STAB WOUNDS TO THE CHEST: A RETROSPECTIVE REVIEW OF 100 CONSECUTIVE CASES Terrence M. Fullum, MD, Suryanarayana M. Siram, MD, FACS, and Massimo Righini, MD, FACS Washington, DC In a retrospective review of 100 consecutive cases of stab wounds to the chest, 44 patients were successfully treated with tube thoracostomy, 14 patients required thoracotomy, 17 patients with small pneumothoraces were observed, and 25 patients were asymptomatic. The overall mortality was 4%, operative mortality was 7.1%, and the mortality rate for cardiac injuries was 50%. Of the eight patients with cardiac injuries, three were dead on arrival to the hospital and one patient died in the operating room. Patients treated with tube thoracostomy had a shorter hospital stay than patients managed by observation alone. Our findings support the opinion that asymptomatic patients (normal chest x-rays) may be discharged after 24 hours of observation and asymptomatic patients with nonprogressive small pneumothoraces (less than 20%) not requiring a chest tube may be discharged after 48 hours of observation. All patients should have close outpatient followup.

Key words * pneumothorax * thoracostomy Stab wounds to the chest may appear innocuous but are associated with significant morbidity and mortality From the Departments of Surgery and Trauma Surgery, Howard University Hospital, Washington, DC, and Department of Surgery, Greater Southeast Community Hospital. Presented at the 93rd Convention and Scientific Assembly of the National Medical Association, Los Angeles, CA, July 30-August 4,1988. Requests for reprints should be addressed to Dr TM. Fullum, Department of Surgery, Howard University Hospital, Washington, DC 20060. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 2

as a result of injuries to intrathoracic structures, including the heart, major vessels, lungs, tracheabronchial tree, esophagus, and spinal cord. Prompt evaluation and treatment is essential to a favorable outcome. The purpose of this study was to evaluate patients with stab wounds to the chest to determine which stab wounds resulted in which types of injuries. We compared the type of injury and its association with morbidity and mortality Asymptomatic patients were observed for 24 hours. Patients with a small (less than 20%) pneumothorax were observed, without closed thoracostomy. Our interests were in the development of a delayed or progressive pneumothorax and the length of hospital stay. Our goal was to establish an early but safe time to discharge these patients from the hospital, with close outpatient follow-up.

METHODS AND TREATMENTS We conducted a retrospective review of 100 consecutive cases of isolated stab wounds to the chest. Patients included 88 males and 12 females; their average age was 33 years. Although, according to Oporah et all in their studies, 10% to 15% of stab wounds to the chest will have associated intra-abdominal injuries, patients with this type of injury were excluded from our study. Initial patient evaluation included establishment of an adequate airway, treatment of shock when present, restoration of normal cardiorespiratory physiology, and the recognition of any complications or sequelae.2'3 Also, during the initial evaluation, objective findings were recorded, which included the location of the wound, vital signs, presence or absence of respiratory distress, chest physical findings, and evidence of tension pneumothorax. 109

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TABLE 1. RESULTS OF 100 STAB WOUNDS TO THE CHEST Pneumothorax Hemothorax Hemopneumothorax Number Chesttube (CT) No chesttube Average length of stay (CT/no CT) Longest length of stay Shortest length of stay (CT/no CT) Thoracotomy Cardiac injury Deaths

Pericardiocentesis Massive air leak Shock (systolic less than 90 mmHg)

50 33 17 4.9/6.0

16 16 0 10.5

9 9 0 8.6

25 0 25 1.2

13.9 2/3

42 5

22 7

2 1

4 0 0

7 5 1 (dead on arrival) 3 0 7

3 3 3 (2 dead on arrival) 1 1 3

0 0 0

0 4 0

A chest x-ray was obtained at the appropriate time, and the patients were categorized according to injury type: pneumothorax, hernothorax, hemopneumothorax, cardiac injury, esophagel injury, and bronchial injury. Patients who underwent thoracotomy or emergency room thoracotomy were evaluated for precipitating cause, and all mortalities were reviewed and evaluated for cause of death.

