[Thoracic and abdominal and limb wounds by gun shot]

In Japan, we are permitted to own fire arms only for hunting and clay pigeon shooting, but gunshot wound victims have neen rarely seen due to the strict laws against owing guns, and the lack of related crimes. Therefore, surgeons should be familiar with ballistics, practical gunshot wound management, and the possibility of delayed lead poisoning ssociated with bullet residue. A 69-year-old man was brought to our hospital because he was accidentally shot by his companion's shotgun during hunting. On admission, although he had stable vital sign and multiple gunshot wounds on his right forearm and femur, chest X-ray and computed tomography (CT) revealed a few of bullets and its flagments on his back, into spleen and pericardium. Following local debridment after removal of the bullets in his right forearm and femur at an emergency room, broken heart muscle and diaphragm were repaired and hematoma in the anterior mediastinum was removed at the operating room. The patient was discharged on the 25th post-operative day and his post-operative course was uneventful. In case of gunshot injuries, in addition to prompt diagnosis and evaluation of organ injuries, careful follow up for possible delayed lead poisoning is important.

[Conservative treatment of oesophageal perforation in a child caused by a toothbrush]

Traumatic perforation of the oesophagus is a condition with high morbidity and mortality. We report a case of a one-year-old girl with traumatic oesophageal perforation caused by a fall with a toothbrush. She underwent a conservative regimen consisting of drainage of the mediastinum by a naso-cavitary drain, antibiotics and a feeding tube. No sign of mediastinitis was found on a follow-up computed tomography 19 days later, and she was discharged in good condition.

Methemoglobinemia after a mediastinal stab wound

BACKGROUND

Methemoglobinemia is a relatively common, potentially fatal syndrome resulting from oxidative stress. Of the numerous causes identified, toxins are the most common precipitating event.

OBJECTIVES

Describe methemoglobinemia after a stab wound in a man with previously undiagnosed cytochrome b5 reductase deficiency.

CASE REPORT

In this case report, we describe a 27-year-old man with no past medical history who developed clinically significant methemoglobinemia after a mediastinal stab wound. After an extensive toxicologic work-up failed to reveal the etiology of the symptoms, genetic testing was performed, which revealed the individual to have a previously undiagnosed cytochrome b5 reductase deficiency. It is hypothesized that the physiologic stress from the expanding mediastinal stab wound resulted in enough oxidative stress to cause methemoglobinemia in this predisposed individual. A discussion of methemoglobinemia ensues.

CONCLUSION

This case describes an uncommon presentation of a common toxicologic condition and presents a discussion regarding the evaluation, management, and pathophysiology of methemoglobinemia.

Pediatric thoracic and abdominal trauma

Thoracic and abdominal injuries in children are commonly the result of blunt trauma, making their diagnosis difficult. Unidentified injuries can cause significant morbidity and mortality and must be identified early. Understanding the anatomic and physiologic differences between children and adults is important to adequately manage children with these injuries. The following review provides salient points in the recognition and management of both thoracic and abdominal injuries in children from blunt trauma.

[Thoracoscopic surgery for traumatic mediastinal hematoma]

We report a rare case of traumatic mediastinal hematoma treated by thoracoscopic surgery. A 78-year-old man accidentally fell down from the roof, and he was urgently transferred to our hospital. Soon after the arrival, he showed breathlessness followed by cardiopulmonary arrest, necessitating tracheal intubation and resuscitation. Computed tomography (CT) showed a large cervical hematoma extending to the tracheal bifurcation level of mediastinum, causing tracheal obstruction. Five days later, the large mediastinal hematoma was removed by thoracoscopic surgery. The patient recovered without any complications after our treatments.

A case of nasogastric tube perforation of the nasopharynx causing a fatal mediastinal complication

Iatrogenic nasopharyngeal perforations secondary to improper nasogastric tube insertion probably occur more frequently than has been reported. Our review of the literature found very few cases. We report the case of a 79-year-old woman who died of mediastinal complications following the improper insertion of a nasogastric tube that resulted in a nasopharyngeal perforation. We also review the proper technique for inserting these tubes.

[Therapeutic approach in hemodynamically stable transmediastinal gunshot wounds]

Transmediastinal gunshot wounds may result in damage to the heart, large blood vessels, esophagus or lung. In hemodynamically stable patients, diagnostic examinations have critical importance and the preferred therapies still have unresolved points. In this paper, we present our experience with five patients, three of whom were operated for transmediastinal gunshot wounds after diagnostic tests; all were hemodynamically stable. Before deciding on operation, diagnostic tests should be performed in hemodynamically stable patients with transmediastinal gunshot wounds.

Is there a role for secondary thoracic ultrasound in patients with penetrating injuries to the anterior mediastinum?

