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Chest Wounds, Penetrating

Depending on their size, penetrating chest wounds may cause varying degrees of damage to bones, soft tissue, blood vessels, and nerves. Mortality and morbidity from a chest wound depend on the size and severity of the wound.

Gunshot wounds are usually more serious than stab wounds, both because they cause more severe lacerations and cause rapid blood loss and because ricochet often damages large areas and multiple organs. With prompt, aggressive treatment, up to 90% of patients with penetrating chest wounds recover.

Causes

Stab wounds from a knife or ice pick are the most common penetrating chest wounds; gunshot wounds are a close second. Wartime explosions or firearms fired at close range are the usual source of large, gaping wounds.

Signs and symptoms

In addition to the obvious chest injuries, penetrating chest wounds can also cause the following:

• A sucking sound occurs as the diaphragm contracts and air enters the chest cavity through the opening in the chest wall.
• Level of consciousness varies, depending on the extent of the injury. If the patient is awake and alert, he may be in severe pain, which will make him splint his respirations, thereby reducing his vital capacity.
• Tachycardia stems from anxiety and blood loss.
• A weak, thready pulse results from massive blood loss and hypovolemic shock.

Penetrating chest wounds may also cause lung lacerations (bleeding and substantial air leakage through the chest tube), arterial lacerations (loss of more than 100 ml of blood/hour through the chest tube), and exsanguination. Pneumothorax (air in the pleural space causing loss of negative intrathoracic pressure and lung collapse), tension pneumothorax (intrapleural air accumulation causing potentially fatal mediastinal shift), and hemothorax can also result.

Diagnosis

An obvious chest wound and a sucking sound during breathing confirm the diagnosis. Consider any lower thoracic chest injury a thoracicoabdominal injury until proven otherwise.

Further tests to provide baseline data include:

• pulse oximetry and arterial blood gas analysis to assess respiratory status
• chest X-rays before and after chest tube placement to evaluate the injury and tube placement (In an emergency, don't wait for chest X -ray results before inserting the chest tube.)
• complete blood count. including hemoglobin (Hb) level, hematocrit, and differential (Low Hb level and hematocrit reflect severe blood loss; in early blood loss, these values may be normal.)
• palpation and auscultation of the chest and abdomen to evaluate damage to adjacent organs and structures.

Treatment

Penetrating chest wounds require immediate support of respiration and circulation, prompt surgical repair, and measures to prevent complications.

In case of penetrating wounds, these require attention, but generally only after the airway has been secured and a chest drain inserted. Supportive therapy may include mechanical ventilation .