RESULTS In the review of 100 consecutive cases of stab wounds to the chest, we found 50 cases of pneumothorax, 16 of hemothorax, 9 of hemopneumothorax, and 25 cases without complications (Table 1). Of the 75 complicating injuries, 44 were treated successfully with tube thoracostomy; 17 patients with a small pneumothorax (less than 20%) were observed. Nine patients required emergency thoracotomy (within 6 hours of injury). Six patients were taken to the operating room within 2 hours of cardiac injury, and three within 6 hours because of continued bleeding of an intercostal vessel. Five patients underwent thoracotomy 48 to 72 hours after injury because of continued air leak from a bronchopleural fistula. There were four deaths, all secondary to cardiac or major vessel injury, and three patients were dead on arrival. One patient died in the operating room after receiving several stab wounds with injuries to the 110

Asymptomatic

0 0 0

trachea, heart, and ascending aorta. The overall mortality rate was 4% (4/100), operative mortality 7.1% (1/14), and the mortality rate associated with cardiac injuries was 50% (4/8). The three patients who arrived at the emergency room without vital signs received emergency room thoracotomies without success, confirming the view of Rohmon4 that the performance of emergency room thoracotomies in patients who are dead on arrival is a fruitless procedure. All 9 of the 14 patients who underwent emergency thoracotomy for suspected cardiac injury or continued bleeding presented to the emergency room with signs of hypovolemic shock, and three of the five patients with cardiac injuries who went to the operating room had previous pericardiocentesis as a temporizing maneuver for cardiac tamponade prior to surgery. Patients with a pneumothorax that resolved with placement of a closed thoracostomy tube were discharged after removal of the chest tube, in an average of 4.9 days (Table 2). The presence of a hemothorax increased hospital stay to an average of 8.6 days and was associated with a higher incidence of thoracotomy (Table 1).

DISCUSSION Between the years 1981 and 1984, 100 patients were admitted to Greater Southeast Community Hospital JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 2

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TABLE 2. INDICATIONS FOR REMOVAL OF CHEST TUBE Pneumothorax Resolution of pneumothorax with placement of chest tube No air leak after 48 hours of suction No recurrence of pneumothorax when suction discontinued Hemothorax Resolution of hemothorax with placement of chest tube Less than 50cc drainage in 24 hours No recurrence of hemothorax or pneumothorax when suction discontinued

TABLE 3. INDICATIONS FOR CLOSED THORACOSTOMY 1. Pneumothorax greater than 20% 2. Expanding pneumothorax 3. Patients needing general anesthesia with endotracheal intubation Any size pneumothorax Subcutaneous emphysema Patients at risk for developing delayed pneumothorax

TABLE 4. INDICATIONS FOR THORACOTOMY 1. Penetrating stab wounds to heart Entrance wound over cardiac region

with isolated stab wounds to the chest. Stabbing is the most common cause of penetrating wounds of the chest, accounting for as many as 75% to 80% in some reported series.2'5 The switchblade is the most common instrument. It is approximately 6 to 8 inches long and can cause quite traumatic injury internally, although the external wound may appear deceptively innocuous. This is particularly true of the "ice pick " wound which may lead to a pneumothorax, massive hemothorax, or even cardiac tamponade. The anterior chest and sternum are the most vulnerable areas for penetrating stab wounds. Posterior wounds may fail to penetrate because of the large muscle mass and the scapula. The depth and direction of penetration cannot always be estimated from examination of the external wound.2 In reviewing the literature, we found that much of our knowledge about all types of penetrating thoracic trauma has resulted from the study of war injuries.2'6 The mortality from penetrating chest trauma in World War I was 40% to 50%, and in World War II it was 12%. In a review of penetrating chest trauma with no associated injury in civilian life, the mortality ranged from 11.6%, as reported by Steinke7 in 1939, to 0.9%, as reported by Gray2 in 1958. Gray also reported that stab wounds accounted for 4% of the total mortality (3.8% with and without associated injuries), with shotgun wounds accounting for the highest percentage (32%). The overall mortality rate in our series was 4%, decreasing to 1%, excluding three patients dead on arrival. Although most stab wounds to the chest can be managed with closed thoracostomy (Table 3) or JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 2

Cardiac tamponade 2. Massive or progressive hemothorax Greater than 1 000cc initially Greater than 800cc in 4 hr 3. Esophageal injury

Odynophagia Mediastinal or cervical emphysema 4. Major tracheal or bronchial injury Refractory pneumothorax Massive air leak

observation, in some instances emergency thoracotomy is indicated (Table 4). Penetrating wounds of the heart are particularly associated with a high mortality, but these patients can be salvaged with prompt surgical intervention. The mortality for cardiac wounds was 15.8% in the series reported by Oporah et al,I with no intraoperative mortalities. In our series, the mortality for patients with cardiac injuries arriving to the emergency room while still alive was 20% (1/5). The role of pericardiocentesis is controversial and not recommended by Maynard8 and Ransdell.9 In our series, pericardiocentesis was performed on patients with evidence of cardiac tamponade and only as a temporizing measure that did not delay emergency thoracotomy. A negative pericardiocentesis may lull one into a false sense of security, particularly if the blood is clotted. Late hemorrhage due to dislodgement of a blood clot has been reported,2'10'11 and the late 111