Pericardial tamponade (PT) after penetrating thoracic injury can be lethal if not diagnosed and treated promptly. Most patients present with PT shortly after their injuries occur, but delayed presentation of PT (delayed pericardial tamponade [DPT]) has occurred as late as 73 days after initial injury. Initial evaluation of patients with an anterior mediastinal penetrating injury includes physical examination, chest x-ray, and echocardiography. CT scans of the chest can clarify the tracts of penetrating injuries in stable patients. With increased accessibility to these radiographic modalities, PT has been diagnosed in a more timely fashion, and the incidence of DPT has decreased. However, the absence of pericardial effusions on all of these studies at initial presentation does not clear the patient from risk for developing DPT.

Triage and Outcome of Patients with Mediastinal Penetrating Trauma

BACKGROUND

A retrospective study was conducted detailing an experience with echocardiography and contrast-enhanced helical computed tomographic angiographic (CTA) scans in the evaluation of stable patients with mediastinal penetrating trauma (MPT).

METHODS

Unstable patients underwent emergent operative intervention, and stable patients underwent chest roentgenogram, transthoracic echocardiography (TTE), and CTA. Further testing (angiogram, bronchoscopy, esophagoscopy, esophagogram) was done only if one of these studies revealed evidence of a trajectory in the vicinity of major vasculature or viscera.

RESULTS

Between 1997 and 2003, 207 patients had MPT. Seventy-two (35%) were unstable (45 gun shot wounds, 27 stab wounds) and 19 died in the emergency department. Fifty-three had emergent intervention and 32 survived. Work-up was done on 135 stable patients (65%) consisting of 46 gunshot wounds and 89 stab wounds, of which 5 had a positive TTE result and underwent a repair of a cardiac injury. CTA evaluation was normal in almost 80% of patients, who subsequently did not require further evaluation or treatment. In the stable patients, endoscopy or esophagography confirmed one tracheal injury and no esophageal injury. In the entire group, 10 patients (7%) had occult injury, and there were no deaths or missed injuries.

CONCLUSIONS

In cases of MPT, unstable patients require surgery, and in stable patients, TTE and chest CTA are effective screening tools. Patients with a negative TTE and CTA results can be observed and may not require further testing or endoscopy, whereas patients with positive TTE or CTA results require further assessment to exclude occult injury.

Screening helical computed tomographic scanning in haemodynamic stable patients with transmediastinal gunshot wounds

AIM

The purpose of this study was to review and evaluate the efficacy of contrast-enhanced helical computed tomographic (CT) scanning in evaluating potential mediastinal injuries in stable patients with transmediastinal gunshot wounds (TMGSWs).

METHODS

During the review period, 01 January 2002-31 May 2005, the medical records of all haemodynamically stable patients with TMGSWs were retrieved and reviewed for demographics, diagnostic workup, treatment and complications. Screening CT was considered inconclusive in the presence of a mediastinal haematoma, pneumomediastinum or a missile track in proximity of major mediastinal structures. Inconclusive CT scans were further evaluated with angiography, and/or oesophography, and/or cardiac ultrasound.

RESULTS

Fifty consecutive haemodynamically stable patients with TMGSWs were identified. Thirty-five CT scans were performed, of which 29 (82.9%) were conclusive. Further diagnostic evaluation in the remaining six patients showed no injury. All patients were observed in a high-care unit and there were no missed injuries. The hospital charges generated with the CT scan based protocol were significantly less than with standard evaluation.

CONCLUSION

Contrast enhanced helical CT scanning is a safe, efficient and cost effective screening tool for evaluating haemodynamically stable patients with TMGSWs.

Traumatic pseudoaneurysm from the aorta to the left common carotid artery presenting as widened mediastinum

Diagnosis of pseudoaneurysm of the aorta or its main branches is a challenge in patients with blunt chest trauma. Computed tomography helps to demonstrate intrathoracic hemorrhage and suspected great vascular injury when a chest radiograph reveals widening of the mediastinum. Aortic angiography remains the gold standard in the determination of the site, and severity of vascular injury for definitive surgical intervention. Timing of surgical repair is controversial. Delayed repair of traumatic pseudoaneurysm of the aorta after primary control of associate injuries decreases mortality significantly, thus improving prognosis. We report a case of successful repair of a traumatic pseudoaneurysm of the aortic arch with extension to the left common carotid artery in an 18-year-old female patient. The diagnosis, surgical approaches, and timing of operation are discussed along with case presentation.

