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Transmediastinal gunshot wound


A transmediastinal gunshot wound (TMGSW) is a penetrating injury to a person's thorax in which a bullet enters the mediastinum, possibly damaging some of the major structures in this area. Hemodynamic instability has been reported in approximately fifty percent of cases with a mortality rate ranging from twenty to forty percent. Some studies have shown marked improvement in the mortality rate of patients who survived transfer to the operating room rather being treated surgically in the ER.

Complications caused by a TMGSW can range from mild to life-threatening depending on which structures are damaged. It can be rapidly lethal if a major structure is involved. Some of the possible complications caused by a TMGSW are:

Previously every stable patient that suffered a TMGSW received extensive evaluation that included chest radiography, oesophagography, esophagoscopy, angiography, bronchoscopy, cardiac ultrasound. Grossman et al. found evidence that the trajectory of the bullet can be delineated with the use of Computed Tomographic Scan (CT). Subsequently other studies demonstrated the use of CT as a screening tool for stable patients who suffered TMGSW is a reliable tool for ruling out, diagnosing and avoiding missed injuries. For example Stassen et al. showed data of 22 stable patients who were screened with CT, chest x ray and abdominal ultrasound; seven patients showed a positive CT scan and required additional evaluation, and of these seven patients, three required surgical management. Additionally the work of Burack et al., whose evaluation of stable patients with penetrating injuries to the mediastinum — this time including stab wounds — relied mostly on CT and ultrasound, showed similar results. The work of Ibirogba et al. did so as well. Recent data suggests that the use of CT scan with some additional noninvasive techniques, such as ultrasound and chest roentgenogram are reliable screening tools to decide whether patients need further evaluation.

The criteria to define a patient as stable or unstable could have variations from institution to institution. For example Burack et al. used a list of 6 criteria in his paper that defined an unstable hemodinamic state:


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