Injury, Int. J.

Care Injured 42 (2011) 900–904

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Urgent thoracotomy for penetrating chest trauma: Analysis of 158 patients

of a single center§
Serdar Onat a,*, Refik Ulku a, Alper Avci a, Gungor Ates b, Cemal Ozcelik a
a
Department of Thoracic Surgery, Faculty of Medicine Dicle University, 21280 Diyarbakir, Turkey
b
Department of Chest Diseases, Faculty of Medicine Dicle University, Diyarbakir, Turkey

A R T I C L E I N F O A B S T R A C T

Article history: Background: Penetrating injuries to the chest present a frequent and challenging problem, but the
Accepted 1 February 2010 majority of these injuries can be managed non-\operatively. The aim of this study was to describe the
incidence of penetrating chest trauma and the ultimate techniques used for operative management, as
Keywords: well as the diagnosis, complications, morbidity and mortality.
Urgent thoracotomy Methods: A retrospective 9-year review of patients who underwent an operative procedure following
Penetrating chest trauma penetrating chest trauma was performed. The mechanism of injury, gender, age, physiological and
outcome parameters, including injury severity score (ISS), chest abbreviated injury scale (AIS) score, lung
injury scale score, concomitant injuries, time from admission to operating room, transfusion
requirement, indications for thoracotomy, intra-operative findings, operative procedures, length of
hospital stay (LOS) and rate of mortality were recorded.
Results: A total of 1123 patients who were admitted with penetrating thoracic trauma were
investigated. Of these, 158 patients (93 stabbings, 65 gunshots) underwent a thoracotomy within
24 h after the penetrating trauma. There were 146 (92.4%) male and 12 (7.6%) female patients, and their
mean age was 25.72  9.33 (range, 15–54) years. The mean LOS was 10.65  8.30 (range, 5–65) days.
Patients admitted after a gunshot had a significantly longer LOS than those admitted with a stab wound
(gunshot, 13.53  9.92 days; stab wound, 8.76  6.42 days, p < 0.001). Patients who died had a significantly
lower systolic blood pressure (SBP) on presentation in the emergency room (42.94  36.702 mm Hg)
compared with those who survived (83.96  27.842 mm Hg, p = 0.001). The overall mortality rate was 10.8%
(n = 17). Mortality for patients with stab wounds was 8/93 (8.6%) compared with 9/65 (13.8%) for patients
with gunshot wounds (p = 0.29). Concomitant abdominal injuries (p = 0.01), diaphragmatic injury (p = 0.01),
ISS (p = 0.001), chest AIS score (p < 0.05), ongoing output (p = 0.001), blood transfusion volume (p < 0.01)
and SBP (p = 0.001) were associated with mortality.
Conclusion: Penetrating injuries to the chest requiring a thoracotomy are uncommon, and lung-sparing
techniques have become the most frequently used procedures for lung injuries. The presence of
associated abdominal injuries increased the mortality five-fold. Factors that affected mortality were ISS,
chest AIS score, SBP, ongoing chest output, blood transfusion volume, diaphragmatic injury and
associated abdominal injury.
ß 2010 Elsevier Ltd. All rights reserved.

Introduction thoracic trauma require definitive operative repair.11 A thoracoto-

Reports of chest injuries appeared as early as 3000 BC, in the
Edwin Smith Surgical Papyrus.4 Most penetrating injuries to the
chest can be managed with simple procedures such as a tube
thoracostomy; however, 10–15% of patients who present with
my performed within the first few hours of injury is considered an
urgent thoracotomy.23 Indications for urgent thoracotomy include
the presence of cardiac tamponade, high chest tube output,
persistent air leak and injury to the diaphragm. In this study, we
evaluated these issues, and we present our experiences and
practices.

§
Materials and methods
The English in this document has been checked by at least two professional
editors, both native speakers of English. For a certificate, see: http://www.textcheck.
com/certificate/dIzkAY. The Thoracic Surgery Department of the Faculty of Medicine of
* Corresponding author. Tel.: +90 5333949268; fax: +90 4122488440. Dicle University often admits severe trauma patients from
E-mail address: onatserdar21@hotmail.com (S. Onat). southeast Turkey, an area populated by nearly 7 million residents.