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development of constrictive pericarditis from unevacuated hemopericardium remains a potential hazard. 10, 1I1 Although none of our asymptomatic patients developed a delayed pneumothorax, it has been recorded in 10% of cases. More than 98% of cases of delayed pneumothorax will occur within 6 hours of injury; however, delayed pneumothorax can occur as late as 48 hours, and there have been documented cases as late as 5 days. It has been suggested that these patients can be evaluated without hospitalization if inspiration and expiration chest x-rays remain negative 6 hours after injury.12 However, we recommend that the patient be admitted and additional chest x-rays taken in 6 hours (inspiration and expiration) and 24 hours (anterior-posterior and lateral). All asymptomatic patients can be discharged at this time and be advised to return in 5 days for follow-up evaluation, or earlier if any symptoms develop. Patients with a pneumothorax of less than 20% should be admitted and observed. 13 Repeat chest x-rays should be obtained in 6 hours, 24 hours, and again in 48 hours. If the pneumothorax is unchanged or shows evidence of resolving in 48 hours, these patients can be discharged and advised to return in 5 days, or earlier if symptoms develop. In our series, the average length of stay for patients with less than a 20% pneumothorax managed only with close observation was 6 days, and none of these patients were discharged until evidence of resolution of the pneumothorax was apparent. In addition, no patient required a chest tube or showed progression of a pneumothorax after 24 hours.

CONCLUSION Most stab wounds to the chest can be managed with tube thoracostomy or by close observation if the pneumothorax is nonprogressive (less than 20%) and there is no evidence of hemothorax. Asymptomatic patients can be discharged in 24 hours with follow-up evaluation in 5 days. Patients who develop a pneumothorax successfully treated with closed thoracostomy can be discharged in 48 to 72 hours. Morbidity is increased with the presence of a

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hemothorax, shock, or a large air leak, and these patients may require thoracotomy. Mortality is associated with cardiac and major vessel injuries, which may be heralded by cardiac tamponade, massive or progressive hemothorax, and signs of hypovolemic shock. Although no spinal cord injuries or tension pneumothorax were seen in our series, they are potentially lethal complications and must be considered in all patients with stab wounds to the chest. With a thorough understanding of the potential complications associated with stab wounds to the chest, prompt evaluation and treatment can minimize morbidity and mortality. By following specific guidelines, the evaluation and treatment of asymptomatic patients and patients with small nonprogressive pneumothoraces can be safe and costeffective as well. Literature Cited 1. Oporah SS. Penetrating stab wounds of the chest: experience with 200 consecutive cases. J Traum. 1976;1 6:98102. 2. Gray AR. Penetrating injuries to the chest clinical results in the management of 769 patients. Am J Surg. 1960;1 00:134138. 3. Elkin DC, Cooper FW Jr. thoracic injuries: a review of cases. Surg Gynecol Obstet. 1943;77:271-274. 4. Rohmon M. Emergency room thoracotomy for penetrating cardiac injuries. J Trauma. 1983;23:7-10. 5. Sherman RT. Experiences with 472 civilian penetrating wounds of the chest. Milit Med. 1988;1 31:63-67. 6. Carter BN, Bakey DC. Current observations on war wounds of the chest. J Thorac Surg. 1944;13:271-273. 7. Steinke P. Penetrating gunshot and stab wounds of the thorax: report of 87 cases. J Thorac Surg. 1939;8:658-661. 8. Maynard AD. Penetrating wounds of the heart. Surg Gynecol Obstet. 1952;94:605-607. 9. Ransdell HT. Gunshot wounds of the heart: a review of 20 cases. Amer J Surg. 1960;99:788-793. 10. McKusick VA. Constrictive pericarditis following traumatic hemovepicardium. Ann Surg. 1955;1 42:97-101. 11. Raker JW. Traumatic hemopericardium producing late constructive pericarditis. Ann Surg.1958;148:134-136. 12. Weigelt JA. Management of asymotonatic patients following stab wounds to the chest. J Trauma. 1982;22:41-48. 13. Muckart DJ. Delayed pneumothorax and hemothorax following observation for stab wounds of the chest. J Trauma. 1985; 16(4):247-8.

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 2

Stab wounds to the chest: a retrospective review of 100 consecutive cases.

In a retrospective review of 100 consecutive cases of stab wounds to the chest, 44 patients were successfully treated with tube thoracostomy, 14 patie...
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