Selective Operative Management of Penetrating Chest Injuries

  • Andrew John NicolEmail author
  • Sorin Edu
  • Pradeep Navsaria
Trauma Surgery (J. Diaz, Section Editor)
Part of the following topical collections:
  1. Trauma Surgery


Purpose of Review

The aim of this review was to review the recent literature with respect to penetrating chest injuries so as to provide an update on the current/changing management of these injuries.

Recent Findings

The management of a stable patient following penetrating chest trauma with a hemopericardium on ultrasound has changed from routine sternotomy to a pericardial window and drainage, with a sternotomy reserved for those patients who have active bleeding at the time of the pericardial window. It is imperative to diagnose and repair an occult left-sided diaphragm injury and this can be achieved laparoscopically once a hollow organ injury has been excluded. Small pneumothoraces less than 2 cm may be observed in asymptomatic patients provided the patient is not on positive pressure ventilation, and hemothoraces of less than 300 mL may be managed with observation alone.


There are new management strategies evolving in the patient presenting with penetrating thoracic trauma and it is important that surgeons managing these patients are aware of these changes.


Penetrating chest trauma Penetrating cardiac trauma Diaphragm injuries Chest injuries Subxiphoid pericardial window Operative management chest trauma 


Compliance with Ethical Guidelines

Conflicts of interest

Andrew John Nicol, Sorin Edu, and Pradeep Navsaria declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Van Waes OJ, Halm JA, Van Imhoff DI, et al. Selective nonoperative management of penetrating thoracic injury. Eur J Emerg Med. 2018;25(1):32–8.PubMedGoogle Scholar
  2. 2.
    • Nicol AJ, Navsaria PH, Beningfield S, Hommes M, Kahn D. Screening for occult penetrating cardiac injuries. Ann Surg. 2015;261(3):573–8. Ultrasound screening for a pericardial effusion after penetrating trauma can result in false positives and false negatives particularly if there is an associated hemothorax.CrossRefGoogle Scholar
  3. 3.
    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;46:543–52.CrossRefGoogle Scholar
  4. 4.
    Ma OJ, Mateer JR, Ogata M, et al. Prospective analysis of a rapid ultrasound examination performed by emergency physicians. J Trauma. 1995;38:879–85.CrossRefGoogle Scholar
  5. 5.
    Rozycki GS, Balllard RB, Feliciano DV, et al. Surgeon performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg. 1998;228:557–67.CrossRefGoogle Scholar
  6. 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;46:543–52.CrossRefGoogle Scholar
  7. 7.
    Bokhari F, Nagy K, Roberts R, et al. The ultrasound screen for penetrating truncal trauma. Am Surg. 2004;70:316–21.PubMedGoogle Scholar
  8. 8.
    Tayal VS, Beatty MA, Marz JA, et al. FAST (focused assessment with sonography in trauma) accurate for cardiac and intraperitoneal injury in penetrating anterior chest trauma. J Ultrasound Med. 2004;23:467–72.CrossRefGoogle Scholar
  9. 9.
    • Ball CG, Williams BH, Wyrzykowski AD, et al. A caveat to the performance of pericardial ultrasound in patients with penetrating cardiac wounds. J Trauma. 2009;67:1123–4. Ultrasound screening may result in false negatives.Google Scholar
  10. 10.
    Nicol AJ, Navsaria PH. The J wave: a new electrocardiographic sign of an occult cardiac injury. Injury. 2014;45:112–5.CrossRefGoogle Scholar
  11. 11.
    Nicol AJ, Navsaria PH, Beningfield S, et al. A straight left heart border: a new radiological sign of a hemopericardium. World J Surg. 2014;38:211–4.CrossRefGoogle Scholar
  12. 12.
    Jhunjhunwala R, Mina MJ, Roger EI, et al. Reassessing the cardiac box: a comprehensive evaluation of the relationship between thoracic gunshot wounds and cardiac injury. J Trauma Acute Care Surg. 2017;83:349–55.CrossRefGoogle Scholar
  13. 13.
    •• Nicol AJ, Navsaria PH, Hommes M, et al. Sternotomy or drainage for a hemopericardium after penetrating trauma. A randomized controlled trial. Ann Surg. 2014;259:438–42. This is the first randomized trial on stable patients with a hemopericardium after penetrating trauma and showed that simple drainage is sufficient if there is no active bleeding at the time of the procedure.CrossRefGoogle Scholar
  14. 14.
    Hommes M, Nicol AJ, van der Stok J, et al. Subxiphoid pericardial window to exclude occult cardiac injury after penetrating thoracoabdominal trauma. Br J Surg. 2013;100(11):1454–8.CrossRefGoogle Scholar
