Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 318 - файл
.pdf
17 Plain X-Rays forPenetrating Trauma
https://t.me/medicina_free
Fig. 17.4 Image of bilateral pneumothoraces manifested on chest
X-ray as deep sulcus sign bilaterally (red ellipses). Note the subtle displaced right lower rib fracture (white arrow)
147
recess. Signicant collections require drainage because
hemothorax predisposes the patient to developing empyema.
A common practice after tube thoracostomy is to obtain
daily chest X-rays to evaluate the residual hemothorax.
However, it should be cautioned that chest X-rays may be
misleading for this purpose. A prospective trial has demonstrated that X-ray signs do not reliably distinguish retained
hemothorax from parenchymal conditions following trauma.
It is recommended to use CT instead to determine whether
surgical evacuation of residual hemothorax is needed.
Lung parenchymal injuries are also regular ndings on
chest radiography after penetrating injury. Pulmonary contusions occur after disruption of the alveolar capillaries and
interstitial blood vessels along the tract of injury. This leads
to hemorrhage into the surrounding lung tissue and edema.
Contusions appear as “ground-glass” peripheral air-space
opacities (particularly when they occur inlocations that are
not gravity dependent), which may not be apparent on the
initial radiograph. These inltrates typically develop within
6h of the injury and begin to resolve over the following days.
It may take up to 2 weeks for these signs to completely clear
on the chest X-ray. Pulmonary lacerations often have similar
initial radiographic appearance as contusions. However, they
may be distinguishable by the “air-meniscus” sign, which is
from incomplete lling of blood in a laceration cavity resulting in a small air crescent over the clotted blood. Additionally,
radiographic signs from lacerations may persist for up to 3 to
5 weeks (Fig.17.6).
Fig. 17.5 Large left hemothorax (red asterisk) from left internal mam-
mary artery laceration following left chest stab injury. Rightward shift
of the trachea and mediastinum indicate tension
Hemothorax is another common pleural abnormality
found on chest X-rays in penetrating thoracic trauma. The
source of bleeding may be from the chest wall including
blood vessels of the chest wall such as internal mammary or
intercostal blood vessels, lung parenchyma, heart, or the
great vessels. Typically, a volume of 200–300mL radiodense
blood collecting in the pleural space is necessary for the
hemothorax to be readily identiable on chest X-ray. The
presentation may vary from an opacied hemothorax
(Fig.17.5) to a subtle blunting of the involved costophrenic
17.4.3 Mediastinum
Cardiac injuries are difcult to diagnose on plain lms but
certain associated imaging ndings can be identied.
Irregular convexities of the heart border or marked shift of
the cardiac silhouette signify underlying cardiac injury or
cardiac herniation. In rare cases we may observe pericardial
effusions as a globally enlarged heart (“water bottle” sign).
The differential diagnosis for a “widened” mediastinum
(i.e., loss of the normal mediastinal contours, including
loss of a dened aortic knob and thickened right paratracheal stripe) in penetrating trauma should include sternal
fracture, thoracic vertebral fracture, or ligamentous injury
and life- threatening great vessel injuries (Fig.17.7). Other
radiographic abnormalities that may be encountered with
great vessel injury include the apical cap, loss of aortic contour, tracheal or esophageal deviation to the right, depression of the left main stem bronchus, or a left pleural
effusion. Several studies have suggested efciency in using
X-rays to exclude injuries to the great vessels in certain
trauma presentations. A single center experience with penetrating trauma to upper thorax was able to retrospectively
validate the use of clinical exam and chest radiography in
148
ab
https://t.me/medicina_free
Fig. 17.6 Right pulmonary laceration from a posterior stab injury with parenchymal consolidation (red circle, panel a) and evolvement into a
loculated hematopneumatocele 6 weeks later best seen on upright imaging (blue circle, panel b)
S. Wang et al.
An injury tract traversing the mediastinum should make
one suspicious for aerodigestive injuries. The nonspecic
ndings on plain lms include subcutaneous emphysema,
pneumothorax, or pneumomediastinum. Though tracheobronchial injuries occur more commonly in blunt than penetrating settings, their classic radiographic signs irrespective
of mechanism may include the “double wall” sign (secondary to intramural gas in the proximal-transected airway) and
the “fallen lung” sign (bronchial fracture with associated
inferior lung collapse). Occasionally, frank herniation of the
endotracheal tube or its balloon through the tracheal defect
may be observed. Another telltale sign that can be encountered clinically is the increasing soft tissue emphysema or
pneumothorax refractory to tube thoracostomy evacuation,
which suggests continuous air leak from a tracheobronchial
injury. Esophageal injuries, on the other hand, present as cer-
Fig. 17.7 “Widened” mediastinum with markedly thickened right
paratracheal stripe (red arrows) and left paraspinal line (white arrow)
after gunshot wound to the chest
vical emphysema proximally or left pleural effusion distally
on plain lms. Contrast esophagography under conventional
uoroscopy is the conrmatory test of choice.
