WTA 2014 ALGORITHM Western Trauma Association Critical Decisions in Trauma: Penetrating chest trauma Riyad Karmy-Jones, MD, Nicholas Namias, MD, Raul Coimbra, MD, Ernest E. Moore, MD, 09/30/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3Ypodx1mzGi19a2VIGqBjfv9YfiJtaGCC1/kUAcqLCxGtGta0WPrKjA== by http://journals.lww.com/jtrauma from Downloaded Martin Schreiber, MD, Robert McIntyre, Jr., MD, Martin Croce, MD, David H. Livingston, MD, Jason L. Sperry, MD, Ajai K. Malhotra, MD, and Walter L. Biffl, MD, Portland, Oregon Downloaded from http://journals.lww.com/jtrauma his is a recommended algorithm of the Western Trauma Historical Perspective TAssociation for the acute management of penetrating chest The precise incidence of penetrating chest injury, varies injury. Because of the paucity of recent prospective randomized depending on the urban environment and the nature of the trials on the evaluation and management of penetrating chest review. Overall, penetrating chest injuries account for 1% to injury, the current algorithms and recommendations are based 13% of trauma admissions, and acute exploration is required in by on available published cohort, observational and retrospective BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3Ypodx1mzGi19a2VIGqBjfv9YfiJtaGCC1/kUAcqLCxGtGta0WPrKjA== 5% to 15% of cases; exploration is required in 15% to 30% of studies, and the expert opinion of the Western Trauma Asso- patients who are unstable or in whom active hemorrhage is ciation members. The two algorithms should be reviewed in the suspected. Among patients managed by tube thoracostomy following sequence: Figure 1 for the management and damage- alone, complications including retained hemothorax, empy- control strategies in the unstable patient and Figure 2 for the ema, persistent air leak, and/or occult diaphragmatic injuries management and definitive repair strategies in the stable patient. range from 25% to 30%.1Y6 In civilian practice, this low in- Figure 1 will discuss damage-control techniques; Figure 2 will cidence has been generally attributed to ‘‘low-kinetic energy’’ focus on more definitive repairs. Because of the variety of pos- mechanisms. In zones of conflict, among properly outfitted sible mechanisms, presentation, injury sites, and operative soldiers, body armor also results in a lower requirement for approaches, we recognize that there will be variability in decision operation and incidence of complications.1,5,6 making, local resources, institutional consensus, and patient- The reported incidence of specific injuries also varies, specific factors that may require deviation from the algorithms depending on site and characterization of the patient popula- presented. The algorithms and accompanying text represent our tion. Demetriades7 reported an overall incidence of great vessel consensus for a safe and reasonable approach in these complex injury of 5.3% following gunshot wounds and 2% after stab cases and attempts to incorporate historically validated ap- wounds to the chest. Rhee et al.8 described an overall incidence of proaches with the advent of newer imaging, interventional, penetrating cardiac injuries as 1 per 210 admissions. Sixty-five resuscitative, operative, and selective/expectant management percent of the patients admitted to the University of Louisville approaches. with peristernal penetrating injuries sustained a cardiac injury.9 In patients requiring urgent (nonYemergency department) tho- racotomy, cardiac injuries are found in approximately 16% to Submitted: April 4, 2014, Accepted: June 30, 2014. 52% following stab wounds and 10% to 37% following gunshot From the Department of Surgery (R.K.-J.), Legacy Emanuel; and Oregon Health and wounds, and lung injuries are found in 30% to 59% of stab Sciences University (M.S.), Portland, Oregon; University of Miami School of 10Y12 Medicine (N.N.), Miami, Florida; University of California-San Diego Medical wounds and 65% to 86% of gunshot wounds. Center (R.C.), San Diego, California; Denver Health Medical Center (E.E.M. It is clear that mortality is significantly impacted by W.L.B.); and University of Colorado School of Medicine (R.M.), Denver, preadmission hypotension, the ability to perform aggressive Colorado; University of Tennessee-Memphis Health Science Center (M.C.), on resuscitation and operative intervention, and appropriate im- 09/30/2020 Memphis, Tennessee; University Hospital (D.H.L.), Newark, New Jersey; 13,14 University of Pittsburgh (J.L.S.), Pittsburg, Pennsylvania; Virginia Common- aging in stable patients. Focusing on blood products rather wealth University (A.K.M.), Richmond, Virginia. than crystalloids and in some settings ‘‘hypotensive’’ resusci- This algorithm was