retrieved from multiple databases and reviewed. Indications, contraindications, total number and outcome of patients submitted to EDRT were primary endpoints.

RESULTS

A total number of 7236 patients received EDRT, but only 7.8% survived. Penetrating trauma and witnessed cardiopulmonary arrest with the presence of vital signs at the trauma center are the most favorable conditions to perform EDRT.

CONCLUSIONS

EDRT should be reserved for acute resuscitation of selected dying trauma patient. Risks of futility, costs, benefits of the surgical procedure should be carefully evaluated before performing the surgical procedure.

Penetrating cardiac injuries: predictive model for outcomes based on 2016 patients from the National Trauma Data Bank

BACKGROUND

Penetrating cardiac injuries are uncommon and lethal. The objectives of this study are to examine the national profile of cardiac injuries, identify independent predictors of outcome, generate, compare and validate previous predictive models for outcomes. We hypothesized that National Trauma Data Bank (NTDB) given its large number of patients, would validate these models.

METHODS

The NTDB was queried for data on cardiac injuries, using survival as the main outcome measure. Statistical analysis was performed utilizing univariate and stepwise logistic regression. The stepwise logistic regression model was then compared with other predictive models of outcome.

RESULTS

There were 2016 patients with penetrating cardiac injuries identified from 1,310,720 patients. Incidence: 0.16%. Mechanism of injury: GSWs-1264 (63%), SWs-716 (36%), Shotgun/impalement-19/16 (1%). Mean RTS 1.75, mean ISS 27 ± 23. Overall survival 675 (33%). 830 patients (41%) underwent ED thoracotomy, 47 survived (6%). Survival stratified by mechanism: GSWs 114/1264 (10%), SWs 564/717 (76%). Predictors of outcome for mortality-univariate analysis: vital signs, RTS, ISS, GCS: Field CPR, ED intubation, ED thoracotomy and aortic cross-clamping (p < 0.001). Stepwise logistic regression identified cardiac GSW's (p < 0.001; AOR 26.85; 95% CI 17.21-41.89), field CPR (p = 0.003; AOR 3.65; 95% CI 1.53-8.69), the absence of spontaneous ventilation (p = 0.008; AOR 1.08, 95% CI 1.02-1.14), the presence of an associated abdominal GSW (p = 0.009; AOR 2.58, 95% CI 1.26-5.26) need for ED airway (p = 0.0003 AOR 1386.30; 95% CI 126.0-15251.71) and aortic cross-clamping (p = 0.0003 AOR 0.18; 95% CI 0.11-0.28) as independent predictors for mortality. Overall predictive power of model-93%.

CONCLUSION

Predictors of outcome were identified. Overall survival rates are lower than prospective studies report. Predictive model from NTDB generated larger number of strong independent predictors of outcomes, correlated and validated previous predictive models.

Rapid Transfusion Devices for Hemorrhagic Cardiothoracic Trauma

Cardiothoracic trauma patients are frequently hypovolemic and hypothermic and may require massive transfusion, which can itself causesuch complications as acidosis, electrolyte imbalance (hypocalcemia and hyperkalemia), hypothermia, di lutional coagulopathy, and adultrespiratory distress syn drome. At the present time, there are a number of rapid infu sion devices such as Level I® (capable of delivering 37°C at a flow rate of up to 600 ml/min), Fluid Management System® (FMS®) (which can deliver 37.5°C of fluid at a flow rate of up to 500 ml/min), Rapid Infusion System® (RIS®) (which can pro vide up to 1,500 ml of 37°C fluid in one and one half minutes), and Rapid Solution Administration Set® (RSASO) (which can not only deliver a maximum of 2,200 m/min, but can warm the fluid to normothermia at a flow rate of 500 ml/min). However, pressurized devices such as Level IO can cause air embolism, interstitial infiltration and the compartment syndrome, and the flow rate is not operator-controlled. Devices such as FMS®, RIS®, and RSAS® incorporate a cardiotomy reservoir which has the potential for clot formation when any calcium-con taining solution is added. In this article, rapid infusion devices are compared, and complications associated with massive transfusion are described.

