Updated: 5/31/2018

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
  • Prognosis
    • significant morbidity and mortality
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
  • Making the diagnosis
    • based on clinical presentation and imaging
Differential
  • Diaphragmatic injury
    • distinguishing factor
      • may have displaced abdominal contents into the thorax
      • distended abdomen
      • no penetrating injury in mediastinum
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
 

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