0020–1383/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2010.02.004
 S. Onat et al. / Injury, Int. J. Care Injured 42 (2011) 900–904
With 1100 beds, it is the largest teaching hospital in the region.
Most trauma patients are transferred to this center for final
diagnosis and treatment.
We retrospectively reviewed the medical records of 1123
patients with penetrating trauma to the chest, who were admitted
to our emergency department between January 2000 and May
2009. Our study is retrospective and permission from a Local Ethics
Committe is not requirement in our country. Patients who had
undergone a thoracotomy within 24 h after a penetrating
traumatic injury were included. Demographic (mechanism of
injury, gender and age), physiological and outcome data were
collected, including injury severity score (ISS), concomitant
injuries, time from admission to operating room, transfusion
requirement (units of packed red blood cells), indications for
thoracotomy, intra-operative findings, procedures performed
during thoracotomy, length of hospital stay and rate of mortality.
The number of reoperations was also examined. Injury was
characterized by the ISS, the chest abbreviated injury scale (AIS)
score and the specific thoracic injury based on the lung injury scale
(LIS) score.3 Advanced Trauma Life Supports (ATLS) guidelines
were used for initial assessment.
The length of hospital stay was categorized as 7 days or >7
days. Operations were performed in an operating room, which is
located about 15 m from the emergency room in our hospital. The
patients those underwent emergency thoracotomy were excluded
even though operations had been performed in theatre. Single
lumen endotracheal intubation was used in most cases (n = 155,
98.1%) due to the need for rapid airway access.
The patients were managed according to the algorithm
presented in Fig. 1. Thoracotomy indications included an initial
chest tube output of >1000 ml or continued output of 250 ml/h for
3 successive hours; deterioration of hemodynamic condition;
massive hemothorax associated with shock (systolic blood
pressure, <90 mm Hg); signs of pericardial tamponade; massive
air leak; or radiographic evidence of a large hemothorax
(opacification of more than half of the involved lung on a plain
chest radiograph).
Patients who had undergone a thoracotomy for blunt traumatic
injury, a resuscitative thoracotomy, or a non-therapeutic thora-
cotomy, and those younger than 15 years of age were excluded. The
Fig. 1. Indications for thoracotomy. Abbreviations: ORT: operation room
thoracotomy; Pnx: pneumothorax; Htx: hemothorax; Htpnx: hemopneumothorax
and CT: chest tube.
901
patients who had transmediastinal injury and underwent emer-
gency room thoracotomy or sternotomy were excluded from this
study. A non-therapeutic thoracotomy was defined as a thoracot-
omy performed in the absence of intra-thoracic pathology
requiring surgical intervention. Also excluded were patients with
a penetrating chest wound in which the tract entered the
abdominal cavity causing isolated injuries to abdominal organs.
The results are expressed as means  SD. Univariate analysis was
performed using a x2 test for categorical data. Fisher’s exact test was
used when a data table had at least one cell with an expected
frequency of <5. An independent paired t-test and a Levene test for
equality of variances were used for continuous variables. Statistical
significance was set at p  0.05. All statistical analyses were
performed using SPSS 16 for Windows (SPSS, Chicago, IL, USA).
Results
Over the 9-year period, a total of 158 patients (14.06%) underwent
a therapeutic thoracotomy following penetrating trauma. The
patients included 93 (58.9%) stab wounds and 65 (41.1%) gunshot
wounds. There were 146 (92.4%) males and 12 (7.6%) females, and
their mean age was 25.72  9.33 (range, 15–54) years.
Of the 158 patients, 132 underwent a thoracotomy within 4 h
after admission; 20, within 5–8 h; and 6, within 9–24 h. Mean time
to thoracotomy was 3.16  3.45 h.
Patients who suffered from a gunshot injury tended to have a
higher ISS than those admitted with a stab wound, but the
difference was not significant (overall ISS, 18.92  9.98; range, 9–
50; for gunshots, 20.63  10.42; for stab wounds, 17.72  9.53,
p = 0.07). The LIS score was significantly higher in gunshot victims
(11.37  3.34) than in stabbing victims (9.12  0.93; p = 0.001),
whereas the chest AIS score (overall, 13.36  6.46) was lower in
gunshot victims (12.10  4.36) than in those with a stab wound
(14.23  7.50; p = 0.026). The demographic, physiological and out-
come data according to the mechanism of injury are shown in Table 1.
The indications for a thoracotomy were initial output (n = 51),
ongoing output (n = 45), shock (systolic blood pressure,
<90 mm Hg; n = 43), signs of pericardial tamponade (n = 14),
radiographic signs of a large hemothorax (n = 3) and massive air
leak (n = 2). The cause of massive air leak was big chest-wall
(<4 cm) defect due to gunshot. Ninety-eight patients were initially
treated with a tube thoracostomy. The mean blood loss with the
initial chest tube tended to be greater for gunshot wounds
(1069.05  464.06 ml) than for stab wounds (942.16  433.86 ml),
but the difference was not significant (p = 0.18). The ongoing chest
tube blood loss tended to be greater for stab wounds
(829.03  355.15 ml) than for gunshot wounds
(715.38  341.19 ml), but again the difference was not significant
(p = 0.32).
Incisions were left anterolateral in 50 cases (31.6%; 41
stabbings, 9 gunshots), right anterolateral in 14 (8.9%; 12
stabbings, 2 gunshots), left posterolateral in 33 (20.9%; 19
stabbings, 14 gunshots), right posterolateral in 58 (36.7%; 20
stabbings, 38 gunshots), clamshell in 1 (0.6%; 1 stabbing), and
sternotomy in 2 (1.2%; 2 gunshots). Two patients who underwent
sternotomy had transmediastinal injury.
Thoracic injuries were analysed according to the mechanism of
injury, and the intra-operative findings for thoracic injuries are listed
in Table 2. The most common intra-thoracic injury was pulmonary
(70.3%, n = 111). Generally, we used lung-sparing techniques in
operation. Operative techniques for parenchymal injuries included
pneumonorrhaphy (n = 76), stapled pulmonary tractotomy (n = 14),
clamp pulmonary tractotomy (n = 12) and wedge resection (n = 11).
Anatomical resection was not performed in any of the cases.
Overall, 113 patients (71.5%) had isolated thoracic injuries, and
45 patients (28.5%) had associated penetrating injuries. Thirty-eight
902 S. Onat et al. / Injury, Int. J. Care Injured 42 (2011) 900–904