accurately ruling out great vessel injuries. A study in blunt
trauma showed that liberal use of chest CT did not increase
17.4.4 The Asymptomatic Patient
detection of aortic injury, but X-rays alone were inadequate
if the patient presented with high Injury Severity Score
(ISS) (>27) and sustained other signicant injuries (e.g.,
pelvic fracture), though this data is difcult to extrapolate
to those with penetrating injury. It is therefore imperative to
interpret plain lm information in the clinical context
regarding the penetrating thoracic injury and judiciously
utilize cross-sectional imaging in hemodynamically stable
patients.
It is important to recognize that the aforementioned X-ray
signs are not common ndings. Up to 60% of civilian penetrating thoracic injuries are asymptomatic and have normal
chest X-rays. There is a general consensus that the asymptomatic patients typically require observation with repeat
chest radiography. Most centers will repeat imaging at a 3-h
interval. With the increasing availability of the extended
focused assessment with sonography in trauma (eFAST)
17 Plain X-Rays forPenetrating Trauma
https://t.me/medicina_free
Fig. 17.8 Right main stem intubation (blue arrow) with the tip of the
endotracheal tube terminating at the bronchus intermedius (red arrow)
149
serving as an adjunct, this interval may be safely reduced to
1h, as reported by a recent prospective study. We agree with
and strongly recommend this shortened observation period
in the asymptomatic patient, which potentially reduces
crowding in the emergency room, preventing unnecessary
radiation exposure for the patients, without compromising
patient outcomes.
17.4.5 Iatrogenesis Imperfecta
One of the greatest utilities of chest radiography is to evaluate therapeutic interventions in a rapid manner. In the resuscitation bay, it is critical to timely conrm the correct
placement of endotracheal tubes, thoracostomy tubes, central venous catheters, and nasogastric tubes, prior to transporting the patient to the next destination. The endotracheal
tube should terminate approximately 2–3 cm above the
carina. There are reported increased incidence of right main
stem (1–6%) or esophageal intubation (4–8%) in emergency
setting (Fig.17.8), and identifying them rapidly with radiography prevents untoward complications. Nasogastric tube
positioning also requires radiographic conrmation, especially if there is no return of gastric contents upon placement
or clinical signs of potential airway or pleural placement
(Fig.17.9). Chest tubes often serve as the rst-line therapeutic and diagnostic measure for certain life-threatening conditions such as tension pneumothorax or hemothorax. Incorrect
positioning (such as subcutaneous or transdiaphragmatic
placement) requires immediate removal or replacement for
trauma patient stabilization and triage. Chest X-rays are
therefore indispensable in these settings.
Fig. 17.9 Nasogastric tube placement through the left bronchus (blue
arrow) and perforation of the lung and diaphragm into the left upper
abdomen (red arrow). Associated pneumothorax (white arrowheads)
17.5 Abdominal Radiography
Though less frequently utilized than chest X-rays, plain
abdominal lms are indicated in certain settings to further
guide diagnostics after penetrating injuries. This is especially true in selected penetrating abdominal trauma that is
amenable to nonoperative management.
17.5.1 Determination ofTrajectory
In addition to a complete physical examination, plain abdominal lms can be useful in approximating the trajectory of a
missile. A common practice is to mark the external surface
wounds with radiopaque markers (i.e., paper clip) and obtain
a two-view series of the abdomen. By aligning the surface
markers, one may gain appreciation of the missile trajectory
that helps look for potential injuries to the intervening structures. This may offer adequate information distinguishing a
tangential abdominal wall trajectory from one that traverse
the peritoneal cavity. The rule of thumb is that the sum of
external wounds and retained missiles should be an even
number; otherwise, it is necessary to repeat examination in
commonly overlooked areas (e.g., the axillae, inguinal
regions, perineum) or perform additional imaging to look for
missiles.
