Penetrating Thoracic Trauma Patients with Gross Physiological Derangement: A Responsibility for the General Surgeon in the Absence of Trauma or Cardiothoracic Surgeon?

Abstract

Penetrating trauma is becoming increasingly common in parts of the world where previously it was rare. At the same time, general surgeons and surgical trainees are becoming more specialized, and less comfortable operating within areas beyond their zone of specialization. The purpose of this manuscript is to assess the technical difficulties encountered in operating on patients who have sustained penetrating trauma, and to prove to general surgeons that the technical skills and techniques required are no different to those required for abdominal surgery, and do not require additional dexterity. This prospective study was conducted in an Academic Trauma unit over a 3-year period. All patients who were operated upon for penetrating thoracic trauma were included in the study. The pre-operative management, techniques of surgical repair and the outcome were assessed. One hundred and forty-five patients were included in the study over a 3-year period. There were 97 patients with stab wounds, 47 with gunshot wounds and 1 patient with an injury from an angle grinder. Mortality was six times greater in those patients with gunshot wounds, than those with stab wounds. Several patients had multiple thoracic organ injuries. There were 57 patients who were operated upon for thoracic vessel injury. There was a 3.5% mortality overall. Eighty-eight patients sustained pulmonary injury with a 7% mortality, and they were managed mainly by simply repair, tractotomy or stapled partial non-anatomical lobectomy. Of the 39 patients with cardiac trauma, there was 17% mortality, and all cases were managed by simple repair. There were 5 patients with an oesophageal injury of whom 3 died (mortality of 60%). Twenty-four patients had thoraco-abdominal injuries with 30% mortality. Most of the injuries in the chest can be managed by simple procedures to control life-threatening bleeding. The techniques required are similar to those taught to and are practiced comfortably by general surgeons used to work in the abdominal cavity. We encourage the general surgeon who receives a grossly unstable patient with penetrating thoracic trauma to operate, instead of adding risk to the patient's physiology by a transfer to cardio-thoracic or dedicated trauma units.