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Transmediastinal gunshot wounds: A prospective study
McCABE AND WARREN • TRAUMA: AN ANNOTATED BIBLIOGRAPHY
present study was to prospectively evaluate the incidence of intracranial injury in patients who sustained minimal head injury (MHI), and the practice of mandatory hospital admission or supervised observation of patients after MHI, particularly when CT scan was negative. MHI was defined as a Glasgow Coma Scale (GCS) score of 14 or 15, and a sustained LOC or posttraumatic amnesia. In this study, all patients who were admitted for minimal head injury underwent a standardized neurologic examination followed by a helical CT. A total of 2,152 patients underwent both a physical examination and a cranial CT scan within 12 hours of admission. The CT was negative for intracranial injury in 1,788 patients. The authors determined the negative predictive power of a cranial CT scan to be 99.7%, and concluded that patients who have no intracranial injury and do not have other body system injuries or a persistence of any neurologic finding can be safely discharged from the emergency department without a period of either in-patient or out-patient observation,
CHEST Blunt Chest Trauma in the Elderly Patient: How Cardiopulmonary Disease Affects Outcome. Alexander JQ, Gutierrez CJ, Mariano MC, et al. Am Surgeon 2000;66:855-857. There has been a trend in the past decade to recognize that, just as pediatric patients are "not just small adults," elderly patients are not just "older adults." This retrospective review showed that elderly patients with cardiopulmonary disease have a much higher rate--nearly 5 0 % - - o f developing complications from trauma causing only multiple rib fractures than do patients without any preexisting cardiac or pulmonary problems. The authors conclude that such patients should probably be admitted to an intensive care unit from the outset to prevent complications.
Blunt Hemopericardium Detected by Surgeon--Performed Sonography. Carrillo EH, Schirmer TP, Siderman MJ, et al. J Trauma 2000;48:971-974. This article shows the utility of performing FAST (focused abdominal sonography for trauma) in the patient who has suffered blunt chest trauma. In the 2 cases reported in this article, sonography allowed for quick demonstration of the presence of pericardial fluid. All facilities that see trauma patients frequently would benefit by having the ability to perform this procedure.
Factors Affecting Prognosis With Penetrating Wounds of the Heart. Tyburski JG, Astra L, Wilson RF, et al. J Trauma 2000;48:587-591. The authors reviewed the experience with emergency department thoracotomy at Detroit Receiving Hospital from 1980 to 1997 to determine if there were any relevant features that can predict survival. The overall survival rate of this series is impressive. Of 154 patients with stab wounds, there was a 58% survival rate. In the patients with gunshot wounds (148 patients), there was a 23% survival. Of note, survival was defined in this article as alive at discharge from the hospital, but there was no discussion of neurologic status on discharge. Factors which predicted successful outcome of emergency department thoracotomy included the physiologic status of the patient and the anatomic structures involved; the presence of cardiac tamponade was also found to be a good prognostic factor. The authors found no survivors in patients who suffered a cardiac arrest at the scene, and there were no survivors among the 93 patients with gunshot wounds of the heart.
Transmediastinal Gunshot Injuries. Degiannis E, Benn C-A, Leandros E, et al. Surgery 2000;128:54-58. Transmediastinal gunshot injuries are understandably highly lethal. In the past decade a point of contention among trauma
443
surgeons has been the proper evaluation of such wounds in hemodynamically stable patients: should one study the great vessels with angiography first, as had been the general consensus, or should one study the esophagus first? The argument for studying the esophagus first is that (1) if a patient is indeed hemodynamically stable, he or she is unlikely to have a major vascular injury that requires repair, and (2) esophageal wounds that are not repaired within 12 hours have a greatly increased rate of serious septic complications. The authors of this retrospective review of 118 patients with transmediastinal gunshot wounds seen over the course of 5 years at Baragwanath Hospital (an extremely busy trauma center in Johannesburg, South Africa) argue that angiography should remain the first examination. Fifty-seven of their patients were stable; only one had a positive angiography, whereas 17 had positive results of esophageal studies. All of these 17 were repaired within 12 hours, and all did well; the one with aortic injury also did well with immediate surgery, The authors feel, and I agree, that angiography should remain the initial examination, and it should be able to be completed within at most a few hours, so that the next examination-investigating the esophagus--can be completed expeditiously as well. Assuming that patients who are hemodynamically stable do not have a serious vascular injury may be correct in most patients, but not in all, and missing the diagnosis may well be a death sentence.
