Dear Editor
Mediastinal penetrating trauma patients are subject to numerous surgical procedures and are reported to have high mortality rates. On admission, all hemodynamically stable patients require a computerized tomography (CT).[1] Out of all stable patients, only 10% will require surgical treatment.[2]
Based on three exemplifying cases managed in our institution according to current literature, we advice a standardized model for the treatment of hemodynamically stable patients.[3]
Patient without anatomically relevant injuries: Conservative management.
Case 1: Left mediastinal gunshot wound (MGW). Bullet transfixiates anterior mediastinum and lodges in a retrosternal position anterior and superior to great vessels [Figure 1]. No anatomical injuries. Patient is observed.
Figure 1.
Chest CT that shows bullet in anterior mediastinum. Without any pericardial or pleural effusion, without pneumomediastinum or visceral injuries
Patient without anatomically relevant injuries in which a complication is clinically suspected: Order complementary exams like upper gastrointestinal endoscopy (UGIE), bronchoscopy, esophagogram, echocardiogram, or angiography. Surgery is only indicated in case of positive findings.
Case 2: Left transfixiating MGW with pre-esophageal tract, no apparent injuries in CT, at 48h evolves with tachycardia and fever [Figure 2]. UGIE is performed and a central esophageal perforation is diagnosed. Surgical exploration revealed acute mediastinitis requiring bilateral thoracotomies, cervical exploration, and esophaguectomy.
Figure 2.
A transmediastinal trajectory is clearly evident. No other injuries are present
Patient with anatomically relevant injury: Immediate surgical management.
Case 3: Left tranxifixating MGW. Bullet grossed anterior to the pericardium. Patient is asymptomatic but CT shows pericardial effusion and myocardial hematoma. [Figure 3] Surgical exploration reveals left hemothorax, pericardial tamponade, and myocardial contusion.
Figure 3.
Moderate pericardial effusion compatible with hemoperircardium, bilateral basal atelectasis and signs suggestive of left hemothorax
After 6 months of follow-up, all three patients are alive. And case 2 is awaiting digestive transit reconstitution.
In conclusion, we advocate for conservative management of hemodynamically stable MGW´s in patients thoroughly studied to exclude anatomical injuries on admission. If complication is clinically suspected, additional exams must be undertaken to make appropriate diagnosis and treat accordingly.
REFERENCES
- 1.Ibirogba S, Nicol AJ, Navsaria PH. Screening helical computed tomographic scanning in haemodynamic stable patients with transmediastinal gunshot wounds. Injury. 2007;38:48–52. doi: 10.1016/j.injury.2006.07.039. [DOI] [PubMed] [Google Scholar]
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