Stable Penetrating Chest Trauma
Annotation for Point I
In the stable patient, transmediastinal gunshot wounds may not be immediately clinically apparent. In a number of cases, the patient has experienced multiple gunshot wounds. However, the diagnosis can be made with clinical examination and CXR in 90% of cases in nonagonal patients.14 After assuring stability, managing hemothorax/pneumothorax, and using FAST to exclude obvious cardiac injury, computed tomography angiography (CTA) should be the next evaluation. CTA may show that the transmediastinal tract is extrathoracic and can exclude major vascular injury.14 Occasionally, metallic artifact precludes an accurate assessment of the arterial wall, and elective angiography may be required. If there is evidence that suggests aerodigestive injuries, bronchoscopy and flexible exophagoscopy should be performed, with or without gastrograffin or thin barium esophagogram as the scenario dictates.