Transmediastinal
Gunshot Wounds: A Prospective Study.
Renz BM, Cava RA, Feliciano DV, et al. J Trauma 2000;48: 416-422. This excellent study from Grady Hospital in Atlanta reviews the management and outcome of patients who have suffered transmediastinal gunshot wounds. The authors hypothesized that patients with transmediastinal gunshot wounds could be immediately triaged according to the systolic blood pressure on ED admission. They divided the patients into 3 groups. Group 1 had a systolic blood pressure greater than 100, group 2 had a systolic blood pressure between 60 and 100, and group 3 had a systolic blood pressure less than 60. Group 3 patients were taken immediately to the operating room. Group 1 patients, and group 2 patients who were stabilized with fluid resuscitation were further evaluated with diagnostic examinations; group 2 patients who did not stabilize promptly with fluids were operated on according to the trajectory of the bullet. The authors found that not all patients with transmediastinal wounds require operative intervention. The results of other diagnostic tests will determine the need for surgery. The discussion at the end of this report by Dr Mattox is excellent.
Helical Computed Tomographic Scan in the Evaluation of Mediastinal Gunshot Wounds. Hanpeter DE, Demetriades D, Asensio JA, et al. J Trauma 2000;49:689-695. This report studies the utility of helical computerized tomography in determining the trajectory of a missile. In general, patients who have suffered mediastinal penetration by missile require endoscopy of both the esophagus and the trachea as well as an assessment of the aorta and cardiac anatomy. In this study, patients who were unstable and failed to respond to fluid resuscitation underwent immediate operative exploration. Patients who were stable and immediately responded to volume resuscitation were evaluated with the helical computerized tomography. The authors found that the computerized tomographic scans provided a rapid, readily available, noninvasive, and highly accurate means to evaluate missile trajectory. If the missile did not approach any significant mediastinal structure, operative intervention was unnecessary. The CT scan eliminated the need for additional evaluation.
present study was to prospectively evaluate the incidence of intracranial injury in patients who sustained minimal head injury (MHI), and the practice of mandatory hospital admission or supervised observation of patients after MHI, particularly when CT scan was negative. MHI was defined as a Glasgow Coma Scale (GCS) score of 14 or 15, and a sustained LOC or posttraumatic amnesia. In this study, all patients who were admitted for minimal head injury underwent a standardized neurologic examination followed by a helical CT. A total of 2,152 patients underwent both a physical examination and a cranial CT scan within 12 hours of admission. The CT was negative for intracranial injury in 1,788 patients. The authors determined the negative predictive power of a cranial CT scan to be 99.7%, and concluded that patients who have no intracranial injury and do not have other body system injuries or a persistence of any neurologic finding can be safely discharged from the emergency department without a period of either in-patient or out-patient observation,
CHEST Blunt Chest Trauma in the Elderly Patient: How Cardiopulmonary Disease Affects Outcome. Alexander JQ, Gutierrez CJ, Mariano MC, et al. Am Surgeon 2000;66:855-857. There has been a trend in the past decade to recognize that, just as pediatric patients are "not just small adults," elderly patients are not just "older adults." This retrospective review showed that elderly patients with cardiopulmonary disease have a much higher rate--nearly 5 0 % - - o f developing complications from trauma causing only multiple rib fractures than do patients without any preexisting cardiac or pulmonary problems. The authors conclude that such patients should probably be admitted to an intensive care unit from the outset to prevent complications.
Blunt Hemopericardium Detected by Surgeon--Performed Sonography. Carrillo EH, Schirmer TP, Siderman MJ, et al. J Trauma 2000;48:971-974. This article shows the utility of performing FAST (focused abdominal sonography for trauma) in the patient who has suffered blunt chest trauma. In the 2 cases reported in this article, sonography allowed for quick demonstration of the presence of pericardial fluid. All facilities that see trauma patients frequently would benefit by having the ability to perform this procedure.
