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