The persistent diagnostic challenge of thoracoabdominal stab wounds.
BACKGROUND
Penetrating thoracoabdominal trauma, with potential injury to two anatomic cavities, significantly challenges surgical management, yet this injury pattern has not been reviewed across a large patient series.


METHODS
The trauma registry of a major level 1 center was queried for all adult patients admitted with thoracoabdominal stab wounds between January 1996 and December 2011.


RESULTS
The study identified 617 patients; 11% arrived hypotensive (systolic blood pressure < 90 mm Hg), 6.5% had Glasgow Coma Scale (GCS) score less than 8, and 3.6% were in cardiac arrest. Of those arriving alive, 350 (59%) of 595 underwent surgery (88% laparotomy, 3% thoracotomy, and 9% both procedures). Nontherapeutic laparotomy was performed on 12.3% of these patients. Cardiac injury occurred in 71% (29 of 41) of the patients arriving alive undergoing thoracotomy. Among this group, only 1 (2.4%) of 41 had a major thoracic vessel or aortic injury without cardiac trauma. Diaphragmatic injury (DI) occurred in 224 (38%) of 595, with 72 (32.1%) of these 224 demonstrating no computed tomographic evidence of DI. Either hollow viscus injury or DI occurred in 50%. Only 36.8% of liver, 58% of spleen, and 29.8% of kidney injuries required surgical repair. The need for dual-cavitary intervention was associated with a precipitous increase in patient mortality.


CONCLUSIONS
Patients with thoracoabdominal stab wounds present considerable clinical challenges due to high surgical need, high occult DI incidence, persistently high rates of negative laparotomy, and significant mortality with dual-cavitary intervention. Many patients with solid-organ injuries do not require intervention. High incidence of hollow viscus injury and DI ultimately limits nonoperative management. Laparoscopy is necessary to exclude occult DI. In unstable patients, determination of which anatomic cavity to explore primarily requires exclusion of cardiac injury. In those with equivocal clinical or ultrasonographic evidence of cardiac trauma, laparotomy, with transdiaphragmatic pericardial window, if a causative abdominal injury is not immediately apparent, seems the most effective strategy.


METHODS
Epidemiologic study, level III.
From the Division of Trauma Surgery and Surgical Critical Care, Los Angeles County Medical Center-University of Southern California, Los Angeles, California.
Regan J
RJ
Berg
Efstathios
E
Karamanos
Kenji
K
Inaba
Obi
O
Okoye
Pedro G
PG
Teixeira
Demetrios
D
Demetriades
D000007:Abdominal Injuries / Q000175:diagnosis* / Q000401:mortality / Q000601:surgery; D000328:Adult; D000368:Aged; D002423:Cause of Death; D015331:Cohort Studies; D003422:Critical Care / Q000379:methods; D019317:Evidence-Based Medicine; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D010535:Laparoscopy / Q000379:methods; D007813:Laparotomy / Q000379:methods; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D011379:Prognosis; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D013898:Thoracic Injuries / Q000175:diagnosis* / Q000401:mortality / Q000601:surgery; D013908:Thoracotomy / Q000379:methods; D014193:Trauma Centers; D014951:Wounds, Stab / Q000175:diagnosis* / Q000401:mortality / Q000601:surgery*; D055815:Young Adult