Penetrating Chest Trauma
The presentation and management of a patient of penetrating trauma depends on three interrelated factors: stability, mechanism, and location of the wound. For the purposes of this discussion, stability requires that the airway be secure (with or without intubation), that the patient is both oxygenating and ventilating at an acceptable level, and that continued hemodynamic stability is documented. Patients with evidence of shock or impending collapse (systolic blood pressure < 90 mm Hg and/or persistent tachycardia > 120 beats per minute, not explained by pain or anxiety and/or persistent hypoxemia) should be managed by airway control combined with aggressive blood product resuscitation. In essence, a stable patient is one in whom there is time to consider different diagnostic and therapeutic options; the unstable patient is one in whom the approach is predicated on getting to the operating room as soon as possible with minimal delay for extraneous testing. This excludes the agonal patient. Clearly, there are times when the scenarios overlap (e.g., transmediastinal gunshot wound with suspicion of tamponade), and the pathways described are not mutually exclusive.