Stab and gunshot wounds of the chest diagnosis and treatment

Abstract

1. 1. Penetrating wounds of the chest in civilian practice are caused primarily by stabbing with knives or ice picks and gunshots with pistols. Because of depth of penetration, gunshot wounds are usually more serious than stab wounds. 2. 2. The physiologic effects of penetrating wounds of the chest are impairment of ventilation and reduction of cardiac output. Ventilation may be affected by pneumothorax, hemothorax, injury of pulmonary parenchyma, diaphragm, chest wall or phrenic nerves and retention of tracheobronchial secretions. Cardiac output is affected by a reduction in circulating blood volume secondary to hemorrhage and by cardiac tamponade. 3. 3. Thoracoabdominal injury, with involvement of intra-abdominal structures causing hemorrhage or peritonitis, greatly increases the physiologic affects of injury. 4. 4. Early diagnosis of injury is essential if treatment is to be instituted promptly. Initial examination should be made for presence of obstruction of the airway, tension pneumothorax, massive hemothorax and cardiac tamponade. Only after the presence of these conditions has been ruled out, or they have been corrected, if present, should one proceed with a general examination. Needle aspiration of the pleural or pericardial space may establish the diagnosis and afford an early opportunity to temporarily relieve these conditions. 5. 5. Roentgenographic examination is not usually necessary during resuscitation, and may be contraindicated. However, once resuscitation has been completed roentgenograms of the chest and abdomen will define the full extent of injury. 6. 6. When wounds of the trachea or major bronchi and esophagus are suspected, bronchoscopy and esophagoscopy may indicate the site and extent of injury. 7. 7. Objectives of treatment of penetrating wounds of the chest are restoration of normal ventilation and cardiac output. A patent airway should be established first, by insertion of an oral airway in the unconscious patient, and by aspiration of blood and mucus from the larynx and trachea. If associated injuries to the oropharynx are present or if other measures fail, tracheostomy should be performed. When the diagnosis of pneumothorax or hemothorax has been made, the patient is treated by insertion of a catheter through a lower intercostal space in the mid-axillary line. The catheter is connected to waterseal drainage. For a majority of injuries this is all that is needed for the evacuation of air and blood from the chest and expansion of the lung. 8. 8. Reduction in blood volume should be corrected by prompt replacement of whole blood. Measurement of central venous pressure is a reliable guide to blood replacement and, in addition, helps to differentiate between shock resulting from blood loss and cardiac tamponade. 9. 9. Patients with cardiac tamponade may be treated satisfactorily by aspiration of the pericardial space. Rarely is operative repair necessary. 10. 10. The loss of large amounts of air and blood from the chest suggests injury to the trachea and major bronchi or to the heart and great vessels and may necessitate thoracotomy. 11. 11. Thoracoabdominal wounds are managed by providing catheter drainage of the chest, if there is pneumothorax or hemothorax, and by exploring the abdomen. A combined thoraco-abdominal incision is to be avoided whenever possible.