Nonvascular Mediastinal Trauma

This article discusses the radiologic and clinical features of nonvascular mediastinal trauma, and focuses on the tracheobronchial tree, the esophagus, and the thoracic duct. Blunt chest and penetrating trauma account for most of the causes of such nonvascular injuries, but iatrogenic and inhalation injuries are other well-known causes. The injury distribution and clinical manifestations are different for each structure. In our combined experience at a level 1 trauma center, the overall prevalence of injury in each organ is low compared with vascular injuries. As such, and given the frequent nonspecific nature of clinical signs and symptoms of nonvascular mediastinal injuries, the diagnosis often is delayed and results in poor treatment outcome.

Occult mediastinal great vessel trauma: the value of aortography performed during angiographic screening for blunt cervical vascular trauma

PURPOSE

To determine the value of aortography in the assessment of occult aortic and great vessel injuries when routinely performed during screening angiography for blunt cerebrovascular injury (BCVI).

METHODS

One hundred and one consecutive patients who received both aortography and screening four-vessel angiography over 4 years were identified retrospectively. Angiograms for these patients were evaluated, and the incidence of occult mediastinal vascular injury was determined.

RESULTS

Of the 101 patients, 6 (6%) had angiographically documented traumatic aortic injuries. Of these 6 patients, one injury (17%) was unsuspected prior to angiography. Four of the 6 (67%) also had BCVI. One additional patient also had an injury to a branch of the subclavian artery.

CONCLUSION

Routine aortography during screening angiography for BCVI is not warranted due to the low incidence (1%) of occult mediastinal arterial injury. However, in the setting of a BCVI screening study and no CT scan of the chest, aortography may be advantageous.

Traumatic retropharyngeal haematoma in an anticoagulated patient: Case report and proposal for a clinical protocol

Retropharyngeal haematomas (RPHs) are rare but potentially life-threatening conditions that require a prompt diagnosis. However, the clinical scenario is not always straightforward as their presentation may be insidious, with no specific signs or symptoms. Treatment of RPH is conservative in the majority of cases, with close observation. Nevertheless, surgical intervention is sometimes indicated for large, non-resolving haematomas. We present the case of a 53-year-old woman on anticoagulant therapy who required evacuation of a traumatic RPH. We also propose a clinical protocol for the management of these entities according to our experience and previous literature reports.

[Flap transverse sternotomy during operations on the vessels and organs of the upper mediastinum and the first cervical zone]

A surgical approach to vessels and organs of the upper mediastinum was grounded, developed and tested. An experimental study of flap transverse sternotomy was carried out in 20 cadavers. A wide approach with throwing of the presternum was the best for manipulations in proximal parts of the aortic branches. This approach was also less traumatic.

[Traumatic chest lesions. Computed tomography findings]

Trauma is nowadays one of the most common causes of death and traumatic thoracic lesions are important agravant to trauma patients. In this work the aspects of computed tomography from 200 cases of thoracic trauma were studied. Lung lesions predominated, found in 192 cases (96%), manifested as contusions in 178 cases (89%), atelectasis in 41 cases (20.5%), lacerations in 15 cases (7.5%) and hematomas in 6 cases (3%). Pleural lesions were showed in 140 cases (70%), among them in 121 cases (60.5%) there were hemothorax and in 84 cases (42%), pneumothorax. Mediastinal lesions were observed in 28 cases (14%), with pneumomediastinum in 18 cases (9%), mediastinal hematoma in 7 cases (3.5%), hemopericardium in 4 cases (2%) and aortic lesions in 3 cases (1.5%). Diaphragmatic rupture was seen in 8 patients (4%). Soft tissue emphysema was demonstrated in 36 cases (18%).

Total mediastinal traverse with isolated internal mammary artery transection

Transmediastinal gunshot wounds are infrequent but life-threatening injuries. The course of the projectile and the bullet track often is unpredictable. Prompt and specific diagnostic and therapeutic interventions are necessary to quickly identify and repair potentially life-threatening injuries to the heart, great vessels, and the aerodigestive tract. Multiple diagnostic algorithms exist for work-up of these injuries, and the therapeutic interventions are diverse and challenging. We describe a patient with total mediastinal traverse, who presented with right-sided hemopneumothorax. The work-up revealed surprisingly an isolated left internal mammary artery transection with a significant hemorrhage that mandated surgical intervention in left chest.

Hemomediastinum Resulting from Subclavian Artery Laceration During Internal Jugular Catheterization

The complications associated with internal jugular vein catheterization are inadvertent arterial puncture, pleural and mediastinal injuries, pneumothorax, hemothorax, and hemomediastinum. Complications caused by laceration of a subclavian artery are rare. We present a case of hemomediastinum resulting from laceration of the subclavian artery during central venous catheterization. After right internal jugular vein catheterization, the left lateral decubitus position was maintained for 6 h during surgery. The severe hypotension was first noted in the supine position after transfer to the postanesthesia care unit. Chest radiograph showed a bulging of the right upper mediastinum. During the upper half sternotomy, a 5-mm long laceration was found at the posteroinferior side of the right subclavian artery near its origin from the innominate artery.