  15. 15.
    D’Souza N, Clarke D, Laing G. Prevalence, management and outcome of traumatic diaphragm injuries managed by the pietermaritzburg metropolitan trauma service. Ann R Coll Surg Eng. 2017;99:394–401.CrossRefGoogle Scholar
  16. 16.
    Matushima K, Khor D, Berona K, Antoku D, Dollbaum R, Kahn M, Demetriades D. Double jeopardy for penetrating trauma: get FAST, get it right. World J Surg. 2018;42:99–106.CrossRefGoogle Scholar
  17. 17.
    Berg RJ, Karamanos E, Inaba K, et al. The persistent diagnostic challenge of thoracoabdominal stab wounds. J Trauma Acute Care Surg. 2014;76(2):418–23.CrossRefGoogle Scholar
  18. 18.
    Berg RJ, Inaba K, Okoye O, et al. The peril of thoracoabdominal firearm trauma: 984 civilian injuries reviewed. J Trauma Acute Care Surg. 2014;77(5):684–91.CrossRefGoogle Scholar
  19. 19.
    Zellweger R, Navsaria PH, Hess F, et al. Transdiaphragmatic pleural lavage in penetrating thoracoabdominal trauma. Br J Surg. 2004;91(12):1619–23.CrossRefGoogle Scholar
  20. 20.
    Petrone P, Asensio JA, Marini CP. Diaphragmatic injuries and post-traumatic diaphragm hernias. Curr Probl Surg. 2017;54(11–32):88.Google Scholar
  21. 21.
    Shaw JM, Navsaria PH, Nicol AJ. Laparoscopy-assisted repair of diaphragm injuries. World J Surg. 2003;27(6):671–4.CrossRefGoogle Scholar
  22. 22.
    McDonald AA, Robinson BRH, Alarcon L, Dorion H, Haut ER, Juern J, Madbak F, Reddy S, Weiss P, Como JJ. Evaluation and management of traumatic diaphragmatic injuries: a practice management guideline from the East Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2018;85(1):198–207.CrossRefGoogle Scholar
  23. 23.
    Kong VY, Oosthuizen GV, Clarke DL. The selective conservative management of small traumatic pneumothoraces following stab injuries is safe: experience from a high-volume trauma service in South Africa. Eur J Trauma Emerg Surg. 2015;41(1):75–9.CrossRefGoogle Scholar
  24. 24.
    Walker SP, Barratt SL, Thompson J, et al. Conservative management in traumatic pneumothoraces: an observational study. Chest. 2018;153(4):946–53. Scholar
  25. 25.
    Kulvatunyou N, Erickson L, Vijayasekaran A, et al. Randomized clinical trial of pigtail catheter versus chest tube in injured patients with uncomplicated traumatic pneumothorax. Br J Surg. 2014;101(2):17–22. Scholar
  26. 26.
    Wells BJ, Roberts DJ, Grondin S, et al. To drain or not to drain? Predictors of tube thoracostomy insertion and outcomes associated with drainage of traumatic hemothoraces. Injury. 2015;46(9):1743–8. Scholar
  27. 27.
    Demetri L, Martinez Aguilar MM, Bohnen JD, et al. Is observation for traumatic hemothorax safe? J Trauma Acute Care Surg. 2018;84(3):454–8.CrossRefGoogle Scholar
  28. 28.
    Eddine SBZ, Boyle KA, Dodgion CM, et al. Observing pneumothoraces: the 35 millimeter rule is safe for both blunt and penetrating chest trauma. J Trauma Acute Care Surg. 2019;86:557–64.CrossRefGoogle Scholar
  29. 29.
    Karmy-Jones R, Holevar M, Sullivan RJ, Fleisig A, Jurkovich GJ. Residual hemothorax after chest tube placement correlates with increased risk of empyema following traumatic injury. Can Respir J. 2008;15(5):255–8.CrossRefGoogle Scholar
  30. 30.
    Ramanathan R, Wolfe LG, Duane TM. Initial suction evacuation of traumatic hemothoraces: a novel approach to decreasing chest tube duration and complications. Am Surg. 2012;78(8):883–7.PubMedGoogle Scholar
  31. 31.
    Kugler NW, Carver TW, Milia D, et al. Thoracic irrigation prevents retained hemothorax: a prospective propensity scored analysis. J Trauma Acute Care Surg. 2017;83(6):1136–41.CrossRefGoogle Scholar
  32. 32.
    Hendriksen BS, Kuroki MT, Armen SB, et al. Lytic therapy for retained traumatic hemothorax: a systematic review and meta-analysis. Chest. 2019;155:805–15.CrossRefGoogle Scholar
  33. 33.
    Sanna S, Bertolaccini L, Brandolini J, et al. Uniportal video-assisted thoracoscopic surgery in hemothorax. J Vis Surg. 2017;14(3):126. Scholar
  34. 34.
    Billeter AT, Druen D, Franklin GA, et al. Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review. Langenbecks Arch Surg. 2013;398:515–23.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Andrew John Nicol
    • 1
    Email author
  • Sorin Edu
    • 1
  • Pradeep Navsaria
    • 1
  1. 1.Trauma Centre, Groote Schuur HospitalUniversity of Cape TownCape TownSouth Africa

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