Table 1
Demographic, physiological and outcome data according to mechanism of injury (gunshot vs. stabbing).

Parameter Gunshot Stabbing (n = 93) p value

(n = 65)

Age (years) 26.49  8.993 25.17  9.573 0.38

Length of hospital stay (days) 13.5357  9.92694 8.7647  6.42845 0.002
Blood transfusion requirement (units) 4.50  3.409 3.27  1.695 0.009
Initial chest tube output (ml) 1069.05  464.069 942.16  433.863 0.18
Ongoing chest tube output (ml) 715.38  341.189 829.03  355.146 0.329
SBP (mm Hg) 81.58  31.136 78.12  31.811 0.496
ISS 20.63  10.426 17.72  9.539 0.076
LIS 11.37  3.340 9.12  0.935 0.001
Gender ratio (M:F) 60:5 86:7 0.9
Associated injury (n) 28/65 17/93 0.01
AIS 12.1077  4.36292 14.2366  7.50275 0.026

Abbreviations: SBP; systolic blood pressure, ISS; injury severity score, LIS; lung injury scale score, AIS; chest abbreviated injury scale score.

Table 2 days were morbidity (p = 0.03), diaphragmatic injury (p < 0.003),

Intra-operative findings during thoracotomy.
chest wall defect (p < 0.01), associated injuries (p < 0.01), ISS
Finding Stabbing Gunshot p value (p < 0.001), chest AIS score (p < 0.001) and mechanism of injury
injury (n = 93), injury (n = 65), (gunshot/stabbing; p = 0.002). There was no correlation between the
n (%) n (%)
type of incision and LOS (p = 0.148).
Lung (n = 111) 54 (58.1) 57 (87.7) 0.001 The overall mortality rate was 10.8% (n = 17). Patients who died
Intercostal artery (n = 27) 23 (24.7) 4 (6.2) 0.01 had a significantly lower systolic blood pressure (SBP) on
Internal mammary artery (n = 15) 14 (15.1) 1 (1.5) 0.01
presentation in the emergency room (42.94  36.702 mm Hg)
Cardiac (n = 34) 30 (32.3) 4 (6.2) 0.001
Tracheobronchial (n = 2) 0 2 (3.1) >0.05 than those who survived (83.96  27.842 mm Hg; p = 0.001). Of the
Diaphragmatic (n = 40) 22 (27.7) 18 (27.7) >0.05 17 patients who died, 12 died during surgery (70%). Mortality for
Vascular (n = 3) 1 (1.1) 2 (3.1) >0.05 patients with stab wounds was 8/93 (8.6%) compared with 9/65
Chest wall (n = 10) 0 10 (15.4) 0.001
(13.8%) for patients with gunshot wounds (p = 0.29). The mortality
rates for non-cardiac and cardiac penetrating chest injuries were
8.9% and 17.6%, respectively. For patients who underwent combined
patients underwent a concomitant laparotomy. In 11 of these 38 procedures thoracotomy + laparotomy, the mortality rate was
patients laparotomy was carried out first. The most common intra- 26.3%. Excluding cardiac and associated injuries, the mortality rate
abdominal injuries were to the liver and diaphragm; injuries were was 1.2%. Mortality was significantly associated with diaphragmatic
also present in the small bowel, colon, spleen, kidney, stomach and injury (p = 0.01), associated abdominal injury (p = 0.01), ISS
intra-abdominal great vessels. There was a statistically significant (p = 0.001), chest AIS score (p < 0.05), ongoing output (p = 0.001),
difference in the risk for death between patients with and without blood transfusion volume (p < 0.01) and SBP (p = 0.001) (Tables 4
