Stable Penetrating Chest Trauma
Annotation for Point F
Mansour et al.12 found that the most common indication for urgent thoracotomy following penetrating injury was excessive chest tube output (28% following stab and 50% following gunshot wounds). An acute evacuation of blood on tube placement exceeding 1,500 cc should prompt consideration for operative exploration. Persistent bleeding has been defined as 200 cc/h for four or more hours. Practically, a limit of 1,500 cc over a 24-hour period as an indication to consider operation results in less delay and perhaps less complications.35 Large retained hemothorax, transient instability, or other clinical indicators (e.g., acidosis with no other explanation, air leak, suspicion of relevant injuries such as diaphragm)may prompt exploration with less blood output than the classic ‘‘1,500’’ cc.35 Relying exclusively on chest tube output can lead to an underestimation of the injury severity.33 In stable patients in whom the blood loss seems to be ‘‘slowing,’’ VATS may be an option. Intercostal bleeding can be controlled with clips, lung bleeding with wedge resection, and diaphragm laceration with suture repair. Thoracotomy is advisable if the bleeding is persistent or if there is any doubt of the origin or of patient stability. The choice of approach (posterolateral vs. anterolateral vs. sternotomy) is dictated by whether the hemorrhage is unilateral and what structures are suspected to be involved. In general, a posterolateral approach (VATS or thoracotomy) affords the greatest exposure in stable patients with unilateral injuries.