IMPLICATIONS

The authors describe the delayed presentation of hemomediastinum resulting from subclavian artery laceration after internal jugular vein catheterization.

Trans-mediastinal gunshot wounds: are "stable" patients really stable?

Gunshot wounds that traverse the mediastinum frequently cause serious injury to the cardiac, vascular, pulmonary, and digestive structures contained within. Most patients present with unstable vital signs signifying the need for emergency operation. An occasional patient will present with stable vital signs. Work-ups for such a patient may range from surgical exploration to radiographic and endoscopic testing to mere observation. We report our experience with diagnostic work-up of the stable patient with a transmediastinal gunshot wound. All stable patients who present to our urban level I trauma center following a transmediastinal gunshot wound undergo diagnostic work-up consisting of chest radiograph, cardiac ultrasound, angiography, esophagoscopy, barium swallow, and bronchoscopy. The work-up is dependent on the trajectory of the missile. Information on these patients is kept in a prospective database maintained by the trauma attending physicians. This database was analyzed and comparisons were made using Student's t-test and the Fisher exact c2 as appropriate. Over a 68-month period, 50 stable patients were admitted following a transmediastinal gunshot wound. All of these patients had a chest radiograph followed by one or more of the above tests. 8 patients (16%) were found to have a mediastinal injury (4 cardiac, 3 vascular, and 1 tracheo-esophageal) requiring urgent operation (group 1). The remaining 42 patients (84%) did not have a mediastinal injury (group 2). There was no difference between groups with respect to blood pressure, pulse, respiratory rate, pH, base deficit, or initial chest tube output. There was one death in each group, and three complications in group 2. Patients may appear stable following a transmediastinal gunshot wound, even when they have life-threatening injuries. There is no difference in vital signs, blood gas, or hemothorax to indicate which patients have serious injuries. We advocate continued aggressive work-up of these patients to avoid missing an injury with disastrous consequences.

Reevaluation of diagnostic procedures for transmediastinal gunshot wounds

BACKGROUND

Little controversy surrounds the treatment of hemodynamically unstable patients with transmediastinal gunshot wounds (TMGSWs). These patients generally have cardiac or major vascular injuries and require immediate operation. In hemodynamically stable patients, debate surrounds the extent and order of the diagnostic evaluation. These patients can be uninjured, or can have occult vascular, esophageal, or tracheobronchial injuries. Evaluation has traditionally often included angiography, bronchoscopy, esophagoscopy, esophagography, and pericardial evaluation (i.e., pericardial window) for all hemodynamically stable patients with TMGSWs. Expansion of the use of computed tomographic (CT) scanning in penetrating injury led to a modification of our protocol. Currently, our TMGSW evaluation algorithm for stable patients consists of chest radiograph, focused abdominal sonography for trauma, and contrast-enhanced helical CT scan of the chest with directed further evaluation. The purpose of this study is to evaluate the efficiency of contrast-enhanced helical CT scan for evaluating potential mediastinal injuries and to determine whether patients can be simply observed or require further investigational studies.

METHODS

Medical records of hemodynamically stable patients admitted with TMGSWs over a 2-year period were reviewed for demographics, mechanism of injury, method of evaluation, operative interventions, injuries, length of stay, and complications. CT scans were considered positive if they contained a mediastinal hematoma or pneumomediastinum, or demonstrated proximity of the missile track to major mediastinal structures.

RESULTS

Twenty-two stable patients were studied. CT scans were positive in seven patients. Directed further diagnostic evaluation in those seven patients revealed two patients who required operative intervention. Sixty-eight percent of patients had negative CT scans and were observed in a monitored setting without further evaluation. There were no missed injuries. The hospital charges generated with the CT scan-based protocol are significantly less than with the standard evaluation.

CONCLUSION

Contrast-enhanced helical CT scanning is a safe, efficient, and cost-effective diagnostic tool for evaluating hemodynamically stable patients with mediastinal gunshot wounds. Positive CT scan results direct the further evaluation of potentially injured structures. Patients with negative results can safely be observed in a monitored setting without further evaluation.

Major mediastinal injury from crossbow bolt

We treated a 26-year-old male who sustained a self-inflicted injury to the mediastinum with a crossbow bolt. Injuries involved penetration of the sternum 1 cm below the sternomanubrial joint, right lung, pericardium, ascending aorta, right pulmonary artery, esophagus, and azygos vein. He was treated successfully with cardiopulmonary bypass and hypothermia. Exposure was achieved with a combination of a sternotomy and right thoracotomy.

