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Initial evaluation and management of penetrating thoracic trauma in adults

Julie Mayglothling, MD, FACEP, FCCM
Eric Legome, MD
Section Editor
Maria E Moreira, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM


The presentation of penetrating thoracic trauma can vary widely, from stable patients with few complaints to hemodynamically unstable patients requiring immediate life-saving interventions. Even apparently stable patients with penetrating chest injuries can deteriorate precipitously and a focused evaluation must be rapidly performed to assess for life-threatening conditions.

This topic review will discuss the epidemiology, mechanisms, and general approach to the initial management of injuries sustained by adults with penetrating thoracic trauma. Blunt thoracic trauma, thoracic trauma in children, and definitive management of specific injuries are reviewed separately. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and stabilization of children with thoracic trauma".)


Penetrating chest trauma is generally less common but more deadly than blunt chest trauma. According to small retrospective reviews, chest injuries are a relatively common cause of preventable death among trauma patients [1,2]. Thoracic wall penetration occurs most often from gunshots and stabbings, which comprise up to 10 and 9.5 percent, respectively, of all major trauma in the United States [3]. Other causes of penetrating thoracic injury include being impaled by objects as a result of industrial accidents, falls, collisions, blast injuries, and fragmenting military devices.

The incidence of penetrating thoracic trauma varies geographically. In the United States, 9 percent of all trauma related deaths occur from injuries to the thorax, of which one-third involve a penetrating mechanism [4,5]. In Europe, the incidence of penetrating trauma is reported to be as low as 4 percent [6]. However, in countries or regions engaged in warfare, up to 95 percent of military deaths may result from a penetrating mechanism [7]. Urban centers tend to have higher rates of interpersonal violence and a correspondingly higher percentage of injuries involve penetrating mechanisms compared to rural regions.

Most penetrating chest injuries do not require major operative intervention and many patients are managed with observation and serial evaluation using radiography or simple tube thoracostomy. Approximately 15 to 30 percent of penetrating thoracic injuries require surgery, as opposed to less than 10 percent of injuries from blunt chest trauma.


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