ABSTRACT

Introduction: Transmediastinal trauma has been an important cause of admission to emergency rooms, specially recently, due to improvements in pre-hospital care and the new «scoop and run» protocols have reflected in even more patients that arrive alive and with hemodynamic stability (44-53%). Objective: We intend to review series of patients all over the world with transmediastinal trauma so we can demonstrate the situations that doctors and surgeons in the emergency rooms endure. We present a problem of this sort and questions that every physician should answer when diagnosing and treating transmediastinal injuries with a review of the most representative cases of this subject to gain a wide optic when resolving problems in trauma patients. Material and methods: We conducted a search in PubMed with MESH interlinked words «transmediastinal trauma», «transmediastinal injury», «transmediastinal gunshot» for a systematical review of the literature. We included articles in English, Spanish and French, only original texts from the last 35 years, together with highly cited publications that seemed necessary for full understanding. Moreover, we included several sets of guidelines to respond the questions we present. Results: A total of 15 original articles were taken into consideration, published between 1981 and 2013, all of them with level III of evidence according to the United States Agency for Health Research Quality; 8 articles were patient reviews, from which 3 were prospective studies thus giving us the chance to evaluate mortality and analyze diagnostic and therapeutic success in order to arrive to an informed conclusion about the best way to handle transmediastinal injuries. Discussion and conclusions: After a careful analysis of the aforementioned reviews, 602 patients with transmediastinal trauma were studied, 46.8% arrived to the emergency department with clinical hemodynamic stability, 53.1% presented with instability and 25% of them were submitted to an emergency department thoracotomy, 51.4 were transferred to an operating room for emergent surgery with an overall mortality of 41.6% which means that almost 1 out of every 2 patients with transmediastinal trauma eventually dies. Transmediastinal injuries may seem overwhelming every time, never the less, an organized and logical diagnostic approach will spare patients from unnecessary surgeries and untreated occult lesions. Furthermore we consider that every emergency room physician that encounters with transmediastinal trauma should ask himself the same questions we present in this review, this way we will be able to adequately treat and ultimately discharge patients free from complications.

KEYWORDS

Transmediastinal trauma, transmediastinal injury, transmediastinal gunshot.

REFERENCES

1. Okoye OT, Talving P, Texeira PG, et al. Transmediastinal gunshot wounds in a mature trauma centre: changing perspectives. Injury 2013;44(9):1198-1203. doi: 10.1016/j.injury.2012.12.014.

2. Lichte P, Oberbeck R, Binnebösel M, Wildenauer R, Pape HC, Kobbe P. A civilian perspective on ballistic trauma and gunshot injuries. Scand J Trauma Resusc Emerg Med 2010;18:35. doi: 10.1186/1757-7241-18-35.

3. Nagy KK, Roberts RR, Smith RF, et al. Trans-mediastinal gunshot wounds: are “stable’’ patients really stable? World J Surg 2002;26(10):1247-1250.

4. Degiannis E, Benn CA, Leandros E, Goosen J, Boffard K, Saadia R. Transmediastinal gunshot injuries. Surgery 2000;128(1):54-58.

5. Zarain-Obrador L, Al-Lal YM, de Tomás-Palacios J, Amunategui-Prats I, Turégano-Fuentes F. Transmediastinal and transcardiac gunshot wound with hemodynamic stability. Case Rep Surg 2014;2014:985097. doi: 10.1155/2014/985097.

6. Rozycki GS, Feliciano DV, Ochsner MG, et al. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma 1999;46(4):543-551.

7. Stassen NA, Lukan JK, Spain DA, et al. Reevaluation of diagnostic procedures for transmediastinal gunshot wounds. J Trauma 2002;53(4):635-638.

8. Ibirogba S, Nicol AJ, Navsaria PH. Screening helical computed tomographic scanning in haemodynamic stable patients with transmediastinal gunshot wounds. Injury 2007;38(1):48-52.

9. Burack JH, Kandil E, Sawas A, et al. Triage and outcome of patients with mediastinal penetrating trauma. Ann Thorac Surg 2007;83(2):377-382.

10. Bastos R, Baisden CE, Harker L, Calhoon JH. Penetrating thoracic trauma. Semin Thorac Cardiovasc Surg 2008;20(1):19-25. doi: 10.1053/j.semtcvs.2008.01.003.

11. Renz BM, Cava RA, Feliciano DV, Rozycki GS. Transmediastinal gunshot wounds: a prospective study. J Trauma 1999;48(3):416-421.

12. Richardson JD, Flint LM, Snow NJ, Gray LA Jr, Trinkle JK. Management of transmediastinal gunshot wounds. Surgery 1981;90(4):671-676.

13. Asensio JA, Berne J, Demetriades D, et al. Penetrating esophageal injuries: time interval of safety for preoperative evaluation-how long is safe? J Trauma 1997;43(2):319-324.

14. Asensio JA, Chahwan S, Forno W, et al.; American Association for the Surgery of Trauma. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma 2001;50(2):289-296.

15. Casós SR, Richardson JD. Role of thoracoscopy in acute management of chest injury. Curr Opin Crit Care 2006;12(6):584-589.