Stable Penetrating Chest Trauma

Annotation for Point O

If the diagnosis is still in question, exploration by subxiphoid pericardialwindow, pleuroscopy, or VATS will rule out injury. Most commonly, this occurs in the setting of a residual hemothorax.²² FAST has diminished the role of subxiphoid windowto diagnose cardiac injuries, but this approach can still be appropriate based on the setting and the team’s comfort level.^49,50 In stable patients, particularly after stab wounds, there has been increasing experience in not performing sternotomy if the window is ‘‘mildly’’ positive. This implies that there is no ongoing hemorrhage. Recent work has suggested that in this setting, injuries are superficial, do not involve the heart, and/or have closed.⁵¹ This requires a great deal of confidence and close observation. Options include direct observation by lifting on the xiphoid, exploration with mediastinoscope or thoracoscope to inspect the surface of the heart, and/or application of biologic glues over possible injury sites.