Penetrating Chest Trauma - When do we operate?

Urgent Surgical Indications – Approximately 15% of penetrating chest trauma require operative management.

1. Cardiac Tamponade - The presence of cardiac tamponade, most often identified by ultrasound during the FAST examination, requires urgent intervention with either a pericardial window or median sternotomy. For hemodynamically unstable patients, emergent pericardiocentesis and placement of a catheter may be needed.  This procedure is not definitive and a thoracotomy or pericardial window is still indicated.
2. Massive air leak – This usually occurs in the setting of a major tracheobronchial injury and is unlikely to heal without surgical intervention.  Massive air leak is defined as one present during all phases of respiration and preventing full expansion of the affected lung or impairing ventilation through diminished tidal volume. 
3. Large volume of blood drained immediately after chest tube insertion – This usually indicates a large vascular injury that requires an operation urgently.  Many authors use 1500 mL of immediate chest tube drainage as the threshold for surgical thoracotomy, but others use 1000 mL. Ongoing bleeding at a rate of 200 to 300 mL/hour is another common indication for chest exploration.

thanks to Dr. Keith Hood for this entry