Updated: 12/8/2021

Mediastinal Traversing Wounds

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  • Snapshot
    • A 40-year-old man is brought to the emergency room after a bar fight. His friends report that he was stabbed in the chest by his opponent. His blood pressure is 100/70 mmHg, pulse is 110/min, and respirations are 22/min. A focused assessment by sonography in trauma (FAST) exam reveals a hemothorax and he is immediately prepped for surgical exploration.
  • Introduction
    • Clinical definition
      • penetrating injury to mediastinal can involve the
        • heart
        • great vessels
        • tracheobronchial tree
        • lung parenchyma
  • Epidemiology
    • Demographics
      • male > female
  • Etiology
    • Stab wounds are the most common cause
    • Gunshot wounds
    • Puncture wounds
    • Pathogenesis
      • tissue damage results from
        • laceration along trajectory
        • shock waves
        • cavitation
        • crush injuries
  • Presentation
    • Symptoms
      • varies based on mechanism and location
      • pain
    • Physical exam
      • tenderness at the penetrating site
      • bleeding
        • may present with hemorrhagic shock
      • difficulty breathing
  • Imaging
    • Chest radiography
      • indication
        • typically as initial imaging
        • if patients are stable
      • findings
        • penetrating trauma
        • any foreign bodies
        • any pneumothorax
    • Focused assessment by sonography in trauma (FAST)
      • indication
        • to assess for pericardial fluid
        • if patients are stable
      • findings
        • pericardial fluid
    • Computed tomography
      • indication
        • results of initial imaging are unclear
        • if patients are stable
      • findings
        • any pneumothorax or hemothorax
        • any pericardial effusion
        • any myocardial injuries
        • any foreign bodies
  • Studies
    • Labs
      • trauma panel
  • Differential
    • Diaphragmatic injury
      • distinguishing factor
        • may have displaced abdominal contents into the thorax
        • distended abdomen
        • no penetrating injury in mediastinum
  • DIAGNOSIS
    • Making the diagnosis
      • based on clinical presentation and imaging
  • Treatment
    • Management approach
      • treat with Advanced Trauma Life Support protocol
      • expectant management of any specific injuries, such as pneumothorax or broken ribs
    • Conservative
      • high flow oxygen
        • indication
          • any airway compromise
    • Medical
      • intravenous fluid resuscitation
        • indication
          • for all patients with hypotension
      • intravenous pain medication
        • indication
          • for all patients
    • Operative
      • surgical repair
        • indication
          • unstable patients who require urgent repair
        • modalities
          • exploratory thoracoscopy or thoracotomy
  • Complications
    • Death
    • Mediastinitis
  • Prognosis
    • Significant morbidity and mortality
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