Resuscitative thoracotomy

Resuscitative thoracotomy is often performed on trauma patients with thoracoabdominal penetrating or blunt injuries arriving in cardiac arrest. The goal of this procedure is to immediately restore cardiac output and to control major hemorrhage within the thorax and abdominal cavity. Only surgeons with experience in the management of cardiac and thoracic injuries should perform this procedure.

Changes in the patterns, presentation and management of penetrating chest trauma patients at a level II trauma centre in southern Pakistan over the last two decades

Penetrating chest trauma can be used as an indicator of violence in the country. We aimed to look at the changes in its incidence and management at a major trauma centre in the country. We also wanted to look at any effect of prehospital time on surgical intervention and outcome of the victim. In this retrospective descriptive study, we observed the presentation and management of 191 penetrating chest injury patients at a level II trauma hospital in Pakistan in the last 20 years. The study sample was divided into two groups: Group 1, 1988-1998 and Group 2, 1999-2009. No significant change in incidence of trauma was observed between the two groups. The delay in the time between event and arrival showed an increase in the number of surgical procedures performed. Also the number of thoracotomies performed went up significantly in the second decade from 5.7 to 16.5% with a P<0.05. Six (3.1%) mortality cases were observed in 20 years. It was seen that the greater the prehospital time, the greater the chances of surgery. Also seen was the increase in mortality as critical cases could make it to the hospital alive in recent times due to improved transportation services.

Stab wound of the neck with contralateral hemo-pneumothorax

A rare case of stab wound of the neck with contralateral hemo-pneumothorax with a mediastinal shift is presented. After tube thoracostomy and computed tomography, the patient had angiographic coil embolotherapy of transected internal mammary artery (IMA). Subsequently, neck exploration with the repair of sternocleidomastoid was done. The patient underwent decortication on the 11(th) post-operative day for persistent residual hemothorax. IMA transection most often occurs from ipsilateral parasternal stab wounds and rarely from iatrogenic trauma. It is important to recognize the presentation of this rare entity as appropriate aggressive diagnostic and therapeutic interventions may be warranted.

[Emergency treatment of thoracic trauma]

Thoracic trauma, most often associated with other serious injuries, is the main cause of death in the first 45 years of life. The percentage of chest injuries in multiple trauma, mainly from blunt impact, has remained relatively constant at 80% during the last 30 years. Isolated thoracic injuries comprise only 25% of all trauma cases, 90% of chest injuries are due to blunt impact, while penetrating injuries make up 5-10%. Since 25% of deaths from trauma are attributable to chest injuries, they determine the survival rate in multiple trauma to a significant extent. The pattern of chest injuries is variable, frequently in different combinations comprising rib cage and diaphragm, lung parenchyma, airway and mediastinal organs. This article details the immediate simultaneous diagnostic and therapeutic procedures in the prehospital phase, management in the emergency room, the relative importance of computed tomography, ultrasound examination and endoscopy in the primary diagnostic evaluation and the principles of anaesthetic management of thoracic trauma.

Blood Pressure Effects of Thoracic Gunshot Wounds: The Role of Bullet Image Diameter

Differences in handgun bullet diameter, expansion, and penetration (no exit) versus perforation (with exit) may be the cause of variable blood pressure effects after thoracopulmonary injury. Forty nonlethal isolated gunshot wounds of the thorax were evaluated excluding wounds of the heart, great vessels, and spinal cord. Chest radiographs were assessed for bullet base diameter, bullet expansion, and wound length. Large bullets were defined as having radiographic base images of 9 mm or more in diameter. Systolic blood pressures were compared between penetrating large and small bullet groups and with perforating wounds. Response times and demographics were compared. Wounds caused by large bullet penetration resulted in lower initial systolic blood pressures than wounds caused by small bullet penetration (98 vs 125 mm Hg, P < 0.05). The average age, transport time, and wound length were similar among the bullet groups. We conclude that penetrating thoracopulmonary wounds caused by large bullets resulted in lower initial systolic blood pressure.

