Transmediastinal Gunshot Wounds

Cornwell, Edward E.; Kennedy, Frank; Ayad, Ihab; Berne, Thomas V.; Velmahos, George C.; Asensio, Juan A.; Δημητριάδης, Δημήτριος

doi:10.1001/archsurg.1996.01430210047009

Cited by 44 publications

(8 citation statements)

References 12 publications

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“…It has been advocated that esophageal injury should be evaluated expeditiously so it is repaired without unnecessary delay because of the high incidence of septic complications and suture line failures. Consequently, esophagography is performed before angiography [17]. This approach allows management of transmediastinal injuries in a more orderly and appropriate manner.…”

Section: Discussionmentioning

confidence: 99%

Penetrating chest wounds: 24 years experience

Mandal

Sanusi

2001

World j. surg.

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Thoracic and thoracoabdominal penetrating wounds are frequently encountered in urban medical centers in the United States. This study was undertaken to determine the clinical characteristics and in hospital outcome of these injuries. This was a longitudinal, nonblinded study using the established standard of care of patients with penetrating chest trauma. It consists of an analysis of a consecutive series of 3049 patients treated at one trauma center between April 1972 and March 1996. There were 1347 stab wounds and 1702 gunshot wounds. Antibiotic prophylaxis was administered to patients who underwent laparotomy or thoracotomy or who had lung contusion with hemoptysis (41.6%, 1296/3049). Of 3049 patients, 196 had cardiac injuries. All of them underwent thoracotomy, and the mortality was 21.9%. In contrast, among 2853 patients without cardiac injuries, only 257 (9%) required thoracotomy; the mortality in this group was 1.5%. Patients with thoracoabdominal injuries (899/3049) had a mortality of 4.3% compared to 2.1% among those who had isolated chest injuries. The overall mortality was 2.8%. Of 1702 patients with gunshot wounds, 85 (5%) sustained transaxial injuries, with an overall mortality of 36.5%. The complication rate among the survivors was 6% with only 2.5% being infectious. We conclude that the mortality for noncardiac penetrating injuries of the chest is low. The presence of associated abdominal injuries increases the mortality twofold. More than one-third of the patients with transaxial wounds die. Gunshot wounds of the heart result in higher mortality than stab wounds to the heart. The infection rate is low.

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Section: Discussionmentioning

confidence: 99%

Penetrating chest wounds: 24 years experience

Mandal

Sanusi

2001

World j. surg.

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“…In our series the one death in the mediastinal injury group occurred as a result of intraoperative exsanguination. Mortality in the stable patients ranges from 0 to 10% [3,5,9] with morbidities occurring in up to 60% of patients [1]. Our mortality rate was comparable at 4%.…”

Section: Discussionmentioning

confidence: 53%

“…Patients who sustain a gunshot wound to the mediastinum may present with a spectrum of vital signs ranging from stable, normal vital signs to moribund [1]. Most trans-mediastinal gunshot wounds (TM-GSW) are rapidly lethal because of cardiac tamponade or exsanguination [2] and many of these patients do not live to be transported to the hospital.…”

Section: Discussionmentioning

confidence: 99%

“…Degiannis et al [4] recommend that this be done early during the patient evaluation because an unrecognized aortic injury may become rapidly lethal. Cornwell et al [1] disagree, stating that an aortic injury is very unlikely in a stable patient and cites the higher incidence of complications when a diagnosis of esophageal injury is delayed. In our center, we have 24-hour angiography support and can perform both tests in under 2 hours; we preferentially obtain the angiogram first.…”

Section: Discussionmentioning

confidence: 99%

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Trans‐mediastinal Gunshot Wounds: Are "Stable" Patients Really Stable?

Nagy¹,

Roberts²,

Smith³

et al. 2002

World j. surg.

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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.

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“…However, performing these studies may delay operative repair and potentially increase morbidity. [ 3 4 5 6 ] Because of the rarity of this injury, previously published studies trying to address the pros and cons of PDE have been limited by small sample size and single center bias. [ 1 6 7 ]…”

Section: Introductionmentioning

confidence: 99%

Preoperative evaluation of penetrating esophageal trauma in the current era: An analysis of the National Trauma Data Bank

Yeh

Hwabejire

Moya

et al. 2015

J Emerg Trauma Shock

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Background:Preoperative diagnostic evaluation (PDE) of penetrating esophageal injury (PeEsIn) can delay treatment and increase morbidity. We sought to study the relationship among PDE, delay in definitive treatment, and patient mortality in PeEsIn.Materials and Methods:The 2008-2010 National Trauma Data Banks were queried for PeEsIn. Exclusion criteria were death within 1 day of injury, and missing data about survival to discharge or operative intervention. Data extracted included demographics, vital signs, injury severity, diagnostic procedures (endoscopy, computed tomography, and fluoroscopy), time to procedures and/or operation, hospital-free days, and mortality.Results:Of 280 patients, 75 underwent PDE and 205 did not. There were no significant differences in baseline demographics, vital signs or injury severity between the two groups. The median time to the first operation was shorter in the nonPDE cohort compared to the PDE cohort (2 vs. 3 h; P = 0.018). Median hospital-free days at day 60 were significantly less in nonPDE (42 days, interquartile range ([IQR] = [28, 50]) versus PDE patients (47 days, IQR = [38, 51]) (P = 0.007). Mortality was not statistically different.Conclusions:PDE in PeEsIn slightly delays the time to operation without worsening mortality, and is a predictor of more hospital-free days.

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Transmediastinal Gunshot Wounds

Abstract: Esophageal evaluation should precede aortography in the workup of stable patients with transmediastinal gunshot wounds.

Cited by 44 publications

References 12 publications

Penetrating chest wounds: 24 years experience

Penetrating chest wounds: 24 years experience

Trans‐mediastinal Gunshot Wounds: Are "Stable" Patients Really Stable?

Preoperative evaluation of penetrating esophageal trauma in the current era: An analysis of the National Trauma Data Bank

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