Mediastinal impalement with survival: a case report

Mediastinal impalement injuries are rare and often fatal. Very few instances of survival after mediastinal impalement have been reported. We present the unusual case of an 18-year-old man who was involved in a motor vehicle crash in which a wooden fencepost intruded through the windshield and impaled him through the superior mediastinum. The patient remained hemodynamically stable and had no other significant injuries except a left pneumothorax. Arteriogram revealed a bovine aortic arch with the wooden piece passing over the aortic arch between the two brachiocephalic arteries at the precise point that a normal left common carotid artery would have been located. No other injuries were seen on arteriogram, venogram, or esophagram. The foreign body was extracted via thoracotomy along with resection of the apex of the left lung and ligation of the thoracic duct. The patient was discharged on hospital day eight and was doing quite well at one-year follow-up with no residual effects of his accident.

Cardiovascular Injuries associated with Sternal Fractures

OBJECTIVE

To find out if the presence of a sternal fracture indicates cardiac and aortic injuries and to clarify the difference between a retrosternal haematoma and widened mediastinum.

DESIGN

Retrospective study.

SETTING

Teaching hospital, Sweden.

SUBJECTS

418 patients with blunt chest trauma of whom 29 had a fractured sternum (11 with retrosternal haematoma and 18 without) and 389 did not (7 with widened mediastinum and 382 without).

MAIN OUTCOME MEASURES

Definitions, risk factors, morbidity, and mortality.

RESULTS

Retrosternal haematomas were found adjacent to many fractures and ranged in size from a few mm to 2 cm. They were more common in fractures of the body of sternum. There was no significant difference in the number of associated lesions between patients with sternal fractures with or without a retrosternal haematoma. Conversely, patients with a widened mediastinum had a higher injury severity score, longer hospital stay (p < 0.0001), and more associated lesions (p < 0.05) than those with retrosternal haematomas. Six patients still had pain 1 month after injury of whom two had injury-related long-term disability because of pain. No serious cardiac or aortic injuries were detected in this series. The early mortality in our study was 2/29 in patients with sternal fractures and 1/7 in patients with widened mediastinum.

CONCLUSIONS

Sternal fractures are more common than previously reported. An aggressive approach including early operative reduction is recommended even for a stable fracture to reduce the overhelming pain. Sternal fracture with or without retrosternal heamatoma is not a reliable indicator of cardiac and aortic injuries, while mediastinal widening is still a fairly reliable clue that should indicate further investigation.

Penetrating wounds of the torso

Penetrating trauma is on the increase as a result of interpersonal violence throughout the world. It is essential that military surgeons are familiar with such injuries and trained not only in the principles of their management, but also have first-hand operative experience before deployment in the field of conflict. More often than not, this experience is to be gained in the civilian urban setting in countries such as South Africa and the USA. The article addresses the first requirement--the principles of management--and outlines basic measures to enable those unfamiliar with penetrating wounds of the torso to make a reasonable and directed approach to dealing with these patients. It does not attempt to give definitive advice on specific injuries. It is organised according to anatomical regions, but emphasises that this is only in order to put shape to the article; penetrating injuries frequently having no respect for anatomical boundaries. Particular attention is drawn to difficult areas such as mediastinal injuries, and to modern concepts of 'damage control' surgery and the 'abdominal compartment syndrome'. The emphasis throughout is on how to get out of trouble and where particular danger spots may be anticipated. Reference will be made to the differences that may be expected within the military environment as opposed to the civilian setting, where rapid and (usually) safe evacuation to a well-equipped secure facility may not be possible. The article aims to raise the awareness of those involved in the care of patients with penetrating wounds of the torso that a methodical approach with a practised team of experienced individuals can salvage injuries which at first sight may seem terrifying or hopeless.

Significance of a widened mediastinum in blunt chest trauma patients

Eighteen blunt chest trauma patients who had mediastinal widening on chest roengenogram were studied for the correlation with traumatic ruptured of the aorta or its major branches. Seventeen patients were male and one was female. The age ranged from 18 to 39 years, mean 26.17+/-6.85SD. The Injury Severity Score (ISS) ranged from 9 to 34, mean 25.5+/-6.49SD. Fourteen patients (77.8%) sustained motorcycle accidents, 3 patients (16.7%) sustained car accidents and 1 patient (5.5%) fell from a 4 storey building. All patients underwent aortography to search for traumatic rupture of the aorta or its major branches. Six patients had computed tomography of the chest before aortography. Nine patients (50%) had normal aortography. The remaining 9 patients who had positive aortography underwent urgent thoracotomies, 8 of them had traumatic rupture of the aorta or its major branches, the remaining 1 patient had normal operative finding. Of the 8 patients who had traumatic rupture of the aorta or its major branches, 1 patient died. The mortality was 12.5 per cent. The rate of traumatic rupture of the aorta or its major branches in patients who had blunt chest trauma and widening of the mediastinum on chest roengenogram in our study was 44.4 per cent. The sensitivity of aortography for diagnosis of traumatic rupture of the aorta or its major branches was 100 per cent and the specificity was 90 per cent. On the basis of this study, we conclude that blunt chest trauma patients with widened mediastinum on chest roengenogram have a significantly high rate of traumatic rupture of the aorta or its major branches. All blunt chest trauma patients who have widened mediastinum on chest reongenogram should undergo further investigations to exclude traumatic rupture of the aorta or its major branches. We recommend aortography as the investigation of choice due to its accuracy and usefulness in management plan.

