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<< Ballistic Injuries In The Emergency Department (Trauma CME)

Management Of Thoracic Gunshot Wounds

Thoracic ballistic wounds often injure multiple structures and require significant hospital resources to manage emergently. (See Table 8.) Major vascular injuries occur in 4% of penetrating chest trauma cases. If tracheobronchial injuries are present, the proportion of patients with major vascular injuries can be as high as 30% (not including cardiac injuries that occur in 3% of cases).78 Many patients with penetrating thoracic injuries do not survive to the ED, and those that do survive to the ED often require immediate interventions such as tube thoracostomy, intubation, and thoracotomy. Thus, the emergency clinician must be able to rapidly diagnose and treat injuries that are immediately life-threatening.

 

Evaluation Of Thoracic Trauma

Focused assessment with sonography in trauma (FAST) examination has become a mainstay of early trauma management, as bedside ultrasound has become readily available in many institutions. The FAST examination should be performed early in the initial assessment of penetrating thoracic trauma as it can help accurately diagnose a pericardial effusion, hemoperitoneum, pneumothorax, and hemothorax and thus direct timely treatment to the most appropriate location. Bedside ED ultrasound of the pericardium has been shown in multiple studies to have excellent sensitivity, specificity, and accuracy (100%, 97%, and 97%, respectively).79,80 A false-negative examination is possible if the cardiac injury is not contained within the pericardium and is causing a massive hemothorax, but false-positive pericardial ultrasounds are rare. Case reports describing false-positive pericardial ultrasounds have been reported most frequently in the setting of a massive hemothorax or mediastinal injury.81 Tube thoracostomy to relieve the hemothorax followed by a repeat pericardial ultrasound may improve the diagnostic accuracy in these cases.

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