150
https://t.me/medicina_free
Fig. 17.10 Chest X-ray consistent with diaphragmatic injury following stab injury to the left chest. Stomach herniated through the left
hemidiaphragm (red asterisk)
S. Wang et al.
17.5.2 Diaphragmatic Injury
Though penetrating injury to the diaphragm is less frequent
than blunt injuries, the radiographic diagnosis is similar.
Chest and abdominal radiographs are highly variable in their
diagnostic accuracy of diaphragmatic injury (28–70%).
Serial plain lm imaging may increase this yield an additional 12%. Findings consistent with injury include asymmetric elevation of hemidiaphragm, herniation of abdominal
contents into the chest, or opacication of the lower lung
eld with diaphragm asymmetry (Fig.17.10). Occasionally,
missile trajectory may imply diaphragmatic injury, especially when there are a surface marker and a retained missile
Fig. 17.11 Gunshot wound with right hemothorax and diaphragm
injury identied on X-ray as supradiaphragmatic entry point marked by
bullet fragments (blue arrow) and the retained bullet in the abdomen
(red arrow)
above and below the diaphragm (Fig.17.11). Nevertheless,
due to the low sensitivity, we do not recommend plain radiographs as a screening test. Patients with penetrating leftsided thoracoabdominal trauma should be initially observed
if asymptomatic and offered diagnostic laparoscopy prior to
discharge to denitively exclude diaphragmatic injury.
17 Plain X-Rays forPenetrating Trauma
https://t.me/medicina_free
151
17.6 Missile Embolism
Missile injury is secondary to the kinetic energy released as
it passes through the human body. Rarely, a projectile enters
the vascular tree and embolizes through the body to a site
remote from the initial injury. The vast majority of missile
embolism cases is from civilian low-velocity, low-caliber
weapons. This diagnosis should be among the differentials of
an odd-number sum of the external wounds and retained
missiles on radiography. Plain lms of the trunk and extremities (Fig. 17.12) can help make this diagnosis and prompt
further therapeutic management. Certain emerging technology such as the Lodox/Statscan (a low-dose, rapid wholebody AP view X-ray using a movable C-arm) may assist in
expeditious detection of missiles, though this has not been
widely adopted.
Fig. 17.12 Missile embolism into left popliteal vein (red arrow) sec-
ondary to a penetrating injury to the inferior vena cava
17.7 Conclusions
Despite the limitations of X-rays, they can provide a wealth
of rapid information to those experienced in their interpretation. We have presented several scenarios in which plain lm
imaging can be used for the initial evaluation in the patient
sustaining penetrating trauma. In conjunction with physical
examination, conventional radiography allows for more judicious use of adjunctive imaging studies, which in turn can
reduce healthcare costs and resource utilization. We hope
that this review has enhanced your armamentarium of knowledge for care of the injured patient. After all, you never know
when the “scanner” is going to be out of service.
Important Points
• Radiographs have their limitations; learn them, because
there is no substitute for the quick diagnostic information
provided in the unstable patient.
• Subcutaneous emphysema+rib fractures= pneumotho-
rax (even if you cannot see it!).
• If you nd one injury on a chest X-ray, suspect and look
for another.
• Remember to check the subpulmonic and anteromedial
recesses on the supine portable chest lm. This is where a
pneumothorax may hide.
• The most common cause of pneumomediastinum is a
pneumothorax.
• Do not rely on an X-ray to assess drainage of a
hemothorax.
• The differential diagnosis for a “widened” mediastinum is
broad, but only one of them can kill your patient.
• Three hours is enough time to observe an asymptomatic
patient with penetrating chest trauma and negative initial
X-rays, especially if eFAST is also performed.
• Check the positioning of all tubes and lines that are placed
into your patients.
• The sum of external wounds and retained missiles should
be an even number; or there is either a missed wound or
missile embolism.
152
https://t.me/medicina_free
S. Wang et al.
• A surface marker and a retained missile separated by the
diaphragm on X-ray imply diaphragmatic injury.
• X-rays are the least expensive with the least amount of
radiation to screen for missile embolism.
Suggested Reading
Berg RJ, Inaba K, Recinos G, etal. Prospective evaluation of early fol-
low- up chest radiography after penetrating thoracic injury. World J
Surg. 2013;37(6):1286–90.
Bertoldo U, etal. Retrograde venous bullet embolism: a rare occurrence-
case report and literature review. J Trauma. 2004;57(1):187–19.
