Penetrating thoracoabdominal injuries

Penetrating chest wounds: 24 years experience

Thoracic and thoracoabdominal penetrating wounds are frequently encountered in urban medical centers in the United States. This study was undertaken to determine the clinical characteristics and in hospital outcome of these injuries. This was a longitudinal, nonblinded study using the established standard of care of patients with penetrating chest trauma. It consists of an analysis of a consecutive series of 3049 patients treated at one trauma center between April 1972 and March 1996. There were 1347 stab wounds and 1702 gunshot wounds. Antibiotic prophylaxis was administered to patients who underwent laparotomy or thoracotomy or who had lung contusion with hemoptysis (41.6%, 1296/3049). Of 3049 patients, 196 had cardiac injuries. All of them underwent thoracotomy, and the mortality was 21.9%. In contrast, among 2853 patients without cardiac injuries, only 257 (9%) required thoracotomy; the mortality in this group was 1.5%. Patients with thoracoabdominal injuries (899/3049) had a mortality of 4.3% compared to 2.1% among those who had isolated chest injuries. The overall mortality was 2.8%. Of 1702 patients with gunshot wounds, 85 (5%) sustained transaxial injuries, with an overall mortality of 36.5%. The complication rate among the survivors was 6% with only 2.5% being infectious. We conclude that the mortality for noncardiac penetrating injuries of the chest is low. The presence of associated abdominal injuries increases the mortality twofold. More than one-third of the patients with transaxial wounds die. Gunshot wounds of the heart result in higher mortality than stab wounds to the heart. The infection rate is low.

Disembowelment--a retrospective study of patients suffering evisceration following penetrating abdominal injury

Details are presented of 104 patients admitted over a 1-year period with evisceration following penetrating abdominal wounds. Stabbing was the most common cause of injury. Small bowel was the most commonly eviscerated organ, as well as the organ most frequently injured. Exploratory laparotomy was performed on all the patients who survived to reach the operating theatre. The negative laparotomy rate was 12 per cent, and a further 3 per cent had such mild visceral injuries that they did not require operative repair. For comparison a group of 111 patients admitted over the same period, but suffering only omental protrusion, was also examined. The rate of visceral injury in this group was slightly lower. Wound complications, including breakdown, were more commonly seen in the eviscerated patients, but the mortality was 8 per cent in both groups.

Abdominal trauma

Abdominal trauma continues to be the major cause of morbidity and mortality in this country. Unnecessary deaths and complications can be minimized by improved resuscitation, evaluation, and treatment. Rapid resuscitation is necessary to save the unstable but salvageable patient with abdominal trauma. Accurate diagnosis and avoidance of unneeded surgery is an important goal of evaluation. However, most avoidable deaths result from failure to resuscitate and operate on surgically correctable injuries. When the diagnosis is in doubt and clinical judgment suggests surgery, exploration provides definitive treatment as well as diagnosis; moreover, the risks of negative exploration have become acceptable. The new techniques and diagnostic tools available are important in the management of abdominal trauma. These improved methods, however, still depend on experience and clinical judgment for application and determination of the best care for the injured patient.

A retrospective review of 89 stab wounds to the abdomen and chest

This study compared the admission findings in 89 stab victims with the subsequent severity of their injury. The majority of patients were young males who arrived at hospital after 2300 h on a Friday, Saturday or Sunday and had consumed alcohol prior to admission. The presence of "clinical shock" or absent bowel sounds was invariably associated with significant injury. However, 64 of the 89 patients in this study had a normal blood pressure and audible bowel sounds at the time of admission. Thirty of the 64 patients had also suffered significant injury, which frequently was a perforated viscus. A diagnostic laparotomy should be readily performed in such patients in view of the high incidence of occult injury. Experienced anaesthetic support is necessary to ensure a low mortality from the actual laparotomy.