abdominal injury (p = 0.01). Paraplegia was present in 7 (4.4%) and 5).
patients. The requirement for blood transfusion was greater in
gunshot wound cases (4.50  3.41) than in stabbing cases Discussion
(3.27  1.70; p < 0.01).
Five patients (3.2%) required reoperation, consisting of four Although most penetrating thoracic injuries can be managed
(2.5%) thoracotomies and one (0.63%) laparotomy. In 2 cases of with simple procedures, 10–15% of patients who present with
missed pericardial artery injuries, a rethoracotomy was performed thoracic trauma require operative repair and the vast majority
for ongoing bleeding. Empyema and diaphragmatic plication were have sustained a penetrating injury.11,32 Urgent, non-resuscitative
the respective causes for the other two reoperations. The morbidity thoracotomy after a penetrating injury is infrequent, and the
rate in this series was 14.6% (n = 23) (Table 3). number of patients in this study compares favorably with the
Considering all patients, the mean length of hospital stay (LOS) number in other reports.13,19,30 The rate of urgent thoracotomy for
was 10.65  8.30 (range, 5–65) days, with a significantly longer LOS penetrating injuries in our series was 14.06%.
for gunshot victims (13.53  9.92 days) than for stabbing victims The indications for thoracotomy after trauma were derived
(8.76  6.42 days; p < 0.001). Factors associated with a LOS of >7 originally from military experience gained in the management of
thoracic trauma during World War II, the Korean War and
Vietnam.22 Furthermore, most indications for thoracotomy after
Table 3 trauma in civilians are based on experience with penetrating
Morbidity in 23 patients. injuries26,28 and include initial chest output, ongoing output of
Cause of death Stabbing n (%) Gunshot n (%) 250 ml/h for 3 successive hours, massive hemothorax associated
with shock, tamponade, massive air leak and evidence of injury to a
Atelectasis – 6 (30)
ARDS – 3 (15)
great vessel. Many authors use initial chest tube drainage of
Pneumonia – 3 (15) 1500 ml as a trigger for mandatory chest exploration;18,19,22
Empyema 1 (33) – however, our practice is to perform an urgent operation when the
Intra-abdominal abscess 1 (33) – initial blood loss is 1000–1500 ml like some authors.23 Some have
Intra-parenchymal hematoma – 1 (5)
suggested that the volume of blood loss via a thoracostomy tube
Disseminated intra-vascular coagulation 1 (33) –
Deep venous thrombosis – 1 (5) may be an unreliable indicator of chest trauma severity. For
Wound infection – 3 (15) example, a large clotted hemothorax or cardiac tamponade may
Anoxic brain injury – 1 (5) not be associated with significant blood loss through a chest drain.
Multiple organ failure – 2 (10) Karmy-Jones et al.13 reviewed their experience with the timing for
Abbreviation: ARDS, acute respiratory distress syndrome. an urgent thoracotomy because of hemorrhage after trauma and
 S. Onat et al. / Injury, Int. J. Care Injured 42 (2011) 900–904 903