Pulmonary artery bullet injury following thoracic gunshot wound

Thoracic trauma occurs frequently but seldom requires surgery (10-20%, [1]). The mortality rate for gunshot wound of the chest varies from 14.3 to 36.8% [2]. We report, herein an example of bullet injury to the pulmonary artery (PA) following a thoracic gunshot wound. This patient had previous history of coronary surgery. Absolute and relative indications for exploratory thoracotomy in emergency will be reviewed.

Ferimentos penetrantes tóraco-abdominais e de tórax e abdome: análise comparativa da morbidade e mortalidade pós-operatórias

Analisamos 145 doentes portadores de ferimentos penetrantes tóraco-abdominais e de tórax e abdome, operados no Serviço de Emergência da Santa Casa de São Paulo de julho de 1987 a fevereiro de 1996, sendo 72 (49,7%) produzidos por arma branca e 73 (50,3%) por projétil de arma de fogo. Foram estudados fatores relacionados à ocorrência de complicações pós-operatórias (pleuropulmonares, abdominais e sistêmicas), ao prolongamento do tempo de permanência hospitalar e à mortalidade ocorrida durante a internação. Caracterizamos os doentes quanto a sua gravidade, através da aplicação de índices objetivos de trauma, tanto fisiológico (RTS) quanto anatômicos (ISS, PATI, PTTI e PTI). Tanto nos ferimentos tóraco- abdominais quanto de tórax e abdome, o tratamento de escolha foi a drenagem pleural associada à laparotomia exploradora. Os ferimentos tóraco-abdominais apresentaram maior incidência de complicações em geral, em relação aos de tórax e abdome, quando a variável controle foi o ferimento produzido por arma branca. A análise por tipo de complicação mostrou que essa diferença foi dada pelo empiema pleural. Não encontramos diferença significante entre esses ferimentos com relação às demais complicações pleuropulmonares infecciosas, abdominais e sistêmicas. Os fatores que se correlacionaram com a evolução para empiema foram: o tipo de órgão lesado (estômago, esôfago e reto), a presença de fístula digestiva, o ferimento produzido por arma branca e a presença de lesão diafragmática. O prolongamento do tempo de permanência hospitalar foi determinado pela ocorrência de complicações e não pela lesão diafragmática. Houve doze (8,3%) mortes no estudo, sendo que a mortalidade correlacionou-se com maior média de lesões orgânicas por doente, com as lesões de rim, grandes vasos e esôfago, com a ocorrência de complicações especialmente de natureza infecciosa e com o ferimento produzido por projétil de arma de fogo. A análise dos nossos resultados permitiu concluir que os ferimentos penetrantes tóraco-abdominais apresentam maior número de lesões orgânicas por doente quando comparados aos ferimentos de tórax e abdome (sem lesão diafragmática), mas esses ferimentos não diferem quanto à mortalidade pós-operatória. Com relação à morbidade, a lesão diafragmática não foi fator determinante do prolongamento do tempo de permanência hospitalar e, na comparação dos ferimentos tóraco-abdominais e de tórax e abdome, a lesão diafragmática produzida por arma branca foi fator determinante do aparecimento de empiema pleural.

Penetrating cardiac injuries: a population-based study

BACKGROUND

Wide variances exist in reports of survival rates after penetrating cardiac injuries because most are hospital-based reports and thus are affected by the local trauma system. The objective of this study was to report population-based, as well as hospital-based, survival rates after penetrating cardiac injury.

METHODS

Retrospective cohort analysis was performed during a 7-year period of 20,181 consecutive trauma admissions to a regional Level I trauma center and 6,492 medical examiner's reports. A meta-analysis was performed comparing survival rates with available population-based reports.

RESULTS

There were 212 penetrating cardiac injuries identified, for an incidence of approximately 1 per 100,000 man years and 1 per 210 admissions. The overall survival rate was 19.3% (41 of 212) for the population studied, with survival rates of 9.7% (12 of 123) for gunshot wounds and 32.6% (29 of 89) for stab wounds. Ninety-six of the 212 patients were transported to the trauma center for treatment, resulting in an overall hospital survival rate of 42.7% (41 of 96), with a hospital survival rate of 29.3% (12 of 41) for gunshot wounds and 52.7% (29 of 55) for stab wounds.

CONCLUSION

Review of population-based studies indicates that there has been only a minor improvement in the survival rates for the treatment of penetrating cardiac injuries.