Factors Affecting Prognosis With Penetrating Wounds of the Heart. Tyburski JG, Astra L, Wilson RF, et al. J Trauma 2000;48:587-591. The authors reviewed the experience with emergency department thoracotomy at Detroit Receiving Hospital from 1980 to 1997 to determine if there were any relevant features that can predict survival. The overall survival rate of this series is impressive. Of 154 patients with stab wounds, there was a 58% survival rate. In the patients with gunshot wounds (148 patients), there was a 23% survival. Of note, survival was defined in this article as alive at discharge from the hospital, but there was no discussion of neurologic status on discharge. Factors which predicted successful outcome of emergency department thoracotomy included the physiologic status of the patient and the anatomic structures involved; the presence of cardiac tamponade was also found to be a good prognostic factor. The authors found no survivors in patients who suffered a cardiac arrest at the scene, and there were no survivors among the 93 patients with gunshot wounds of the heart.
Transmediastinal Gunshot Injuries. Degiannis E, Benn C-A, Leandros E, et al. Surgery 2000;128:54-58. Transmediastinal gunshot injuries are understandably highly lethal. In the past decade a point of contention among trauma
443
surgeons has been the proper evaluation of such wounds in hemodynamically stable patients: should one study the great vessels with angiography first, as had been the general consensus, or should one study the esophagus first? The argument for studying the esophagus first is that (1) if a patient is indeed hemodynamically stable, he or she is unlikely to have a major vascular injury that requires repair, and (2) esophageal wounds that are not repaired within 12 hours have a greatly increased rate of serious septic complications. The authors of this retrospective review of 118 patients with transmediastinal gunshot wounds seen over the course of 5 years at Baragwanath Hospital (an extremely busy trauma center in Johannesburg, South Africa) argue that angiography should remain the first examination. Fifty-seven of their patients were stable; only one had a positive angiography, whereas 17 had positive results of esophageal studies. All of these 17 were repaired within 12 hours, and all did well; the one with aortic injury also did well with immediate surgery, The authors feel, and I agree, that angiography should remain the initial examination, and it should be able to be completed within at most a few hours, so that the next examination-investigating the esophagus--can be completed expeditiously as well. Assuming that patients who are hemodynamically stable do not have a serious vascular injury may be correct in most patients, but not in all, and missing the diagnosis may well be a death sentence.
Transmediastinal
Gunshot Wounds: A Prospective Study.
Renz BM, Cava RA, Feliciano DV, et al. J Trauma 2000;48: 416-422. This excellent study from Grady Hospital in Atlanta reviews the management and outcome of patients who have suffered transmediastinal gunshot wounds. The authors hypothesized that patients with transmediastinal gunshot wounds could be immediately triaged according to the systolic blood pressure on ED admission. They divided the patients into 3 groups. Group 1 had a systolic blood pressure greater than 100, group 2 had a systolic blood pressure between 60 and 100, and group 3 had a systolic blood pressure less than 60. Group 3 patients were taken immediately to the operating room. Group 1 patients, and group 2 patients who were stabilized with fluid resuscitation were further evaluated with diagnostic examinations; group 2 patients who did not stabilize promptly with fluids were operated on according to the trajectory of the bullet. The authors found that not all patients with transmediastinal wounds require operative intervention. The results of other diagnostic tests will determine the need for surgery. The discussion at the end of this report by Dr Mattox is excellent.
Helical Computed Tomographic Scan in the Evaluation of Mediastinal Gunshot Wounds. Hanpeter DE, Demetriades D, Asensio JA, et al. J Trauma 2000;49:689-695. This report studies the utility of helical computerized tomography in determining the trajectory of a missile. In general, patients who have suffered mediastinal penetration by missile require endoscopy of both the esophagus and the trachea as well as an assessment of the aorta and cardiac anatomy. In this study, patients who were unstable and failed to respond to fluid resuscitation underwent immediate operative exploration. Patients who were stable and immediately responded to volume resuscitation were evaluated with the helical computerized tomography. The authors found that the computerized tomographic scans provided a rapid, readily available, noninvasive, and highly accurate means to evaluate missile trajectory. If the missile did not approach any significant mediastinal structure, operative intervention was unnecessary. The CT scan eliminated the need for additional evaluation.