[Air Embolism of the Left Ventricle due to Pulmonary Stab Wound].

A man in his 50s was stabbed deeply in the back with a knife and brought to the emergency room. He was found to have a significant left hemopneumothorax. He was planned to undergo hemostatic surgery under general anesthesia. However, shortly after the change in a right lateral decubitus position, he experienced ventricular fibrillation. Hemostasis of the intercostal artery injury, the source of bleeding, and suture of the injured visceral pleura were performed under extracorporeal membrance oxgenation( ECMO). Although sinus rhythm was resumed, when positive pressure ventilation was applied to the left lung for an air leak test, ST elevation on the electrocardiogram and loss of arterial pressure occurred. A transesophageal echo revealed air accumulation in the left ventricle. It was determined that air had entered the damaged pulmonary vein from the injured bronchi due to the stab wound, leading to left ventricular puncture decompression and lower left lower lobectomy. Subsequently, his circulatory status stabilized, and ECMO was weaned off. He recovered without postoperative neurological deficits postoperatively. The mortality rate for chest trauma with systemic air embolism is very high. In cases of deep lung stab wounds, there is a possibility of systemic air embolism, so treatment should consider control of airway and vascular disruption during surgery.

Management of contained penetrating cardiac injury in a patient with prior cardiac surgery.

Penetrating cardiac injuries usually require emergent surgical intervention. Our patient presented to the trauma centre with multiple stab wounds to the neck, chest, epigastric region and abdomen. She arrived haemodynamically stable, and her initial Focused Assessment with Sonography for Trauma exam was negative. Her chest X-ray did not show any evident pneumothorax or haemothorax. Due to her injury pattern, she was taken to the operating room for exploratory laparotomy and neck exploration. Postoperatively, she was taken for CT and found to have a contained cardiac rupture. The injury was contained within previous scar tissue from her prior cardiac surgery. Further evaluation revealed that the injury included a penetrating stab wound to the right ventricle and a traumatic ventricular septal defect (VSD). She subsequently underwent a redo sternotomy with the repair of the penetrating stab wound and the VSD. Cardiology, intensive care, trauma surgery and cardiothoracic surgery coordinated her care from diagnosis, management and recovery. This case highlights the challenges in the management of cardiac injuries and the benefits of a multidisciplinary approach to care for complex cardiac injuries.

To the point: Utility of laparoscopy for operative management of stabbing abdominal trauma.

BACKGROUND: Algorithms for managing penetrating abdominal trauma are conflicting or vague regarding the role of laparoscopy. We hypothesized that laparoscopy is underutilized among hemodynamically stable patients with abdominal stab wounds. METHODS: Trauma Quality Improvement Program data (2016-2019) were used to identify stable (SBP ≥110 and GCS ≥13) patients ≥16yrs with stab wounds and an abdominal procedure within 24hr of admission. Patients with a non-abdominal AIS ≥3 or missing outcome information were excluded. Patients were analyzed based on index procedure approach: open, therapeutic laparoscopy (LAP), or LAP-conversion to open (LCO). Center, clinical characteristics and outcomes were compared according to surgical approach and abdominal AIS using non-parametric analysis. RESULTS: 5984 patients met inclusion criteria with 7 â€‹% and 8 â€‹% receiving therapeutic LAP and LCO, respectively. The conversion rate for patients initially treated with LAP was 54 â€‹%. Compared to conversion or open, therapeutic LAP patients had better outcomes including shorter ICU and hospital stays and less infection complications, but were younger and less injured. Assessing by abdominal AIS eliminated ISS differences, meanwhile LAP patients still had shorter hospital stays. At time of admission, 45 â€‹% of open patients met criteria for initial LAP opportunity as indicated by comparable clinical presentation as therapeutic laparoscopy patients. CONCLUSIONS: In hemodynamically stable patients, laparoscopy remains infrequently utilized despite its increasing inclusion in current guidelines. Additional opportunity exists for therapeutic laparoscopy in trauma, which appears to be a viable alternative to open surgery for select injuries from abdominal stab wounds. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Are trauma victims with obesity lucky in penetrating trauma injuries?