Management of chest injuries--a 5 year retrospective survey

One hundred and eighty one patients with chest injuries (145 with blunt injuries and 36 with penetrating injuries) were managed using a standardized protocol at the JIPMER Hospital between 1990 and 1995. The insertion of an intercostal tube drain, provision of analgesia and oxygen was sufficient in 80 per cent of patients. An operation was required in 30 per cent of those with penetrating injuries but in only 6.2 per cent of those with blunt injuries. Most patients with chest injuries do not require an operation and can be treated adequately at District General Hospitals. Those with penetrating injuries are more likely to need surgery than those with blunt injuries.

One hundred five penetrating cardiac injuries: a 2-year prospective evaluation

OBJECTIVES

To analyze the parameters measured in the field, during transport, and upon arrival of the physiologic condition of patients sustaining penetrating cardiac injuries, along with the Cardiovascular Respiratory Score (CVRS) component of the Trauma Score, the mechanism and anatomical site of injury, operative characteristics, and cardiac rhythm as predictors of outcome. We also set out to identify a set of patient characteristics that best predict mortality outcome and to correlate cardiac injury grade as determined by the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) with mortality.

METHODS

This report was a prospective study at American College of Surgeons Level I urban trauma center. Interventions included thoracotomy, sternotomy, or both, for resuscitation and definitive repair of cardiac injury. The main outcome measures used were those parameters measuring physiologic condition of patients, CVRS, mechanism and anatomical site of injury, mortality, and grade of injury.

RESULTS

A total of 105 patients sustained penetrating cardiac injuries: 68 injuries (65%) were gunshot wounds and 37 injuries (35%) were stab wounds. The mean Injury Severity Score was 36. Of the 105 wounds, 23 wounds (22%) involved multiple-chamber injuries. The overall survival was 35 of 105 patients (33%): survival of gunshot wound victims was 11 of 68 patients (16%); survival of stab wound victims was 24 of 37 patients (65%). Emergency department thoracotomy was performed in 71 of the 105 patients (68%) with 10 survivors (14%). CVRS: 94% mortality (50 of 53) when CVRS = 0, 89% mortality (57 of 64) when CVRS = 0 to 3, and 31% mortality (12 of 39) when CVRS 4 to 11 (p < 0.001). The presence of sinus rhythm when pericardium was opened predicted survival (p < 0.001). Anatomical site of injury (injured chamber) and the presence of tamponade did not predict survival. Stepwise logistic regression analysis identified gunshot wound, exsanguination, and restoration of blood pressure as most predictive variables of mortality. AAST-OIS injury grade and mortality: grade I, 0 of 1 (0%); grade II, 1 of 2 (50%); grade III, 2 of 3 (66%); grade IV, 28 of 50 (56%); grade V, 29 of 38 (76%); grade VI, 10 of 11 (91%). Overall incidence: grades IV-VI, 99 of 105 (94%).

CONCLUSIONS

Parameters measuring physiologic condition, CVRS, and mechanism of injury are significant predictors of outcome in penetrating cardiac injuries. AAST-OIS injury grades I-III are rare in penetrating cardiac trauma. AAST-OIS Injury grades IV-VI are common in penetrating cardiac trauma and accurately predict outcome.