Helical computed tomographic scan in the evaluation of mediastinal gunshot wounds

BACKGROUND

The standard evaluation of mediastinal gunshot wounds usually requires angiography and either esophagoscopy or esophagography. In the present study, we have evaluated the role of helical computed tomographic (CT) scanning in reducing the need for angiographic and esophageal studies.

METHODS

This was a prospective study of patients with mediastinal gunshot wounds who were hemodynamically stable and would otherwise require angiography and esophageal evaluation. All patients underwent CT scan of the chest with intravenous contrast to delineate the missile trajectory. If the missile tract was in close proximity to the aorta, great vessels, or esophagus, then traditional evaluation with angiographic or esophageal evaluation was pursued.

RESULTS

A total of 24 patients met the inclusion criteria and underwent CT scan evaluation of their mediastinal gunshot wounds. One patient was taken for sternotomy to remove a missile embedded in the myocardium solely on the basis of the result of the CT scan. Because of proximity of the bullet tract, 12 patients required additional evaluation with eight angiograms and nine esophageal studies. One of these patients had a positive angiogram (bullet resting against the ascending aorta) and underwent sternotomy for missile removal; all other studies were negative. The remaining 11 patients were found to have well-defined missile tracts that approached neither the aorta nor the esophagus, and no additional evaluation was pursued. There were no missed mediastinal injuries in this group. Overall, 12 of 24 patients (50%) had a change in management (either received an operation or avoided additional radiographic or endoscopic evaluation) on the basis of the CT scan.

CONCLUSION

The helical CT scan provides a rapid, readily available, noninvasive means to evaluate missile trajectories. This permits accurate assessment of potential mediastinal injury and reduces the need for routine angiographic and esophageal studies.

[Application of spiral computerized tomography in the study of traumatic lesions of the thoracic aorta]

PURPOSE

Acute thoracic aortic injuries account for up to 10-20% of fatalities in high-speed deceleration road accidents and have an estimated immediate fatality rate of 80-90%. Untreated survivors to acute trauma (10-20%) have a dismal prognosis: 30% of them die within 6 hours, 40-50% die within 24 hours, and 90% within 4 months. We investigated the diagnostic accuracy of Helical Computed Tomography (Helical CT) in acute traumatic injuries of the thoracic aorta, and the role of this technique in the diagnostic management of trauma patients with a strong suspicion of aortic rupture.

MATERIAL AND METHODS

We compared retrospectively the chest Helical CT findings of 256 trauma patients examined June 1995 through August 1999. All patients underwent a plain chest radiograph in supine recumbency when admitted to the Emergency Room. Chest Helical CT examinations were performed according to trauma score, to associated traumatic lesions and to plain chest radiographic findings. All the examinations were performed with no intravenous contrast agent administration and the pitch 2 technique. After a previous baseline study, contrast-enhanced scans were acquired with pitch 1 in 87 patients. All examinations were assessed for the presence of mediastinal hematoma, periaortic hematoma, traumatic pseudodiverticulum, irregular aortic wall or contour and intimal flap as signs of aortic rupture.

RESULTS

Helical CT showed thoracic aortic lesions in 9 of 256 patients examined. In all the 9 cases we found a mediastinal hematoma and all of them had positive plain chest radiographic findings of mediastinal enlargement. Moreover, in 6 cases aortic knob blurring was also evident on plain chest film and in 5 cases depressed left mainstem bronchus and trachea deviation rightwards were observed. All aortic lesions were identified on axial scans and located at the isthmus of level. Aortic rupture was always depicted as pseudodiverticulum of the proximal descending tract and intimal flap. We also found periaortic hematoma in 6 cases and intramural hematoma in 1 case. There were no false positive results in our series: 7 patients with Helical CT diagnosis of aortic rupture were submitted to conventional aortography that confirmed both type and extension of the lesions as detected by Helical CT, and all findings were confirmed by gross inspection at surgery. No false negative results have been recorded so far: untreated aortic ruptures are fatal within 4 months in 90% of patients, or they may evolve into chronic pseudoaneurysm in about 5% of survivors.

