Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
LETTER TO EDITOR  
Year : 2015  |  Volume : 8  |  Issue : 1  |  Page : 70-71
Treatment of hemodynamically stable penetrating mediastinal gunshot wounds in chile: Comparison of 3 cases and literature review


1 Department of Thoracic Surgery, Hospital Barros Luco-Trudeau; Department of Surgery, South Campus, University of Chile, Santiago, Chile
2 Emergency Department, Hospital Barros Luco-Trudeau, Santiago, Chile
3 Department of Surgery, South Campus, University of Chile, Santiago, Chile

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Date of Web Publication30-Jan-2015
 

How to cite this article:
Zepeda CÁ, Castro PP, Castillo F, Sanhueza B, Ruiz I. Treatment of hemodynamically stable penetrating mediastinal gunshot wounds in chile: Comparison of 3 cases and literature review. J Emerg Trauma Shock 2015;8:70-1

How to cite this URL:
Zepeda CÁ, Castro PP, Castillo F, Sanhueza B, Ruiz I. Treatment of hemodynamically stable penetrating mediastinal gunshot wounds in chile: Comparison of 3 cases and literature review. J Emerg Trauma Shock [serial online] 2015 [cited 2020 Jun 4];8:70-1. Available from: http://www.onlinejets.org/text.asp?2015/8/1/70/150406


Dear Editor

Mediastinal penetrating trauma patients are subject to numerous surgical procedures and are reported to have high mortality rates. On admission, all hemodynamically stable patients require a computerized tomography (CT). [1] Out of all stable patients, only 10% will require surgical treatment. [2]

Based on three exemplifying cases managed in our institution according to current literature, we advice a standardized model for the treatment of hemodynamically stable patients. [3]

Patient without anatomically relevant injuries: Conservative management.

Case 1: Left mediastinal gunshot wound (MGW). Bullet transfixiates anterior mediastinum and lodges in a retrosternal position anterior and superior to great vessels [Figure 1]. No anatomical injuries. Patient is observed.
Figure 1: Chest CT that shows bullet in anterior mediastinum. Without any pericardial or pleural effusion, without pneumomediastinum or visceral injuries

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Patient without anatomically relevant injuries in which a complication is clinically suspected: Order complementary exams like upper gastrointestinal endoscopy (UGIE), bronchoscopy, esophagogram, echocardiogram, or angiography. Surgery is only indicated in case of positive findings.

Case 2: Left transfixiating MGW with pre-esophageal tract, no apparent injuries in CT, at 48h evolves with tachycardia and fever [Figure 2]. UGIE is performed and a central esophageal perforation is diagnosed. Surgical exploration revealed acute mediastinitis requiring bilateral thoracotomies, cervical exploration, and esophaguectomy.
Figure 2: A transmediastinal trajectory is clearly evident. No other injuries are present

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Patient with anatomically relevant injury: Immediate surgical management.

Case 3: Left tranxifixating MGW. Bullet grossed anterior to the pericardium. Patient is asymptomatic but CT shows pericardial effusion and myocardial hematoma. [Figure 3] Surgical exploration reveals left hemothorax, pericardial tamponade, and myocardial contusion.
Figure 3: Moderate pericardial effusion compatible with hemoperircardium, bilateral basal atelectasis and signs suggestive of left hemothorax

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After 6 months of follow-up, all three patients are alive. And case 2 is awaiting digestive transit reconstitution.

In conclusion, we advocate for conservative management of hemodynamically stable MGW´s in patients thoroughly studied to exclude anatomical injuries on admission. If complication is clinically suspected, additional exams must be undertaken to make appropriate diagnosis and treat accordingly.

 
   References Top

1.
Ibirogba S, Nicol AJ, Navsaria PH. Screening helical computed tomographic scanning in haemodynamic stable patients with transmediastinal gunshot wounds. Injury 2007;38:48-52.  Back to cited text no. 1
    
2.
Burack JH, Kandil E, Sawas A, O′Neill PA, Sclafani SJ, Lowery RC, et al. Triage and outcome of patients with mediastinal penetrating trauma. Ann Thorac Surg 2007;83:377-82.  Back to cited text no. 2
    
3.
Okoye OT, Talving P, Teixeira PG, Chervonski M, Smith JA, Inaba K, et al. Transmediastinal gunshot wounds in a mature trauma centre: Changing perspectives. Injury 2013;44:1198-203.  Back to cited text no. 3
    

Top
Correspondence Address:
Carlos Álvarez Zepeda
Department of Thoracic Surgery, Hospital Barros Luco-Trudeau; Department of Surgery, South Campus, University of Chile, Santiago
Chile
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.150406

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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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