Table 4 Table 5
Factors associated with mortality: analysis of discrete variables. Factors associated with mortality: analysis of continuous variables.

Factor Mortality n (%) p value Factor Death Survival (mean  SD) p value

Gender 0.7
(mean  SD)
Male 16/146 (11)
Female 1/12 (8.3) Age (years) 24.18  7.09 25.90  9.57 0.373
ISS 30.71  8.57 17.50  9.19 0.001
Mechanism 0.29 Chest AIS score 16.2941  7.1917 13.0071  6.3126 0.047
Gunshot 9/65 (13.8) LIS score 11.33  3.44 10.19  2.64 0.286
Stabbing 8/93 (8.6) Initial output (ml) 1085.71  328.77 992.44  458.99 0.505
Abdominal injury 0.01 Ongoing output (ml) 1500.00  0.00 761.90  322.30 0.001
Present 10/38 (26.3) Transfused blood (units) 7.18  4.87 3.36  1.80 0.005
Absent 7/140 (5.0) SBP (mm Hg) 42.94  36.70 83.96  27.84 0.001
Time to OR (hours) 1.94  1.71 3.30  3.58 0.125
Diaphragm injury 0.01
Present 9/40 (22.5) Abbreviations: SBP; systolic blood pressure, ISS; injury severity score, LIS; lung
Absent 8/118 (6.8) injury scale score, AIS; chest abbreviated injury scale score.

