Western Trauma Association critical decisions in trauma: penetrating chest trauma.

T is a recommended algorithm of the Western Trauma Association for the acute management of penetrating chest injury. Because of the paucity of recent prospective randomized trials on the evaluation and management of penetrating chest injury, the current algorithms and recommendations are based on available published cohort, observational and retrospective studies, and the expert opinion of the Western Trauma Association members. The two algorithms should be reviewed in the following sequence: Figure 1 for the management and damagecontrol strategies in the unstable patient and Figure 2 for the management and definitive repair strategies in the stable patient. Figure 1 will discuss damage-control techniques; Figure 2 will focus on more definitive repairs. Because of the variety of possible mechanisms, presentation, injury sites, and operative approaches, we recognize that therewill be variability in decision making, local resources, institutional consensus, and patientspecific factors that may require deviation from the algorithms presented. The algorithms and accompanying text represent our consensus for a safe and reasonable approach in these complex cases and attempts to incorporate historically validated approaches with the advent of newer imaging, interventional, resuscitative, operative, and selective/expectant management approaches. Historical Perspective The precise incidence of penetrating chest injury, varies depending on the urban environment and the nature of the review. Overall, penetrating chest injuries account for 1% to 13% of trauma admissions, and acute exploration is required in 5% to 15% of cases; exploration is required in 15% to 30% of patients who are unstable or in whom active hemorrhage is suspected. Among patients managed by tube thoracostomy alone, complications including retained hemothorax, empyema, persistent air leak, and/or occult diaphragmatic injuries range from 25% to 30%. In civilian practice, this low incidence has been generally attributed to ‘‘low-kinetic energy’’ mechanisms. In zones of conflict, among properly outfitted soldiers, body armor also results in a lower requirement for operation and incidence of complications. The reported incidence of specific injuries also varies, depending on site and characterization of the patient population. Demetriades reported an overall incidence of great vessel injury of 5.3% following gunshot wounds and 2% after stab wounds to the chest.Rhee et al. described anoverall incidence of penetrating cardiac injuries as 1 per 210 admissions. Sixty-five percent of the patients admitted to the University of Louisville with peristernal penetrating injuries sustained a cardiac injury. In patients requiring urgent (nonYemergency department) thoracotomy, cardiac injuries are found in approximately 16% to 52% following stab wounds and 10% to 37% following gunshot wounds, and lung injuries are found in 30% to 59% of stab wounds and 65% to 86% of gunshot wounds. It is clear that mortality is significantly impacted by preadmission hypotension, the ability to perform aggressive resuscitation and operative intervention, and appropriate imaging in stable patients. Focusing on blood products rather than crystalloids and in some settings ‘‘hypotensive’’ resuscitation seems to have a survival benefit.