The great majority of penetrating chest injuries involving cardiovascular structures result in death before the patient reaches the hospital. Ninety percent of such injuries involve the great vessels, and 10% are cardiac injuries. Pre-hospital mortality for the latter is 80% (higher for gunshot wounds, lower for stab wounds). Penetrating injuries between the clavicles, the costal margins and the anterior axillary lines should be assumed to involve cardiovascular structures until proven otherwise. Debate persists regarding aggressive pre-hospital resuscitation vs. permissive hypotension (70-90 systolic) as the best strategy for getting these patients to the operating room. The surgical approach for the minority of patients who reach the hospital with such wounds depends on the nature and location of the wound, the stability of the patient, and the surgeon's preference.
An unstable patient with a penetrating chest wound is taken directly to the operating room. Groins and thighs as well as chest are prepped in the event that vein graft is needed for a patch. Major bypasses from the proximal aorta require prosthetic material. Prosthetic material can be contaminated in the trauma situation and is less desirable than natural tissue when the latter can be used. The chest is usually explored through a left anterolateral thoracotomy (unless cardiac injury is a high likelihood, in which case a median sternotomy is the incision of choice). The anterolateral thoracotomy incision, through the left 4th or 5th interspace gives the best initial access to the pericardium, left pulmonary hilum and descending aorta, with flexibility for extension as the injury dictates.
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