Indications for thoracotomy in stab injuries of the chest: a prospective study of 543 patients

This is a prospective study of 543 patients with stab wounds of the chest treated in a 15 month period. Four hundred and sixty-seven patients (86 per cent) were selected for conservative treatment with no mortality. Of the 76 patients in the operatively treated group 68 were operated on in the operating theatre with a mortality of 17 per cent, while the remaining eight had a thoracotomy in the resuscitation room with a mortality of 87.5 per cent. Indications for early operation would appear to be the presence of signs of cardiac or major vascular injury (i.e. tamponade, profuse bleeding, an absent or diminished peripheral pulse, and shock not responding to aggressive resuscitation). A cautious digital exploration of the chest wound may help identify these injuries by obtaining information about the knife tract (towards or away from the heart or major vessels). The presence of shock on admission should not be an absolute indication for operation. Half the 156 patients with shock on admission were treated conservatively with no mortality. The presence of a wound over the precordium is not in itself an absolute indication for surgery. Seventy-two such patients, including 14 with shock, were successfully treated non-operatively. Massive air leaks are usually self-controlled and none of the 24 such cases required operation. The amount or rate of blood loss via the thoracotomy tube is not a reliable index of the severity of the injury and it should not be a sole criterion for the selection of the type of treatment.