Boffard KD, Goosen J, Plani F, etal. The use of low dosage X-ray (Lodox/
Statscan) in major trauma: comparison between low dose X-ray and
conventional X-ray techniques. J Trauma. 2006;60(6):1175–83.
Chen RJ, Fu CY, Wu SC, Wang YC, Chung PK, Huang HC, Huang
JC, Lu CW. Diagnostic accuracy, biohazard safety, and cost
effectiveness- the Lodox/Statscan provides a benecial alternative for the primary evaluation of patients with multiple injuries. J
Trauma. 2010;69(4):826–30.
Costantino M, Gosselin MV, Primack SL. The ABC’s of thoracic
trauma imaging. Semin Roentgenol. 2006;41(3):209–25.
Gasparri MG, et al. Physical examination plus chest radiography in
penetrating periclavicular trauma: the appropriate trigger for angiography. J Trauma. 2000;49(6):1029–33.
Govindaraju RC, Kolwalkar JP. Missile embolism from pulmonary
vein to systemic circulation: case report with systematic literature
review. J Emerg Trauma Shock. 2019;12(3):218–21.
Hanpeter DE, etal. Helical computed tomographic scan in the evalua-
tion of mediastinal gunshot wounds. J Trauma. 2000;49(4):689–95.
Heydari F, Masoumi B, Zamani M, Nasr-Esfahani M.Prospective eval-
uation of safe observation period after asymptomatic penetrating
thoracic injury: 1hour is enough. Am J Emerg Med. 2019;3(4):e39.
Ho ML, Gutierrez FR.Chest radiography in thoracic polytrauma. AJR
Am J Roentgenol. 2009;192(3):599–612.
Jones WG II, Ginsberg RJ.Esophageal perforation: a continuing chal-
lenge. Ann Thorac Surg. 1992;53(3):534–43.
Kerr TM, etal. Prospective trial of the six hour rule in stab wounds of
the chest. Surg Gynecol Obstet. 1989;169(3):223–5.
Michelassi F, et al. Bullet emboli to the systemic and venous circula-
tion. Surgery. 1990;107(3):239–45.
Omert L, etal. Role of the emergency medicine physician in airway
management of the trauma patient. J Trauma. 2001;51(6):1065–8.
Plurad D, etal. The increasing use of chest computed tomography for
trauma: is it being overutilized? J Trauma. 2007;62(3):631–5.
Rodriguez-Morales G, Rodriguez A, Shatney CH. Acute rupture of
the diaphragm in blunt trauma: analysis of 60 patients. J Trauma.
1986;26(5):438–44.
Seamon MJ, etal. Follow-up after asymptomatic penetrating thoracic
injury: 3hours is enough. J Trauma. 2008;65(3):549–53.
Shanmuganathan K, Matsumoto J.Imaging of penetrating chest trauma.
Radiol Clin N Am. 2006;44(2):225–38.
Shatz DV, et al. Efcacy of follow-up evaluation in penetrating tho-
racic injuries: 3- vs. 6-h radiographs of the chest. J Emerg Med.
2001;20(3):281–4.
Spaite DW.The future of emergency care in the United States: the insti-
tute of medicine subcommittee on prehospital emergency medical
services. Ann Emerg Med. 2006;48(2):126–30.
Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum:
abdominal CT vs. upright chest lm. J Comput Assist Tomogr.
1992;16(5):713–6.
Tocino I, Miller MH. Computed tomography in blunt chest trauma. J
Thorac Imaging. 1987;2(3):45–59.
Tocino IM, Miller MH, Fairfax WR. Distribution of pneumothorax
in the supine and semirecumbent critically ill adult. AJR Am J
Roentgenol. 1985;144(5):901–5.
Velmahos GC, etal. Predicting the need for thoracoscopic evacuation
of residual traumatic hemothorax: chest radiograph is insufcient. J
Trauma. 1999;46(1):65–70.
von Oppell UO, Bautz P, De Groot M. Penetrating thoracic injuries:
what we have learnt. Thorac Cardiovasc Surg. 2000;48(1):55–61.
Woodring JH, Heiser MJ. Detection of pneumoperitoneum on chest
radiographs: comparison of upright lateral and posteroanterior projections. AJR Am J Roentgenol. 1995;165(1):45–7.