CONCLUSIONS

In our experience Helical CT had much higher diagnostic sensitivity and specificity than plain chest radiography. In agreement with larger published series, in our small one the diagnostic accuracy of Helical CT was 100% in the evaluation of traumatic aortic ruptures. Moreover, Helical CT is faster and less invasive than conventional aortography, which makes this diagnostic modality increasingly used and markedly improves the management of the serious trauma patient. The more widespread use of this diagnostic tool has permitted to standardize the technique and now Helical CT can be used not only as a screening modality for patients that undergo digital aortography, but also as a reliable diagnostic method for surgical planning.

Transmediastinal gunshot injuries

BACKGROUND

Transmediastinal gunshot injuries are a rarely reported injury. Until recently, assessment of the thoracic aorta by angiography preceded the investigation of the esophagus. This order has been recently debated.

METHODS

There were 118 patients with potential transmediastinal injuries included in this retrospective study. Unstable patients who were unresponsive to resuscitation were taken to the operating room without previous investigation. Stable patients were routinely investigated initially for injury of the aorta and then for injury of the esophagus.

RESULTS

There were 51 patients who underwent urgent thoracotomy/sternotomy. In 27, the hemorrhage was of mediastinal origin; 17 of these patients died of intraoperative bleeding. Eight of the patients had aortic injury, and only one of this group survived. There were 57 stable patients who were investigated initially for injury of the aorta by angiography. It was positive in only one patient who underwent an operation with good results. An investigation of the esophagus followed and revealed esophageal injury in 17 patients. All of them were treated operatively, 15 of them with satisfactory outcome.

CONCLUSIONS

Angiography should at present precede esophageal investigations. There is a need for shortening the time between admission and operation. Other modalities that could expedite the investigation of the thoracic aorta and the esophagus should be prospectively evaluated in multi-center studies.

Nonaortic mediastinal injuries from blunt chest trauma

In addition to traumatic aortic injuries (TAI), blunt chest trauma may damage other structures in the mediastinum, including the tracheobronchial tree, the heart and pericardium, and rarely the esophagus. Tracheobronchial injuries may be difficult to separate radiographically from accompanying parenchymal lung injuries. Experience with diagnosis by computed tomography (CT) is still limited. Cardiac injuries often require emergent surgery before extensive imaging can be done. Some patients, usually those with chamber ruptures of the right heart, survive long enough to receive a chest CT, at which time hemopericardium can be detected. Upper esophageal injuries may occur in conjunction with lower cervical or upper thoracic spine injures. Distal esophageal injuries are rarely caused by blunt trauma.

Transmediastinal gunshot wounds: a prospective study

OBJECTIVE

To evaluate admission systolic blood pressure (SBP) in the emergency center (EC) as a means by which patients with transmediastinal gunshot wounds (TM-GSWs) can be triaged to the operating room versus further diagnostic evaluation.

METHODS

A prospective case series presenting concurrent data collected for 68 consecutive patients with TM-GSWs admitted to one urban trauma center over a 4.5-year period. For purposes of analysis, patients were assigned to the following groups based on SBP in the EC: group I, SBP > 100 mm Hg; group II, SBP from 60 to 100 mm Hg; group III, SBP < 60 mm Hg.

RESULTS

The management and outcomes of 68 patients with a mean age of 29 years were evaluated. For patients in group I (n = 20), TM-GSW was diagnosed by findings on x-ray film for 15 patients (75%), at physical examination for 4 patients (20%), and at operation for 1 patient (5%). Indications for immediate operation were found in five patients (25%), whereas further diagnostic evaluation prompted operation for three additional patients. Only one patient developed persistent hypotension from neurogenic shock. There were two deaths from late complications. In patients in group II (n = 16), TM-GSW was diagnosed by findings on x-ray film for 9 patients (56%), at physical examination for 5 patients (31%), and at operation for 2 patients (13%). Six patients with persistent hypotension had indications for immediate operation, whereas further diagnostic evaluation in the remaining patients, who became hemodynamically normal during resuscitation, prompted operation in an additional two patients. There were two intraoperative deaths. For the patients in group III (n = 32), six patients with signs of life underwent immediate operation with one intraoperative death, seventeen patients required EC thoracotomy with 100% mortality, and nine patients were pronounced dead in the EC without an attempt at operation.

CONCLUSION

The diagnosis of TM-GSW for patients in groups I and II is confirmed by finding at physical examination and on chest x-ray films in 90% of cases. In the absence of obvious bleeding, patients with TM-GSWs and SBP > 100 mm Hg may safely undergo further diagnostic evaluation. Sixty percent of such patients did not require an operation. All patients with TM-GSWs and SBP < 60 mm Hg (group III) require immediate operation. For patients with TM-GSWs, SBP from 60 to 100 mm Hg (group II), and without obvious bleeding, it is the response to resuscitation and the results of further diagnostic evaluation that determine the need for operation. Fifty percent of such patients did not require operation.

