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15 year old male with single GSW to left chest

Always ABCDE1. Airway

2. Breathing 3. Circulation4. Disability5. Exposure

Priorities?

ABCDE

Airway: Pt. is able to talk

Breathing: Diminished Bilaterally per EMS

Bilateral needle decompression performed by EMS

Treatment?

Bilateral chest tubes placed

Circulation: BP 91/55, HR 128, RR 30, Sats 100%,

2+ pulses in all extremities, IV access obtained

Disability: GCS 15. No focal neuro deficits

Exposure: Solitary GSW wound in left axilla

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Next Steps

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Follow-up CXR

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Trans-mediastinal GSWWhat could be injured?

1. Heart

2. Aorta/Vena Cava

3. Lungs/Bronchi

4. Esophagus

5. Diaphragm

6. Spleen

7. Stomach

8. Liver

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Decision Making

How to evaluate for each possible injury?

CT scan?

Ultrasound?

OR?

Chest or Abdomen First?

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Trans-mediastinal GSWWhat could be injured?

1. Heart—He’s not dead! FAST scan to evaluate for fluid in the pericardial sac

2. Aorta/Vena Cava—He’s not dead! But could have traumatic pseudoaneurysm. CTA chest

3. Lungs/Bronchi—No air leaks in chest tubes. Bronchoscopy

4. Esophagus—Needs EGD and Esophogram

5. Diaphragm—No great test for this injury. Needs OR to assess

6. Spleen—FAST scan. CT scan. Operate

7. Stomach—EGD, CT scan, Operate

8. Liver—CT scan. Operate7

CT Chest

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CT abdomen

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Order of Operation

Low suspicion of intra-abdominal injury based on CT scan, FAST scan, and clinical exam

However, cannot rule out diaphragm injury.

Started with simultaneous laparoscopy to rule bilateral diaphragm injury, intra-abdominal hemorrhage, or organ injury and endoscopy

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No diaphragm injury, No intra-abdominal injury

Bronchoscopy normal

EGD--

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Trans-mediastinal GSWWhat could be injured?

1. Heart—No pericardial effusion

2. Aorta/Vena Cava—No great vessel injury by CTA

3. Lungs/Bronchi—Bilateral PTX resolved with chest tubes. No air leaks. Normal bronchoscopy

4. Esophagus—Distal esophageal injury

5. Diaphragm—No injury by laparoscopy

6. Spleen--No injury by laparoscopy

7. Stomach--No injury by laparoscopy

8. Liver--No injury by laparoscopy

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Esophageal RepairLeft Thoracotomy due to distal location

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Follow-up

Discharged to home tolerating a regular diet the following week

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Summary

Always ABCDE first

Address life threatening injuries first

Assess what can be injured by the mechanism of injury

Identify and treat injuries

Questions?

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