Trans-Mediastinal Gunshot Wounds

A Trans-mediastinal GSW is any GSW that potentially crosses the mediastinum.

Of the patients that arrive at the hospital with vital signs, 43% are unstable and should go immediately to the OR.

The remaining 57% have normal, stable vitals.

Work up of the stable patient with a trans-mediastinal GSW must take the following structures into consideration:

Lungs - bilaterally at risk
Anterior Mediastinum - Heart
Posterior Mediastinum - Aorta, Esophagus, Tracheo-bronchial tree
Don't forget a potential spine/spinal cord injury.

1. Lungs/pleura -

• get a CXR to determine if there is a hemothorax or pneumothorax present 
• if so, insert chest tube into that side

2. Heart -

• ECHO to rule out pericardial fluid - the presence of any fluid is assumed to be blood until proven otherwise -
• if there is fluid, the patient should go to OR for pericardial window/sternotomy/thoracotomy. 
• ECHO (not just the cardiac view from FAST) is 97% sensitive, 99% specific and 99% accurate. 
• 8% of patients who are "stable" after TM-GSW have an injury.

3. Aorta/great vessels -

• formal angiogram to rule out an injury (CT literature not convincing for penetrating trauma). 
• up to 22% of "stable" TM-GSW patients have an injury

4. Esophagus -

• esophagram and esophagoscopy - must be used in combination as each misses 11-20% of injuries
• 15-30% of "stable" TM-GSW patients have an injury - most are asymptomatic until they develop mediastinal sepsis

5. Trachea/Bronchi -

• least common injury in "stable" patients
• injuries present with mediastinal air or massive air leak in chest tube
• bronchoscopy is done if patient has evidence of injury

Diagnosis of these injuries should be done immediately upon presentation and not left until morning.  Timely diagnosis and treatment will lower the mortality rate for TM-GSW to 4%.

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World J Surg. 2002 Oct;26(10):1247-50. Epub 2002 Sep 6.

Trans-mediastinal gunshot wounds: are "stable" patients really stable?

Nagy KK, Roberts RR, Smith RF, Joseph KT, An GC, Bokhari F, Barrett J.

Source

Department of Trauma, Cook County Hospital, 1835 W. Harrison Street, Room M3241, Chicago, Illinois 60612, USA. kimberly_nagy@rush.edu

Abstract

Gunshot wounds that traverse the mediastinum frequently cause serious injury to the cardiac, vascular, pulmonary, and digestive structures contained within. Most patients present with unstable vital signs signifying the need for emergency operation. An occasional patient will present with stable vital signs. Work-ups for such a patient may range from surgical exploration to radiographic and endoscopic testing to mere observation. We report our experience with diagnostic work-up of the stable patient with a transmediastinal gunshot wound. All stable patients who present to our urban level I trauma center following a transmediastinal gunshot wound undergo diagnostic work-up consisting of chest radiograph, cardiac ultrasound, angiography, esophagoscopy, barium swallow, and bronchoscopy. The work-up is dependent on the trajectory of the missile. Information on these patients is kept in a prospective database maintained by the trauma attending physicians. This database was analyzed and comparisons were made using Student's t-test and the Fisher exact c2 as appropriate. Over a 68-month period, 50 stable patients were admitted following a transmediastinal gunshot wound. All of these patients had a chest radiograph followed by one or more of the above tests. 8 patients (16%) were found to have a mediastinal injury (4 cardiac, 3 vascular, and 1 tracheo-esophageal) requiring urgent operation (group 1). The remaining 42 patients (84%) did not have a mediastinal injury (group 2). There was no difference between groups with respect to blood pressure, pulse, respiratory rate, pH, base deficit, or initial chest tube output. There was one death in each group, and three complications in group 2. Patients may appear stable following a transmediastinal gunshot wound, even when they have life-threatening injuries. There is no difference in vital signs, blood gas, or hemothorax to indicate which patients have serious injuries. We advocate continued aggressive work-up of these patients to avoid missing an injury with disastrous consequences.