Transmediastinal penetrating trauma

Penetrating transmediastinal injury (TMI) is associated with a high mortality rate and presents a challenging diagnostic scenario. Previous dogma mandated surgical exploration or extensive and invasive investigations for all patients sustaining transmediastinal penetrating trauma, regardless of hemodynamic status. Since the late 1990s, the paradigm has changed, with most centers adopting a tiered approach to management based on clinical presentation. Transmediastinal penetrating trauma is a rare injury pattern and can result from gunshot wounds, stab wounds, blast injuries, and other missiles. The most predominant source, however, remains gunshot wounds, accounting for the vast majority of these injuries. A systematic approach in the emergency department to diagnosis and management should be undertaken and patients in extremis or with hemodynamic compromise rapidly identified. The unstable patient forgoes further investigations and the surgeon must use knowledge about the hypothesized trajectory, results of limited imaging, chest tube output, and anticipation of resuscitative maneuvers to select the best operative approach. In patients who are sufficiently stable to undergo CT angiogram (CTA) of the chest, the trajectory of the missile or impalement can often be deduced and this is used to guide further investigation or operation. In those where ambiguity remains, more focused tests such as echocardiography, pericardial window, esophagoscopy or esophagography, and bronchoscopy can be used to assess the mediastinal structures. For the stable patient, management proceeds with cautious and expeditious investigations to determine the extent of underlying organ-specific injuries. Thus, in patients with this injury pattern, determination of the patient's clinical status is critical to determine the appropriate course of management.