Lung injury 0.09 the right hilum, and permits cannulation for cardiopulmonary
Present 9/111 (8.1) bypass if necessary for repair. If there is concern for concomitant
Absent 8/47 (17) injury then left thoracotomy may be preferable.9
Cardiac injury 0.1 In cases of deep central injury, bleeding from central pulmonary
Present 6/34 (17.6) vessels of moderate size may not be controllable, and blood may
Absent 11/124 (8.9) flood the alveoli in the segment, lobe, or entire lung. This can lead
Mammarian artery injury 0.1 to internal blood aspiration in the damaged parenchyma, with
Present 0/15 (0) consequent decreases in alveolar membrane diffusion and
Absent 17/143 (11.9) compliance. This results in worsening atelectasis, intra-pulmonary
Intercostal artery injury 0.04 shunting and hypoxemia, which roughly parallels the extent of
Present 0/27 (0) parenchymal involvement in a pulmonary contusion. Deep central
Absent 17/131 (13) injuries to the lung predispose communication between the
Chest wall injury 0.25 airways and the pulmonary venous plexus. When ventilation
Present 0/10 (0) pressure exceeds 60 mm Hg, the result may be a pulmonary
Absent 17/148 (11.5) venous air embolism, allowing air into the coronary arteries and
Morbidity 0.01 cerebral vessels.10 However, we have no experience with air
Present 6/23 (26.1) embolism in injured patients.
Absent 11/135 (8.1)
Overall, 6% of penetrating thoracic trauma victims require some
degree of pulmonary parenchymal resection.2,6,20,28,31 The higher
mortality associated with a lobectomy (up to 55%) or pneumonec-
found a relationship between ongoing chest output and mortality. tomy (up to 100%) after traumatic lung injury has prompted the
Their results are similar to ours, but their study consisted of both development of quicker and less extensive resection techni-
blunt and penetrating injuries. ques.5,8,13,17,27,33 Over the last decade, there has been a remarkable
Several studies have suggested that performing thoracotomies change in the types of operations performed for lung trau-
in an operating room results in better outcomes, although this is ma.21,28,32 The 70.2% incidence of our patients who required some
clearly related to patient selection.33 The advantages of performing pulmonary parenchymal procedure at thoracotomy was higher
a thoracotomy in an operating room include better instrumenta- than the approximately 40% rate generally reported in the
tion, better lighting, and a technically skilled operating room literature.15 Simple suture (68%) and tractotomy (23%) were used
nursing staff. No parameters studied for the location of the for management. In our study, we did not perform a lobectomy or
thoracotomy were significantly associated with survival after stab pneumonectomy for management, but wedge resection was
wounds, but there might have been an independent benefit of performed in 11(9%) cases. There was no effect of lung
performing a thoracotomy in an operating room after a gunshot (parenchymal) injury on mortality (p = 0.09), and thus the type
wound.34 of procedure did not affect mortality.
Stab wounds are generally focal injuries and are technically Zakharia reported a mortality rate of 1.7%, excluding great
easy to control or repair, whereas gunshot wounds often traverse vessel injuries.35 Our mortality rate was 1.2%, excluding cardiac
multiple structures and are more complex. Although evidence and associated injuries. Karmy-Jones et al.13 reported a mortality of
suggesting that an anterolateral thoracotomy provides inadequate 17% for an urgent thoracotomy due to hemorrhage after
exposure is provided by incision extension and modification penetrating chest trauma. Mortality in our patients who had
data,15 we did not need an extension incision. In our series, the combined procedures was 26.3%, which is lower than the 59%
preponderance of stab wound incisions were treated with an mortality achieved by Asensio et al.1 in their recent series.
anterolateral thoracotomy (53 of 93, 57%), and gunshot wounds, Hirshberg et al.12 reported a 41% mortality rate for 82 patients who
with a posterolateral thoracotomy (52 of 65, 80%). Most of the required combined laparotomy and thoracotomy.
cardiac injuries were managed via anterolateral thoracotomy. Mortality in patients who sustained a cardiac injury was 17.6%,
Penetrating cardiac injury may present without symptoms or which is lower than that reported by Degiannis et al.7 (30.8%). The
clinical signs of cardiac tamponade. In some patients, the chest higher proportion of gunshot wounds in their series (17.1%)
tube output actually reflects intra-pericardial haemorrhage compared with ours (11.8%) may explain the apparent difference.
entering the chest through a hole in the pericardium. Diagnosis Improvements in instrumentation, especially endoscopic sur-
is possible peroperative in these patients due to large hemothorax. gical techniques, have expanded the indications for video-assisted
Repair of penetrating wounds of the heart can be accomplished thoracic surgery (VATS) in the diagnosis and treatment of diseases
through a median sternotomy or anterior thoracotomy. Sternot- within the chest. Although VATS may be a reasonable alternative to
moy allows better exposure to right-sided cardiac structures and a standard thoracotomy in selected stable patients,16 the use of
904 S. Onat et al. / Injury, Int. J. Care Injured 42 (2011) 900–904
VATS in trauma patients remains controversial, because a
relatively stable thoracic trauma patient may become extremely
unstable at any moment, necessitating an immediate thoracotomy.
VATS is an accurate, safe and reliable operative therapy for lung
trauma complications, including post traumatic pleural collec-
tions,25 and may be an alternative modality for the evaluation of
isolated diaphragmatic lacerations due to stab wounds.
Most penetrating chest injuries can be treated with tube
thoracostomy. Surgery should be considered immediately in cases
with initial chest tube output >1000 ml or continued output of
250 ml/h for 3 successive hours; deterioration of hemodynamic
condition; massive hemothorax associated with shock, signs of
pericardial tamponade, massive air leak, or radiographic evidence
of a large hemothorax.
Factors that affected mortality were ISS, chest AIS score, SBP,
ongoing chest output, blood transfusion volume, diaphragm injury
and concomitant abdominal injury. Clearly, an increase in
mortality from 5.3 to 26.3% in patients who have associated
abdominal injuries should alert trauma surgeons to the complexity
of penetrating injuries to the chest and the demand for flexibility
and surgical creativity in their management.
Conflict of interest
The authors inform that there are no conflicts of interest.
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