Computed Tomography intheWorkup
https://t.me/medicina_free
ofPatients withPenetrating Trauma
MarkE.Hamill
18
Penetrating trauma is traditionally an area where rapid operative intervention has been considered the gold standard of
care. When a victim of a penetrating injury presents, physiologic status often dictates the need for rapid operative
exploration with the goal of control of active hemorrhage
and contamination from hollow viscus injuries. Certainly, no
qualied surgeon, when faced with a victim of penetrating
trauma who is hemodynamically unstable with active hemorrhage or evidence of peritonitis, would seriously argue to
undertake an extensive radiological workup. However, when
evaluating a stable patient, there is evolving evidence that
information obtained from high-resolution computed tomography (CT) scanners, augmented with contrast to allow for
CT angiography (CTA), can be valuable in guiding further
care and limiting nontherapeutic operative exploration.
While historically not an area of major concern, it is clear
that nontherapeutic surgical exploration can be a signicant
source of morbidity and mortality as well as dramatically
increasing the length of stay and overall cost. This chapter
will examine the available evidence regarding advanced
imaging in the stable patient with penetrating trauma, looking at the available documentation and guidelines for different anatomy locations. Specically, we will examine its use
in the workup of penetrating injuries to the head and neck,
thorax, abdomen, back and ank, and extremities.
18.1 Head andNeck
In the evaluation of penetrating injuries to the neck, the availability of high-resolution CT scan and CT angiography has
had a dramatic impact on the need for surgical neck exploration. In the past, penetrating injuries to the neck with violation of the platysma, especially those in zone II (the cricoid
cartilage to the angle of the mandible), were thought to man-
M. E. Hamill (*)
Department of Surgery, University of Nebraska Medical Center,
Omaha, Nebraska, USA
e-mail: mhamill@unmc.edu
date surgical exploration. However, this mandatory exploration strategy resulted in a high rate of negative explorations
leading many to suggest the need for more selective exploration based on diagnostic evaluation.
With the advent of newer-generation CT scan technology in the late 1990s, many began to question the need for
invasive diagnostic procedures in the workup of stable
patients with penetrating neck trauma. Multiple small studies suggested that imaging had a high sensitivity and specicity for the detection of signicant injuries in penetrating
zone II neck trauma. In two small series done by urban US
level 1 trauma centers, CT scan was evaluated for its usefulness in the diagnosis of signicant vascular or aerodigestive tract injuries. When CT imaging was used as the
sole initial diagnostic study, Gracias etal. demonstrated
that imaging effectively ruled out injuries in 56% based on
a wound trajectory remote from vital structures. With
3–6-months of follow-up, there were no missed injuries
(new Figs.18.1 and 18.2, old Figs.18.6 and 18.7). However,
this early enthusiasm was not universal with some centers
reporting only a 50% sensitivity in detecting aerodigestive
tract injury with CT imaging. Furthermore, it was suggested that advanced imaging contributed only minimally
to the results of a physical exam.
Several large series have been reported looking specically at the use of CT angiography to evaluate for vascular
injury in penetrating neck trauma. In a patient without hard
signs of vascular injury, it is reported that the physical exam
alone in the region has an especially poor sensitivity and
specicity (57% and 53%) for the detection of occult vascular injury. In specically evaluating CT angiography, Munera
etal. compared the results of CT angiography with conventional angiograms. They clearly demonstrated a good correlation with conventional angiography as well as a high
sensitivity and specicity (90% and 100%) for the detection
of vascular injuries diagnosed by traditional angiography.
Examples of the usefulness of CT Angiography in the diagnosis of symptomatic and occult vascular injuries are demonstrated by Figures 18.3 and 18.4.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_18
153
154
https://t.me/medicina_free
M. E. Hamill
a
Fig. 18.1 Stab wound to the left posterior neck clearly showing wound
tract without evidence of proximity to vascular structures
Fig. 18.2 Slash wound to the left neck which clearly penetrated platysma on exam. CTA neck demonstrating no evidence of proximity or
injury to vascular or aerodigestive tract structures. Treated with wound
washout and closure without formal neck exploration
b
Fig. 18.3 (a) Stab wound to the right neck with evidence of internal
carotid artery (ICA) injury. Patient with large middle cerebral artery
(MCA) territory thrombotic stroke successfully treated with neurointerventional extraction of thrombus and coiling of the right proximal and
distal ICA with excellent functional recovery. (b) CTA reconstruction
of the right ICA injury demonstrating abrupt cutoff of the right ICA
without distal reconstitution
ab
18 Computed Tomography intheWorkup ofPatients withPenetrating Trauma
https://t.me/medicina_free
155
c
d
Fig. 18.4 Multiple stable wounds to the neck with normal neurologic
exam. Preoperative imaging demonstrating (a) wound trajectory in
proximity to carotid artery. Coronal (b), Sagital (c) and Subtraction (d)
reconstructions demonstrating intimal ap in right common carotid
artery. At time of exploration patient with supercial appearing injury
to adventitia with small hematoma. Upon vessel exploration patient
with approximately 50–75% intimal ap and extensive thrombus in
vessel lumen
Another study prospectively examined the usefulness of
CT angiography as the initial screening mechanism in stable
patients with neck injuries penetrating the platysma. Inaba
etal. demonstrated a sensitivity of 100% and specicity of
97.5% for the detection of clinically signicant vascular and
aerodigestive tract injuries. The use of CT angiography has
been shown to decrease the rate of formal surgical neck
exploration, as well as the rate of negative neck exploration
when used in stable patients not requiring emergent
exploration.