Posttraumatic empyema thoracis: a 24-year experience at a major trauma center

The purpose of this paper is to review the outcome of patients with posttraumatic empyema thoracis. Between April 1972 and March 1996, the Division of Cardiothoracic Surgery at the King-Drew Medical Center managed or was consulted on 5,474 trauma patients (4,584 patients with penetrating injuries and 890 with blunt injuries) who were admitted emergently for thoracic and thoracoabdominal injuries and who underwent tube thoracostomy. Patients were not given routine prophylactic antibiotics merely because they had a chest tube placed. Based on our previous reports on thoracic trauma, our criteria for empiric antibiotic administration included (1) emergent or urgent thoracotomy, (2) soft-tissue destruction of the chest wall by shotgun injuries, (3) lung contusion with hemoptysis, (4) associated abdominal trauma requiring exploratory laparotomy, or (5) associated open long-bone fractures. Eighty-seven of these 5,474 patients developed posttraumatic empyema thoracis, for an incidence of 1.6%. These 87 patients were treated with tube thoracostomy, image-guided catheter drainage, or open thoracotomy with decortication. Seventy-nine of 87 patients (91%) were cured without conversion to open thoracostomy. Four patients required conversion to open thoracostomy, and there were three deaths. Even though a majority of our patients required decortication, successful management of posttraumatic empyema thoracis also was achieved with closed-tube thoracostomy or image-guided catheter drainage based on clinical and radiographic findings with appropriate patient selection. When thoracic empyema did occur in our group, Staphylococcus aureus was the most common microbe isolated, followed by anaerobic bacteria. In correlating microbiologic data with outcomes, S. aureus, especially methicillin-resistant S. aureus, was the most frequent cause of antibiotic failure. Because of the low incidence of posttraumatic empyema thoracis, we do not recommend routine antibiotic prophylaxis for all trauma patients who undergo closed-tube thoracostomy. A review of the role of tube thoracostomy, intrapleural fibrinolytic therapy, image-guided catheter drainage, video-assisted thoracoscopy, and open thoracotomy for the management of thoracic empyema is provided.

Effect of immediate fluid resuscitation on the rate, volume, and duration of pulmonary vascular hemorrhage in a sheep model of penetrating thoracic trauma

STUDY OBJECTIVE

To determine the effects of early fluid resuscitation on the rate, volume, and duration of hemorrhage using a sheep model of uncontrolled pulmonary vascular hemorrhage.

METHODS

Sixteen adult sheep were anesthetized and fitted with catheters to measure systemic and pulmonary artery pressures. A branch of the pulmonary vein was then lacerated through an anterolateral thoracotomy, and a chest tube was inserted to monitor hemorrhage volume. Eight animals were assigned to the immediate fluid (IF) resuscitation group and were given 30 mL/kg of lactated Ringer's solution over a period of 10 minutes; this treatment was repeated once if normotension was not achieved. The other eight animals received no fluid (NF) and served as nonresuscitated controls.

RESULTS

The IF animals had a mean hemorrhage volume of 3,494 +/- 1,525 mL, compared with 1,594 +/- 689 mL in the NF group (P < .001). Hemorrhage stopped spontaneously in the NF group at a mean of 29 +/- 9 minutes but took 48 +/- 11 minutes in the IF group (P = .003). During the 20-minute period of fluid resuscitation, the IF animals bled at twice the rate of the NF animals (90 +/- 33 versus 46 +/- 22 mL/minute, respectively; P = .02). During the 10-minute interval after fluids were administered, the rate of hemorrhage remained brisk at 73 +/- 57 mL/minute in the IF group but virtually stopped in the NF group (6 +/- 7 mL/minute; P = .02).

CONCLUSION

In this sheep model of uncontrolled pulmonary vascular hemorrhage, immediate fluid resuscitation significantly increased the rate, volume, and duration of hemorrhage. The vigorous administration of fluids to patients with penetrating chest trauma has the potential to significantly increase blood loss.

Management of 240 cases of penetrating thoracic injuries

We present a review of 240 patients with penetrating thoracic injuries seen in a period of 10 years at a general university hospital in Lima, Peru. The majority of the patients were young males who suffered stab wounds (76.2 per cent). The most frequent symptoms were thoracic pain (N = 202) and dyspnoea (N = 138); and the commonest physical findings were diminished respiratory sounds (N = 192) and tachypnoea (N = 167). Haemopneumothorax (N = 92), haemothorax (N = 81) and pneumothorax (N = 59) were the most frequent lesions. Cardiac lesions were present in 11 patients. The commonest extrathoracic associated lesions was penetrating abdominal injury (N = 43). The majority of the patients only required tube thoracostomy as definitive therapy (N = 143). There were 31 thoracotomies and 54 laparotomies. The most frequent complications were respiratory (N = 34) and neurological (N = 8). Gunshot wounds were more destructive than stab wounds. The first group of patients had a longer hospital stay (11.7 and 7.25 days), longer time with tube thoracostomy (5.98 and 4.18 days), more injured abdominal organs (3.8 and 2.38 organs) and higher mortality (7.01 per cent and 3.82 per cent) than the second group. The overall mortality was 4.58 per cent. The patients with a cardiac lesion had a higher mortality (27.27 per cent) than those who did not (3.49 per cent).

