Penetrating thoracic injuries: what we have learnt.

BACKGROUND: Thoracic injuries, especially cardiac, vascular, and transmediastinal injuries, are amongst the most lethal of penetrating injuries.
METHOD: Our experience at Groote Schuur Hospital is reviewed, where up to 1,000 patients were admitted annually with penetrating chest wounds between 1982 and 1997.
RESULTS: The approximate pre-hospital mortality was 86% with penetrating cardiac injuries, 92 % with extrapericardial vascular injuries, and 11 % with pulmonary injuries. Less than 2% of pneumothorax cases and less than 10% of haemothorax cases required surgical intervention. Thoracoscopic evacuation of retained clots was successful in the majority of the latter. Most penetrating injuries of the thoracic duct required surgical exploration. The mortality of penetrating cardiac injuries varied according to clinical presentation (moribund 52%, hypovolaemia 20% and tamponade 2-5%) and the chamber involved. Higher mortalities were associated with atrial injuries.
CONCLUSIONS: The appropriate use of intercostal drains and therapeutic thoracoscopy are important considerations in penetrating non-cardiac thoracic trauma. Rapid transportation, immediate triage, open-minded use of emergency room thoracotomy, and aggressive surgical management with liberal use of sub-xiphisternal pericardial windows are important factors in improving the survival of penetrating cardiac trauma.