Triage and outcome of patients with mediastinal penetrating trauma.
BACKGROUND
A retrospective study was conducted detailing an experience with echocardiography and contrast-enhanced helical computed tomographic angiographic (CTA) scans in the evaluation of stable patients with mediastinal penetrating trauma (MPT).


METHODS
Unstable patients underwent emergent operative intervention, and stable patients underwent chest roentgenogram, transthoracic echocardiography (TTE), and CTA. Further testing (angiogram, bronchoscopy, esophagoscopy, esophagogram) was done only if one of these studies revealed evidence of a trajectory in the vicinity of major vasculature or viscera.


RESULTS
Between 1997 and 2003, 207 patients had MPT. Seventy-two (35%) were unstable (45 gun shot wounds, 27 stab wounds) and 19 died in the emergency department. Fifty-three had emergent intervention and 32 survived. Work-up was done on 135 stable patients (65%) consisting of 46 gunshot wounds and 89 stab wounds, of which 5 had a positive TTE result and underwent a repair of a cardiac injury. CTA evaluation was normal in almost 80% of patients, who subsequently did not require further evaluation or treatment. In the stable patients, endoscopy or esophagography confirmed one tracheal injury and no esophageal injury. In the entire group, 10 patients (7%) had occult injury, and there were no deaths or missed injuries.


CONCLUSIONS
In cases of MPT, unstable patients require surgery, and in stable patients, TTE and chest CTA are effective screening tools. Patients with a negative TTE and CTA results can be observed and may not require further testing or endoscopy, whereas patients with positive TTE or CTA results require further assessment to exclude occult injury.
Burack
Joshua H
JH
Department of Surgery, Kings County Hospital Center, and State University of New York-Downstate, Brooklyn, New York 11203, USA. jburack@downstate.edu
Kandil
Emad
E
Sawas
Ahmed
A
O'Neill
Patricia A
PA
Sclafani
Salvatore J A
SJ
Lowery
Robert C
RC
Zenilman
Michael E
ME
D000465:Algorithms; D000792:Angiography / Q000592:standards*; D004452:Echocardiography / Q000592:standards*; D004636:Emergency Service, Hospital; D006801:Humans; D008482:Mediastinum / Q000293:injuries*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D036542:Tomography, Spiral Computed / Q000592:standards*; D014218:Triage / Q000379:methods; D014948:Wounds, Gunshot / Q000145:classification; D014950:Wounds, Penetrating / Q000145:classification*; D014951:Wounds, Stab / Q000145:classification