Thoracic gunshot wounds in children under 17 years of age

Over the past decade there has been a significant increase in the incidence of gunshot wounds (GSW) among Americans under 19 years of age. Despite the increase, pediatric GSW have received little attention in the literature, and no study has focused on pediatric victims of thoracic GSW. In the present study, the authors performed a retrospective review of the records of 51 patients under 17 years of age who were treated for thoracic GSW at adjoining level I pediatric and adult trauma centers between July 1987 and June 1995. The primary catchment area for these institutions is a lower socioeconomic, urban tenancy. The study population was 80.4% male and 86.3% black; the mean age was 12.4 years. The mean injury severity score and trauma score were 13.6 and 13.4, respectively. Although statistically significant differences could not be demonstrated with this population size, trends were evident when the group was subdivided by age group (< or = 12 years and > 12 years of age). The younger group was more likely to require a thoracic operation after injury (35.3% v 23.5%), to have unstable vital signs (41.2% v 26.5%), to have a higher total abbreviated injury score (AIS) for the chest (4.8 v 4.0); however, their total extrathoracic AIS was lower (2.1 v 3.1). The younger group spend more time in the hospital and in the intensive care unit (7.6 v 4.6 days and 2.0 v 0.9 days, respectively). The younger children were more likely to have sustained injury by unintentional crossfire (35.3% v 14.7%) and were never injured by intentional assault (0% v 47.2%). Overall, 50% of the patients required surgery, including 93.8% of the patients who had unstable vital signs at the time of arrival. All six deaths (11.8%) owing to the thoracic injury occurred in patients who had mediastinal injury that required an emergency-department thoracotomy (EDT). The authors conclude that among this predominantly black male population, there are different trends with respect to treatment, circumstances, and pattern of injury between the younger and older subpopulations.

Penetrating chest injuries in children: a review of 94 cases

Ninety-four children with penetrating chest injuries were treated at Dicle University School of Medicine during a 6-year period. The mean age was 11.51 +/- 3.31 years, and the male:female ratio was 5.25:1. Forty-five had stab wounds, 27 had high-velocity gunshot wounds, 13 had low-velocity gunshot wounds, seven had a bomb (shrapnel) injury, one had a shotgun wound, and one had a horse bite. Sixty patients had isolated thoracic injuries, and 34 had associated injuries. The most common thoracic injury was hemothorax (28), followed by hemopneumothorax (25). Tube thoracostomy alone was sufficient in 79.8% of the patients (75 of 94). Thoracotomy was performed in 4.25% (4 of 94). In two of the five observed patients, delayed hemothorax developed. The mean duration of hospitalization was 5.13 +/- 1.93 days. The mean Injury Severity Score was 14.71 +/- 8.62. Prophylactic antibiotics were used in all patients. The morbidity rate was 8.51% (8 of 94). Only one death occurred after cervical tracheal repair. The study suggests that the majority of penetrating chest injuries in children can be treated successfully by tube thoracostomy alone or in conjunction with expectant observation.

Factors influencing outcome in stab wounds of the heart

BACKGROUND

The purpose of this study was to identify factors associated with unfavorable outcome following stab wounds to the heart in order to improve selection of patients who may benefit from aggressive resuscitative efforts.

METHODS

Preoperative and operative variables were reviewed for all patients treated for cardiac stab wounds at a level I trauma center from 1987 to 1993 in an attempt to identify factors influencing survival.

RESULTS

Twenty-nine (53%) of the 55 patients who were resuscitated following stab wounds to the heart during the study period survived. Although profound hypotension (systolic blood pressure < 40 mm Hg), cardiopulmonary resuscitation, and emergency room thoracotomies were associated with poor outcome, none were uniformly predictive of death. Some patients survived with each of these characteristics.

CONCLUSIONS

We recommend that all patients suspected of having cardiac stab wounds be fully resuscitated and undergo thoracotomy, as significant survival can be achieved and death is not always the outcome.