Mediastinal Traversing Wounds

DEFINITION
When a missile or other penetrating traumatic object passes through one hemithorax and into the other.

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EPIDEMIOLOGY
Chest trauma
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AETIOLOGY
Penetrating trauma.
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BIOLOGICAL BEHAVIOUR

Pathophysiology
Penetrating objects that traverse the mediastinum can injure the major mediastinal structures.
- eg heart, great vessels, tracheobronchial tree, or oesophagus.

Haemodynamically abnormal pts (50%):

- assume exsanguinating thoracic haemorrhage, tension pneumothorax, pericardial tamponade.

Overall mortality 20%
Doubles in the haemodynamically abnormal.
Overall ~80% will need corrective surgery.


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MANIFESTATIONS

Evidence that an entrance wound enters one hemithorax and lodges in the contralateral thorax.
Any missile injury with metal fragments lodging near the mediastinum should raise suspicion.
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INVESTIGATIONS

Haemodynamically Normal

If a non-operative course is followed, get a CT (contrast-enhanced, helical) or angiogra.
- visualise aorta and major branches.
Complementary oesophagoscopy / bronchoscopy.

CT / USS
For state of heart and pericardium.

If at any time ABCDEs deteriorate, reevaluate immediate for intervention need.

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MANAGEMENT

Rapid surgical consultation.
Perform bilateral tube thoracostomy to relieve haemopneumothorax and measure blood loss.
Indications for urgent thoracotomy same as for massive haemothorax.
- begin on the side with more bld loss.
Manage tamponade.
Consider aortic injury / other great vessel injury.
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REFERENCES