In 2008, the Eastern Association for the Surgery of
Trauma issued a practice management guideline regarding
penetrating zone II neck trauma. After an exhaustive review
of the relevant literature, it was concluded that selective
operative management of penetrating zone II neck injuries is
recommended to minimize unnecessary operations. Highresolution CT angiography was identied as the initial diagnostic study of choice when available. A more recent
guideline from the Western Trauma Association in 2013 suggested the liberal use of CT angiography in any asymptom-
156
https://t.me/medicina_free
atic patient with a clinical suspicion of injury regardless of
the neck zone involved.
Based on the quality of the images generated by the newest generation of CT scanners, some authors are going as far
as suggesting that the classic delineation of penetrating neck
trauma by anatomic zone be abandoned. In a patient without
hard signs of injury or hemodynamic instability, it is suggested that CT angiography be used at the rst imaging
modality. It allows for rapid determination of injury trajectory and provides an excellent assessment tool for the diagnosis of both aerodigestive track and vascular injuries. With
the early use of high-resolution CT angiography, the workup
can be simplied and use of pan endoscopy, oral contrast
studies, and surgical neck exploration can be limited to the
subset of patients in which it is likely to be higher yield.
While some advocate the limited use of imaging in the case
of no signicant physical exam ndings, they do suggest that
it be used liberally when soft signs are present. These “no
zone” approaches suggest that it is possible to both prevent
unnecessary exploration and limit the use of CT imaging by
a judicious clinical approach.
Again, it should be obvious that patients with signs of
obvious life-threatening injury including massive hemorrhage, expanding hematoma, or airway compromise require
emergent surgical exploration. However, in the stable patient
with a penetrating neck injury, CT and CT angiography represent excellent tools for the diagnosis of both aerodigestive
tract and vascular injuries. Their liberal use, followed by the
appropriate use of other diagnostic modalities and selective
surgical exploration, is associated with timely intervention
for injuries, with the prevention of a large number of negative surgical explorations.
M. E. Hamill
Fig. 18.5 Saw injury to the right anterior chest wall without evidence
of intrathoracic penetration. Complicated wound care due to extensive
tissue defect
18.2 Thorax
Penetrating injuries to the thorax represent a critical diagnostic dilemma. A relatively small percentage of the patients will
present in extremis—with evidence of massive hemorrhage
and hemodynamic instability. This subset clearly requires
urgent operative intervention. However, the large majority of
penetrating thoracic injuries can be managed by with observation or simple tube thoracotomy alone. It is estimated that
only approximately 15% of patients with penetrating chest
trauma require any type of therapeutic operative procedure. It
is important to remember that given the potential for serious
morbidity and mortality associated with injury to the heart,
great vessels, or aerodigestive tract structures, rapid accurate
diagnosis is essential (Figs.18.5 and 18.6).
The use of chest CT and CT angiography as a tool for triage of stable patients with penetrating chest trauma has been
well-described in the literature. When combined with echocardiography, chest CT has been demonstrated as able to
Fig. 18.6 Stab wound to the right chest with intrathoracic penetration
and lung injury. No evidence of mediastinal or intrathoracic vascular
injury. Successfully treated with thoracotomy tube drainage
exclude injury in approximately 80% of patients. For those
stable patients who have CT ndings concerning for signicant injury, additional diagnostic procedures such as bronchoscopy or esophagostomy are useful to further evaluate the
areas of concern. Chest CT and CT angiography have been
Соседние файлы в папке @xirurgi_2025