Penetrating injuries of the mediastinum

This study reviews 47 patients who were operated on for acute penetrating mediastinal wounds. These included 40 cases of cardiac tamponade, 2 mediastinal hematomas, 1 contused myocardium, 3 esophageal wounds, and 1 VSD. Stab wounds were most common (73%) followed by gunshot wounds (23%), and shotgun wounds (4%). When measured, central venous pressure was 15 cm or greater in 28 out of 32 patients (87.5%) with proven tamponade. By contrast, Beck's criteria (distended neck veins, distant heart sounds, hypotension) were noted in only 19 (48%) of 40 cases of tamponade. Emergency room pericardiocentesis resulted in improvement in 20 of 22 cases (91%), affording time for definitive operative therapy. The majority of entrance wounds (85%) occurred in the anterior mediastinal region. Peritoneal lavage in 15 cases yielded 5 true positive, 9 true negative, and 1 false positive tests. Most commonly injured areas were right ventricle (20 patients), left ventricle (11 patients), pericardium (5 patients), and right atrium (4 patients). Isolated esophageal injuries occurred in 3 of 11 gunshot wounds (27%). Complications were numerous (70%) and mortality ranges as follows: GSW 27% SW 15% SGW 0%. Central venous pressure determination and early pericardiocentesis are useful in suspected cases of tamponade. In GSW, an esophagogram is indicated to rule out isolated injury. Median sternotomy is the operative exposure of choice for mediastinal injuries causing cardiac tamponade.