presented at the annual meeting of the Western Trauma Asso- tation seems to have a survival benefit.6 ciation, March 2Y7, 2014, in Steamboat Springs, Colorado. The Western Trauma Association (WTA) develops algorithms to provide guidance and recommendations for particular areas but does not establish the standard of Anatomy care. The WTA develops algorithms based on the evidence available in the literature and the expert opinion of the task force in the recent time frame of the The simplest anatomic classification is based on the publication. The WTA considers the use of the algorithm to be voluntary. The likelihood of specific organ injury. Classically, penetrating ultimate determination regarding its application is to be made by the treating injuries between the nipple lines anteriorly or the scapula physician and health care professionals with full consideration of the individual patient’s clinical status as well as available institutional resources and is not posteriorly have the potential for cardiac or great vessel injury. intended to take the place of health care provider’s judgment in diagnosing and The ‘‘danger zone’’ has been described as the region between treating particular patients. the epigastrium to the sternal notch and laterally within 3 cm of Address for reprints: Riyad Karmy-Jones, MD, Legacy Emanuel Medical Center, 2801 the sternum.9,15 Injuries below the level of the tip of the scapula N. Gantenbein Ave, Suite 130, Portland, OR 98774; email: [email protected]. posteriorly or the inframammary crease/nipple anteriorly have DOI: 10.1097/TA.0000000000000426 the potential to traverse the diaphragm, particularly left lower J Trauma Acute Care Surg 994 Volume 77, Number 6 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. J Trauma Acute Care Surg Volume 77, Number 6 Karmy-Jones et al. Figure 1. Management of the stable patient. thoracic injuries.1 As many as 20% of patients with penetrating ventilating at an acceptable level, and that continued hemo- injuries will have associated abdominal injuries.14 Unfortu- dynamic stability is documented. Patients with evidence of nately, particularly with gunshot wounds, any region of the shock or impending collapse (systolic blood pressure G 90 mm chest may be affected, and these anatomic relationships should Hg and/or persistent tachycardia 9 120 beats per minute, not only be considered as generalizations. explained by pain or anxiety and/or persistent hypoxemia) should be managed by airway control combined with aggres- Presentation sive blood product resuscitation. In essence, a stable patient is The presentation and management of a patient of pene- one in whom there is time to consider different diagnostic and trating trauma depends on three interrelated factors: stability, therapeutic options; the unstable patient is one in whom the mechanism, and location of the wound. For the purposes of this approach is predicated on getting to the operating room as soon discussion, stability requires that the airway be secure (with or as possible with minimal delay for extraneous testing. This without intubation), that the patient is both oxygenating and excludes the agonal patient. Clearly, there are times when the * 2014 Lippincott Williams & Wilkins 995 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. J Trauma Acute Care Surg Karmy-Jones et al. Volume 77, Number 6 Figure 2. Management of the unstable patient. scenarios overlap (e.g., transmediastinal gunshot wound with draped to include the neck, supraclavicular area, entire thorax, suspicion of tamponade), and the pathways described are not abdomen, and proximal thighs. A single-lumen tube is the mutually exclusive. optimal initial airway tool in chest trauma. The tube can be advanced into the left main stem bronchus to isolate the right Incisions and Approaches lung, or an endobronchial blocker can be placed to isolate the There are a number of different approaches that can be left. Advancing a single-lumen tube into the right often causes used involving variations in incision, airway management, and obstruction of the right upper lobe bronchus. This rapid iso- positioning. The choice is dictated by stability, mechanism, and lation can be particularly useful in patients with massive uni- surgeon preference/experience. A brief review of these is lateral air leak and/or hemorrhage. A double-lumen tube can be presented in Table 1. In an unstable patient, the optimal po- used in stable patients who require lung isolation or in centers sitioning is supine in the crucifix position, with the patient that are facile with emergent placement. In patients who present 996 * 2014 Lippincott Williams & Wilkins Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized