title: Penetrating thoracoabdominal injuries: ongoing dilemma-which cavity and when?
abstract: The aims of this study were to (1) define characteristics for the thoracoabdominal injury patient population; (2) describe sequences of surgical interventions with combined procedures (i.e., thoracotomy and laparotomy); and (3) describe pitfalls leading to inappropriate sequencing of surgical interventions for thoracoabdominal injuries. It was a retrospective 4-year study (January 1995 to December 1998) conducted at an urban level I trauma center. The study population comprised 254 patients who had sustained thoracoabdominal injuries requiring surgical intervention: 187 (73%) gunshot wounds (GSWs), 64 (25%) stab wounds (SWs), and 3 (2%) shotgun wounds (STWs). The mean revised (RTS) was 6.04; the mean Injury Severity Score (ISS) was 27; the mean estimated blood loss (EBL) was 3000 ml. The overall survival was 175 of 254 (69%). Of the 254, 51 (20%) underwent emergency department (ED) thoracotomy. Altogether, 73 (29%) underwent combined thoracotomy and laparotomy: 59 (81%) GSW, 13 (18%) SW, 1 (1%) STW (mean RTS 5.2, mean ISS 34, mean EBL 6800 ml). Overall survival was 30 of these 73 (41%). A total of 21 of the 73 (29%) underwent ED thoracotomy. In group I (laparotomy then thoracotomy: Lap + Thor, n = 34) the initial procedure was interrupted in 18 (53%). In group II (thoracotomy then laparotomy: Thor + Lap, n = 39) the initial procedure was interrupted in 14 (36%). Pitfalls leading to inappropriate surgical sequencing were persistent hypotension (13/73, 18%) and misleading chest tube output (8/73, 10%). It was concluded that penetrating thoracoabdominal injuries incur high mortality (31%), and the mortality doubles for patients who require combined procedures (59%). Inappropriate surgical sequencing occurred in 32 of 73 (44%) patients undergoing combined procedures. Persistent hypotension, indicating that the wrong cavity was accessed, and misleading chest tube output are the leading pitfalls in thoracoabdominal injury management.
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, University of Southern California, LAC+USC Medical Center, 1200 N. State Street, Room 10-750, Los Angeles, California 90033-4525, USA. asensio@hsc.usc.edu
authors.forename: Juan A
authors.initials: JA
authors.lastname: Asensio
authors.forename: Hector
authors.initials: H
authors.lastname: Arroyo
authors.forename: William
authors.initials: W
authors.lastname: Veloz
authors.forename: Walter
authors.initials: W
authors.lastname: Forno
authors.forename: Esteban
authors.initials: E
authors.lastname: Gambaro
authors.forename: Gustavo A
authors.initials: GA
authors.lastname: Roldan
authors.forename: James
authors.initials: J
authors.lastname: Murray
authors.forename: George
authors.initials: G
authors.lastname: Velmahos
authors.forename: Demetrios
authors.initials: D
authors.lastname: Demetriades
mesh_terms: D000007:Abdominal Injuries / Q000175:diagnosis / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D005260:Female; D006801:Humans; D007813:Laparotomy / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013898:Thoracic Injuries / Q000175:diagnosis / Q000601:surgery*; D013908:Thoracotomy / Q000706:statistics & numerical data*; D014193:Trauma Centers; D015599:Trauma Severity Indices; D014950:Wounds, Penetrating / Q000175:diagnosis / Q000601:surgery*