Operative management of penetrating wounds of the chest in civilian practice

Abstract

Although most patients with penetrating chest wounds can be managed successfully with early tube thoracostomy, blood volume replacement, and close observation, the remainder can be saved only by an aggressive operative intervention. Between July, 1972, and June, 1977, 600 patients with penetrating chest wounds were treated at the Martin Luther King, Jr./Drew Medical Center, with an over-all mortality rate of 2.2 percent. One hundred twenty-five patients required thoracotomy. They included 110 male and 15 female subjects with an average age of 29 years. Fifty-four percent had stab wounds and 46 percent gunshot wounds. On admission 92 percent were in shock. Hemothorax was the most common x-ray finding, being significant (average 1,200 ml.) in 88 percent. Fourteen patients (11 percent) had cardiac arrest before reaching the hospital. They underwent immediate thoracotomy in the emergency room, and two survived. Eighty-five percent of the deaths were due to severe cardiac wounds. Ninety-nine patients (79 percent) underwent early thoracotomy (within 24 hours), with only one death; 92 percent were operated upon within 2 hours of admission. Persistent hemorrhage was the indication in 60 percent. There were no deaths among the 24 patients with cardiac wounds who reached the operating room alive or among the 26 patients who underwent both thoracotomy and exploratory laparotomy. Other indications for early thoracotomy included pulmonary and hilar wounds and perforations of the esophagus, trachea, and major bronchi. Late thoracotomy (after 24 hours) was required in 12 patients. The indications included significant clotted hemothorax in nine, infected hemothorax in one, and subclavian arteriovenous fistula in two patients. All survived. The over-all mortality rate was 10.4 percent, but less than 1.0 percent for the 111 patients who reached us alive. The over-all complication rate was 7 percent, and the average period of hospitalization was 11.8 days.