The chest consists of several compartments divided by anatomic boundaries.  

CHEST: 

• All areas supported within the rib cages, are, by definition, the “chest”. 

• All penetrating wounds to the chest that cannot be determined conclusively to be extra-thoracic should have an admission CXR. 

• All pneumothoraces > 35mm in maximal dimension or effusions > 300mL by CT should be treated with a chest tube. If the initial CXR is normal, a repeat inspiration / expiration CXR should be done 6 hours after the first CXR.  See pneumothorax/hemothorax guideline for further detail. 

• If a CT Chest is performed that verifies extrapleural trajectory without evidence of blast effect to the lung, the 6 hour CXR does not need to be performed. 

CARDIAC BOX: 

• The cardiac box is a rectangle bound by: 

• Superior – the angle of Louis = manubriosternal junction 

• Laterally – mid-clavicular lines 

• Inferior – a line drawn between the costal margin at the level of the mid-clavicular lines which included the upper epigastrium 

• Penetrating injuries in this area are at risk for injury to the heart. 

• An ECHO should be done emergently to evaluate for pericardial fluid – cardiology fellow on call immediately consulted. 

• Any fluid seen on ECHO or a suboptimal study mandates a pericardial window or sternotomy. 

• A CT chest can be also considered to assess for pericardial fluid in a hemodynamically stable patient with an equivocal echo. 

POSTERIOR BOX: 

• Injuries to this area put posterior mediastinal structures (aorta, esophagus and trachea) at risk 

• Superior – scapular spine (top of scapula) 

• Lateral – medial borders of scapulae 

• Inferior – costal margin 

• Workup: 

Gunshot Injuries 

• CXR 

• CT arch 

• Esophagram and EGD if needed. 

• Consider evaluation of trachea with bronchoscopy 

Stab Wounds 

Less likely than GSW to produce injury due to protective muscles 

• CXR 

• IF CXR is completely normal, workup is completed except for a repeat CXR in 6 hours 

• If PTX or effusion, a chest tube is placed. If no particulate matter is recovered, follow patient as indicated 

• If mediastinal air, consider esophageal injury 

• If mediastinal widening, considering aortic injury 

THORACOABDOMEN: 

• Penetrating wounds within the thoracoabdomen are associated with diaphragmatic injuries. 

• Thoracoabdomen is defined within the margins below: 

• Superior margin 

• Anterior – nipples 

• Posterior – tips of scapula 

• Inferior margin – costal margins 

• Workup includes: 

• CXR 

• Diagnostic laparoscopy or Diagnostic Peritoneal Lavage (DPL) 

• Positive DPL >10,000 RBC 

• CT scan is not sensitive for diaphragm injury, however can be considered at the discretion of the attending on call as a suboptimal test to risk stratify the patient 

• Back and flank zone borders: 

• Anterior – mid axillary lines 

• Superior – tip of the scapula 

• Inferior – iliac crests  

• Penetrating injuries originating from this region put retroperitoneal structures at risk without necessarily injuring intra-abdominal organs. 

• Workup 

• Triple contrast (oral, rectal and IV contrast) CT scan 

• The contrast is used to delineate the fat plane of the colon with the retroperitoneal. Any concern for loss of the plane warrants surgical exploration. 

• NOTE: Oral contrast should be drunk immediately prior to CT scan – NO DELAY is needed to let the contrast pass further into the bowel. 

• NOTE: Contrast extravasation from the colon may or may not be present for operative trigger 

• If CT scan is entirely negative and shows the entire track of the knife or bullet and there is no concern for peritoneal violation, then no further workup needed 

• If concern for peritoneal violation, then evaluate with either diagnostic laparoscopy, or diagnostic peritoneal lavage (DPL) 

• DPL >10,000 indicates penetrating into the peritoneal cavity and mandates operative exploration for both GSW and stab wounds 

The anterior abdomen is bounded by: 

Superiorly – costal margin 

Medially – mid-axillary line 

Inferiorly – pubic/iliac bones 

Clinical indications for immediate operation: 

• Unstable patient 

• Obvious missile trajectory 

• Evisceration of abdominal contents 

• Peritonitis 

• Retained sharp implement 

• Gross blood per orifice 

Diagnostic indications that warrant OR include: 

• Free air by upright CXR 

• Positive FAST 

• Positive Diagnostic Peritoneal Aspiration (DPA) 

• Positive DPL (10k for GSW, 100K for stab) 

• Peritoneal violation on CT imaging 

Gunshot Wounds 

• Gunshot wounds that penetrate the peritoneal cavity require an operation as >98% will have an injury that require surgical repair. 

