Management of transmediastinal gunshot wounds

Gunshot wounds that transverse the mediastinum are major management problems for two primary reasons: (1) multiple injuries to vital structures are common and (2) the operative approach to control hemorrhage may not afford the optimum exposure to repair the various injuries encountered. We devised a management plan whereby patients in hemodynamically unstable condition underwent immediate operation and patients in stable condition underwent a rapid work-up to evaluate the organs at risk for injury including angiography, esophagoscopy, esophagography, bronchoscopy, and pericardial exploratory surgery while under local anesthesia. A total of 76 patients were treated. Thirty-three patients in unstable condition underwent immediate thoracotomy for hemorrhage or shock or median sternotomy for cardiac tamponade. Multiple organs were injured (average 2.7) and the mortality rate was high (12 of 33) because of the severity of the injuries. Twenty-seven of 43 patients in stable condition required operation after the systematic evaluation disclosed injuries to the great vessels (11), esophagus (9), trachea and bronchi (6), and heart (6). Three patients died of delayed complications (6.9%). The 16 patients who were in stable conditions and had no demonstrable injury were closely followed without operation with one complication and one death from an associated abdominal injury. A management plan for this difficult subset of patients with penetrating thoracic trauma is detailed.