Surgical Management of Penetrating Thoracic Trauma

Abstract

Due to a combination of geographic and racial factors, a situation exists in which a large volume of penetrating trauma is routed to the city-county charity hospitals of Houston and Harris County, Texas. Experience in management of these patients has allowed development of certain concepts and improved methods of dealing with the numerous alterations in cardiorespiratory physiology which occur in these injuries. Heart wounds are treated primarily by pericardiocentesis, reserving cardiorraphy for those patients who do not respond to pericardial aspiration or who again develop cardiac tamponade following aspiration. Intracardiac injuries are repaired using cardiopulmonary bypass after recovery from the acute phase of injury and establishment of accurate anatomic diagnosis. Pneumo- and/or hemothorax usually are managed by intercostal thoracostomy tube drainage with fluid and blood replacement, reserving thoracotomy for specific indications. However, complete pulmonary re-expansion is accomplished prior to discharge from the hospital by whatever means necessary, thereby eliminating the need for subsequent decortication to prevent loss of pulmonary function. Results of such methods of management over the past ten years have demonstrated their effectiveness in dealing with civilian trauma. Among 921 consecutive patients with penetrating thoracic trauma there were only 57 deaths, an overall mortality rate of 6.2 per cent, including patients in whom cardiac arrest occurred before any therapy could be started. Complications among the survivors were minimal and usually were related to associated injuries rather than to the thoracic wound itself. The average period of hospitalization was only 9.8 days for the 856 survivors, and almost all have returned to normal activity.