Transmediastinal gunshot wounds in a mature trauma centre: changing perspectives

Transmediastinal gunshot wounds are associated with a high mortality and frequently require operative intervention. The purpose of this study was to identify the diagnostic and therapeutic challenges of these injuries in a mature trauma system with decreasing prehospital time intervals.

Patients admitted to a large urban Level 1 trauma centre between 1/2006 and 12/2010 sustaining a firearm injury to the torso were identified. Transmediastinal gunshot wounds were defined as missile tracts traversing the mediastinum identified on CT images, operative notes or autopsy reports.

Overall, 133 patients met study criteria. A total of 116 patients (87.2%) were haemodynamically unstable or had no vital signs on arrival to the Emergency Department. Ninety-seven (83.6%) of these patients required a resuscitative thoracotomy resulting in 8 survivors (6.0%). There were 17 haemodynamically stable patients (12.8%) identified, 14 of whom underwent CT scan evaluation. Six patients subsequently required operative intervention. Only 11 patients (8.3%) in the study population were successfully managed nonoperatively. The overall mortality was 78.9%, and for those who reached the hospital with vital signs, the mortality was 24.3%.

Transmediastinal gunshot wounds encountered in a mature trauma centre are highly lethal injuries requiring resuscitative thoracotomy in most instances. Changing perspectives in these injuries may reflect the effects of an evolving prehospital care.