• Consider diagnostic laparoscopy first if questionable peritoneal violation. 

• DPL can be considered for “tangential” GSWs to rule out peritoneal violation.  

• A positive DPL requiring operative exploration is >10,000 RBC/cc. 

• Selective nonoperative management can be considered for reliable patients (not clinically intoxicated), willing to be observed inpatient 

Anterior Stab Wounds 

• Only 50% penetrate the peritoneal cavity. Of those, only 50% will cause an injury that requires repair. 

• Consider diagnostic laparoscopy first if questionable peritoneal violation. 

• Injury may be diagnosed with a DPL.  

• A positive DPL requiring operative exploration is >10k RBC/cc. 

• Local wound explorations are unreliable. 

• Serial abdominal exams can be considered at the discretion of the attending surgeon. 

Antibiotic Prophylaxis 

• Single pre-op dose of prophylactic antibiotics with broad-spectrum aerobic and anaerobic coverage should be given to all patients with penetrating abdominal wounds. 

• Prophylactic antibiotics should be continued for no more than 24 hours in the presence of a hollow viscus injury. 

• Prophylactic antibiotics should not be continued if no hollow viscus injury is present. 

Introduction: 

Penetrating trauma to the extremities accounts for 5 to 10% of all injuries and vascular injuries compose 1% of his group.  The priorities in penetrating extremity trauma are always preservation of life first and then limb salvage.   

• Hard signs of vascular injury: 

• Active hemorrhage or expanding hematoma 

• To OR with tourniquet or compression 

• Absent pulse or bruit or thrill 

• OR vs CTA 

• Injuries with hard signs generally require immediate operative intervention. 

• If no hard signs: 

• Ankle–Brachial Index (ABI) if lower extremity / Brachial-Brachial Index (BBI) if upper extremity -  should be performed: take the highest pressure of two vessels in the injured extremity and divide it by the the highest pressure of two vessels in the uninjured extremity 

• ABI/BBI < 0.9 -> obtain CTA 

• ABI/BBI > 0.9 -> discharge 

• If unable to perform an ABI/BBI (too many extremities injured, equipment unavailable, etc.) then evaluate for proximity to a major blood vessel AND soft signs of vascular injury. 

• Soft signs of vascular injury: 

• Unequal or decreased pulse 

• Non-expanding hematoma 

• History of large blood loss at the scene 

• Neurologic deficit 

• Penetrating injuries to the extremities in proximity to a major blood vessel PLUS a soft sign on physical exam should undergo a CTA of that extremity. 

• Penetrating injuries in proximity to the subclavian / axillary vessels (non-compressible) should undergo CTA. 

• All penetrating injuries that are trans-pelvic put the abdominal viscera and pelvic “outflow tracts” at risk. The patient’s clinical stability dictates the order of work up. 

• Unstable patients should go immediately to the operating room. 

• Workup if stable: 

• CTA abdomen/pelvis to assess vessels, bony structure and trajectory 

• Retrograde urethrogram (males) and cystogram (male and female) 

• Rigid proctosigmoidoscopy 

• Females – vaginal speculum exam 

• DPL or laparoscopy if peritoneal cavity violation cannot be ruled out 

• CT scan provides considerable useful information on trajectory and structures at risk. 

• Consider 5 minute delayed CT abdomen/pelvis for urologic system assessment if indicated. 

• Note: For patients requiring immediate OR, the RUG/cysto should be done in the front room (if able) as the urethra and bladder are not easily assessed with laparotomy.