[The role of computed tomography in gunshot lesions of the chest. The authors' personal experience]

PURPOSE

CT is a valuable tool in assessing thoracic gunshot wounds. CT is also the method of choice in emergency, because it permits rapid depiction of bullet damage to the chest and to other body districts. This in turn permits correct assessment of the main thoracic injuries, plus adequate and prompt planning of surgical treatment or support intensive care. We report on the role of CT in diagnosing the complex pleuropulmonary, cardiovascular and thoracic wall injuries caused by gunshot wounds, with their specific and acute signs which differ greatly from those of other types of chest trauma.

MATERIAL AND METHODS

In the last 4 years, we observed 76 cases of gunshot injury, twenty-six of them involved the chest. The patients, 25 men and 1 woman (mean age: 32 years, range: 17-48), were all submitted to emergency CT with i.v. contrast agent injection and the CT-angiography technique. The reanimator was always present to monitor the patients' vital functions and shock state. CT of the chest was integrated with CT of the abdomen and pelvis in 4 cases and with CT of the skull in 3 cases, to detect associated bullet wounds if any.

RESULTS

The most frequent CT finding was lung parenchyma tear and bruise (25 cases), followed by hemothorax (18 cases) and subcutaneous chest wall emphysema (9 cases). Pneumothorax was seen in 5 cases, associated with hemothorax in 6; rib injuries were found in 7 cases; pneumomediastinum was found in 4 cases and areas of pulmonary atelectasis in 3; the diaphragm was ruptured in 4 cases. CT showed spinal involvement in 11 patients, with injury of D3 and D5 in 4 and 3 cases, respectively; signs of interrupted spinal marrow were found in 7 cases. Damage from gunshot wounds was detected in the liver, spleen, skull and limbs in 3, 2, 3 and 10 cases, respectively.

DISCUSSION AND CONCLUSIONS

Chest radiography shows major gunshot wound damage to the chest and lungs, except for heart injuries and minimal pneumothorax. When abdominal and skull injuries are associated, CT should be the method of choice because it permits prompt and panoramic assessment of the severity of pulmonary and extrathoracic damage. This results in prompt and targeted treatment, avoiding unnecessary delays which may damage the patient further.

Mediastinal perforation and contralateral hemothorax by a chest tube

Tube thoracostomy is an invasive and common procedure that is often life-saving, but by no means innocuous. We describe herein a case of chest trauma in which the chest tube crossed through the mediastinum between aorta and esophagus and penetrated the contralateral pleural cavity causing mild hemothorax. A literature search has failed to identify a similar case: the misplacement was detected in a control radiograph which led to early adjustment of the tube and no sequalae.

Routine helical computed tomographic evaluation of the mediastinum in high-risk blunt trauma patients

BACKGROUND

The indications and method of evaluation of the mediastinum in blunt deceleration trauma are controversial and vary among centers. Most centers practice a policy of angiographic evaluation only in the presence of an abnormal mediastinum on chest radiography. Routine aortography in the absence of any mediastinal abnormality is not widely practiced. Helical computed tomographic (CT) scan has been successfully used in recent studies in the evaluation of the thoracic aorta.

OBJECTIVE

To determine the role of routine helical CT scan evaluation of the mediastinum in patients involved in high-speed deceleration injuries, irrespective of chest radiographic findings.

DESIGN

A prospective study over a 1-year period. Included in the study were patients with high-speed deceleration injuries who required CT evaluation of the head or abdomen. This group of patients underwent routine helical CT evaluation of the mediastinum irrespective of chest radiographic findings.

SETTING

Large, urban, academic level I trauma center.

RESULTS

A total of 112 trauma patients fulfilled the criteria for study inclusion. Overall, there were 9 patients (8.0%) with aortic rupture. Four (44.4%) of these patients had a normal mediastinum on the initial chest x-ray film and the diagnosis was made by CT scan. The CT scan was diagnostic in 8 of the aortic ruptures (intimal tear or pseudoaneurysm) and was suggestive of aortic injury but not diagnostic in 1 patient with brachiocephalic artery injury. In 42 patients (37.5%), there was a widened mediastinum: an aortic rupture was diagnosed in 5 of them (11.9%) and a spinal fracture in 9 (21.4%). One patient had both aortic rupture and spinal injury.

CONCLUSIONS

The incidence of aortic injury in patients with high-speed deceleration injury is high. A significant proportion of patients with aortic injury have a normal mediastinum on the initial chest radiograph. There is a high incidence of spinal injuries in the presence of a widened mediastinum. We recommend that all trauma patients with high-risk deceleration injuries undergo routine helical CT evaluation of the mediastinum irrespective of chest radiographic findings.