Gunshot and stab wounds are the most common causes of penetrating chest trauma. These wounds are classified according to their velocity. Stab wounds are generally considered low-velocity trauma because the weapon destroys a small area around the wound. Knives and switchblades cause most stab wounds. The appearance of the external wound may be very deceptive, because pneumothorax, hemothorax, lung contusion, and cardiac tamponade, along with severe and continuing hemorrhage, can occur from any small wound, even one caused by a small-diameter instrument such as an
ice pick.
Gunshot wounds may be classified as low, medium, or high velocity. The factors that determine the velocity and resulting extent of damage include the distance from which the gun was fired, the caliber of the gun, and the construction and size of the bullet. A bullet can cause damage at the site of penetration and along its pathway, and a gunshot wound to the chest can produce a variety of pathophysiologic changes. The bullet may ricochet off bony structures and damage the chest organs and great vessels. If the diaphragm is involved in a gunshot wound or a stab wound, injury to the chest cavity must be considered.
Medical Management
The objective of immediate management is to restore and maintain cardiopulmonary function. After an adequate airway is ensured and ventilation is established, examination for shock and intrathoracic and intra-abdominal injuries is necessary. The patient is undressed completely so that additional injuries are not missed. There is a high risk for associated intra-abdominal injuries with stab wounds below the level of the fifth anterior intercostal space. Death can result from exsanguinating hemorrhage or intra-abdominal sepsis.
The diagnostic workup includes a chest x-ray, chemistry profile, arterial blood gas analysis, pulse oximetry, and ECG. The patient’s blood is typed and cross-matched in case blood transfusion is required. After the status of the peripheral pulses is assessed, a large-bore IV line is inserted. An indwelling catheter is inserted to monitor urinary output. A nasogastric tube is inserted and connected to low suction to prevent aspiration, minimize leakage of abdominal contents, and decompress the gastrointestinal tract.
Shock is treated simultaneously with colloid solutions, crystalloids, or blood, as indicated by the patient’s condition. Diagnostic procedures are carried out as dictated by the needs of the patient (eg, CT scans of chest or abdomen, flat plate xray of the abdomen, abdominal tap to check for bleeding).
A chest tube is inserted into the pleural space in most patients with penetrating wounds of the chest to achieve rapid and continuing re-expansion of the lungs. The insertion of the chest tube frequently results in a complete evacuation of the blood and air. The chest tube also allows early recognition of continuing intrathoracic bleeding, which would make surgical exploration necessary. If the patient has a penetrating wound of the heart or great vessels, the esophagus, or the tracheobronchial tree, surgical intervention is required.
ice pick.
Gunshot wounds may be classified as low, medium, or high velocity. The factors that determine the velocity and resulting extent of damage include the distance from which the gun was fired, the caliber of the gun, and the construction and size of the bullet. A bullet can cause damage at the site of penetration and along its pathway, and a gunshot wound to the chest can produce a variety of pathophysiologic changes. The bullet may ricochet off bony structures and damage the chest organs and great vessels. If the diaphragm is involved in a gunshot wound or a stab wound, injury to the chest cavity must be considered.
Medical Management
The objective of immediate management is to restore and maintain cardiopulmonary function. After an adequate airway is ensured and ventilation is established, examination for shock and intrathoracic and intra-abdominal injuries is necessary. The patient is undressed completely so that additional injuries are not missed. There is a high risk for associated intra-abdominal injuries with stab wounds below the level of the fifth anterior intercostal space. Death can result from exsanguinating hemorrhage or intra-abdominal sepsis.
The diagnostic workup includes a chest x-ray, chemistry profile, arterial blood gas analysis, pulse oximetry, and ECG. The patient’s blood is typed and cross-matched in case blood transfusion is required. After the status of the peripheral pulses is assessed, a large-bore IV line is inserted. An indwelling catheter is inserted to monitor urinary output. A nasogastric tube is inserted and connected to low suction to prevent aspiration, minimize leakage of abdominal contents, and decompress the gastrointestinal tract.
Shock is treated simultaneously with colloid solutions, crystalloids, or blood, as indicated by the patient’s condition. Diagnostic procedures are carried out as dictated by the needs of the patient (eg, CT scans of chest or abdomen, flat plate xray of the abdomen, abdominal tap to check for bleeding).
A chest tube is inserted into the pleural space in most patients with penetrating wounds of the chest to achieve rapid and continuing re-expansion of the lungs. The insertion of the chest tube frequently results in a complete evacuation of the blood and air. The chest tube also allows early recognition of continuing intrathoracic bleeding, which would make surgical exploration necessary. If the patient has a penetrating wound of the heart or great vessels, the esophagus, or the tracheobronchial tree, surgical intervention is required.
