Management of Complex Transmediastinal Stab Wound With Cardiac,Esophageal,and Arterial Injury

Penetrating transmediastinal chest injuries are associated with a high mortality. This is due to the number of vital structures in the mediastinum, including the heart, vascular structures, trachea, and esophagus within the mediastinal space. Those with associated cardiac injury have especially poor outcome, with mortality as high as 80%. ¹ Here, we describe a case of penetrating transmediastinal injury from stab wound with vascular, esophageal, and cardiac injury complicated by cardiac tamponade.

The patient is a 24-year-old man, who was brought to the trauma bay after multiple stab wounds to his chest and back. On primary survey, his airway was intact. He was mildly tachypneic, with decreased breath sound on the left side, but saturating at 100% on room air. He was tachycardic to the 130 s, with a blood pressure of 90/60. His Glasgow Coma Scale was 15, but he was distressed and diaphoretic. He was found to have 2 left parasternal stab wounds at the level of third and sixth rib, as well as 1 posterior right paraspinal stab wound at level L1. A chest X-ray (Figure 1) showed white out of the left lung, and a fast exam showed pericardial effusion. The patient was immediately transferred to the operating room. While the anesthesia team was getting ready, the patient’s chest was prepped and a left-sided chest tube was inserted with immediate return of 1 L of blood, and no significant bleeding noted thereafter. Upon induction, patient went into cardiac arrest with pulseless electrical activity. A subxiphoid pericardiotomy and median sternotomy was immediately performed. Return of spontaneous circulation was achieved within 1 minute of the arrest. A through and through cardiac laceration to right ventricle was found with a 2 cm anterior laceration and a 1 cm posterior laceration and each was repaired with pledgeted prolene sutures. The posterior pericardium was violated, but no active bleeding was noted. At this time, the chest tube has accumulated 1500 mL total output since the start of the operation. Given the possibility of lung laceration or aortic injury, a left thoracotomy was performed. No injury to the lung, aorta, or esophagus was appreciated, but there was continued bleeding into the chest. Ultimately, a transected internal mammary artery was found and ligated. There was no significant injury visualized in the posterior mediastinum via the left thoracic anterolateral thoracotomy incision. An esophagoscopy was performed immediately following the sternotomy and left thoracotomy and through-and-through clean-edged esophageal lacerations at 35-40 cm from incisions were identified (Figure 2). Four total endoscopic clips were applied, and a nasogastric tube was inserted under direct visualization to bypass the site of injury for feeding access. In total, the patient received 2 units packed red blood cells and 1 unit of frozen fresh plasma and remained hemodynamically normal. On post-operative day 7, an esophagram was performed and no esophageal leak was seen. Patient was subsequently started on a regular diet which he tolerated well. He was discharged on post-operative day 22 after arranging support for his long-standing psychiatric issues.

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Figure 1.

X-ray at time of presentation with opacity of the left chest.

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Figure 2.

Endoscopic image of esophagus showing through-and-through injury (black arrow) from stab wound.

Several key management decisions contributed to a good outcome in this case. The primary survey was conducted in a horizontal fashion to quickly identify patient needs. Portable X-ray and ultrasound were readily available prior to patient presentation. The primary survey, X-ray, and FAST exam helped confirm the mechanism and allowed estimation of extent of the injury and thus must be performed rapidly with high precision. The patient required 2 interventions: left-sided chest tube and pericardial window, in response to the white out of the left lung and pericardial effusion, respectively. Given that the patient needed surgical intervention with certainty, no time was wasted in transporting patient from emergency room to the operating room, not even to place a chest tube. The few minutes required to place a chest tube may be the difference between patient coding in the emergency room or in the operating room where the environment is more controlled and surgical instruments are more readily available. In the operating room, care continues to be carried out in a horizontal manner. Patient’s chest was prepped, and chest tube was placed while anesthesiologist was preparing for intubation. Prior to induction, all instruments necessary for sternotomy and thoracotomy were set up given the high risk of sudden cardiac arrest in these patients. Adequate preparation and communication with the anesthesiologist ensured minimal duration of cardiac arrest.

Penetrating thoracic trauma with associated cardiac injury carries a high mortality. Tyburski et al found patients presenting with stab wound had better survival than those with gunshot wounds at 58% and 23%, respectively. ¹ The same study found that of the 59 patients with stab wounds and underwent ED thoracotomy, only 20% survived, while those who underwent OR thoracotomy had an 81% survival. Cardiac tamponade appeared to have a protective effect as 66% of patients with tamponade survived compared to 47% without. Several trauma centers have developed “direct to operating room trauma resuscitation (DOR),” where patients who are high risk for life saving intervention and emergency surgery completely bypass the emergency room and are transported directly to the OR that acts as the initial evaluation and resuscitation area. A 2020 study by Johnson and colleagues found that in patients who underwent DOR, the observed mortality was significantly better than expected based on their revised trauma injury severity scores, at 17% vs 25%. ² The most common criterion in the cohort for DOR was penetrating injury to the torso or head in 64% of patients. Though our patient made a stop in the emergency room, the emphasis on minimizing time to definitive surgical intervention remains the same.

In terms of the esophageal injury repair, given the wound edges appeared clean, and to avoid a right thoracotomy in a patient who had just undergone a left thoracotomy, the decision was made to perform an endoscopic repair. It is especially important to advance the scope slowly and deliberately in these cases to avoid exacerbation of any existing injury. Esophageal stent was not used given its tendency to exert excessive radial force on the esophagus and risk of complications such as migration and erosion. Qadeer et al published a pooled analysis in 2007, which includes 17 patients from 11 articles with esophageal perforation that underwent endoscopic clipping. ³ 65% of the patients in the study suffered iatrogenic injury, including all 7 cases of acute perforation, and none of the patients suffered a stab wound. The median healing time was 5 days for acute perforations and 18 days for all patients, and the duration of perforation was found to be a significant predictor of closure time. To our knowledge, there have been only one other reported case of endoscopic repair of esophageal stab wound using only endoscopic clips, published by Zoutendijk and colleagues in 2019; the patient in this case suffered longitudinal entry and exit wounds in the proximal esophagus with a total of 6 clips applied and no leak on the post-operative barium swallow study. ⁴

Penetrating transmediastinal injuries carry a high mortality, but a good outcome is certainly achievable with adequate preparation that starts before the patient arrival, horizontal resuscitation, rapid identification of injury and intervention, and good interdisciplinary communication. Endoscopic clipping may also be a viable option for penetrating esophageal injury due to stab wounds in select cases.