BACKGROUND: We aimed to reveal the protective effect of body mass index (BMI) and subcutaneous adipose tissue thickness (SATT), together with scores covering the abdomen, in patients with penetrating abdominal trauma. METHODS: The data of 234 abdominal penetrating trauma patients over the age of 16 who applied to the emergency general sur-gery unit of Istanbul Medipol Hospital between 2017 and 2021 were analyzed retrospectively. Sex, age, types of penetrating injuries, BMI, need for blood transfusion and intensive care unit (ICU), mortality, Injury Severity Score (ISS), Penetrating Abdominal Trauma Index (PATI), and Flint Colon Injury Score (FCIS) were recorded. RESULTS: The patients were divided into two groups: Gunshot Wound (GW) and Stab Wound (SW).While there was no significant difference in all parameters examined in all patients and GW patients in terms of BMI, a statistically significant difference was found in terms of blood transfusion need in SW patients (p=0.035). As a result of the Receiver Operating Characteristic curve analysis for the SATT variable, the cutoff value between mortality (p=0.866) and SATT (mm) values in all patients was 11 mm for all patients and 12 mm for GW patients. A significant difference was found in all patients and separately in GW and SW groups in terms of ICU and blood transfusion need, length of stay, ISS, PATI, and FCIS scores in non-operated patients (p<0.05). When all patients were examined, a statistically significant difference was found in terms of mortality (p=0.002). CONCLUSION: It is the first study to evaluate penetrating abdominal injuries with both BMI and SATT comprehensively and with all abdominal scores. A cutoff value to be determined for SATT with larger and multicenter studies can take its place as a parameter in the penetrating trauma algorithm.

Paradigms in trauma laparoscopy for anterior abdominal stab wounds: A scoping review.

INTRODUCTION: Anterior abdominal stab wounds (AASW) are a heterogeneous presentation with evolving management over time and heterogenous practice between centres. The aim of this scoping review was to identify, characterise and classify paradigms for trauma laparoscopies for AASW. METHODOLOGY: Studies were screened from Embase, Medline, Scopus, Cochrane Library and Web of Science from 1 January 1947 until 1 January 2023. Extracted data included indications for trauma laparoscopies vs laparotomies, and criteria for conversion to an open procedure. RESULTS: Of 72 included studies, 35 (48.6 %) were published in the United States, with an increasing number from South Africa since 2014. Screening tests to determine an indication for surgery included local wound exploration, computed tomography, and serial clinical examination. Two studies proposed no absolute contraindications to laparoscopy, whereas most papers supported trauma laparoscopies over laparotomies in hemodynamically stable patients with positive or equivocal screening tests. However, clinical decision trees were used inconsistently both between and within many hospital centres. Triggers for conversion to laparotomy were diverse. Older studies typically reported conversion if peritoneal breach was identified. More recent studies reported advances in technical skills and technology allowed attempt at laparoscopic repair for organ and/or vascular injury. CONCLUSION: This review emphasises that there are many different paradigms of practice for AASW laparoscopy, which are evolving over time. Significant heterogeneity of these studies highlights that meta-analysis of outcomes for trauma laparoscopy is not appropriate unless the included studies report homogenous treatment paradigms and patient cohorts. The decision to perform a trauma laparoscopy should be based on surgeon/hospital experience, patient factors, and resource availability.

Surgical exploration for penetrating neck trauma - an audit of results in 145 patients.

BACKGROUND: Selective non-operative management (SNOM) is the current gold standard for the treatment of patients with penetrating neck trauma. The policy revolves around the liberal use of computed tomography angiography (CTA) in those patients who are haemodynamically stable, irrespective of the anatomical zone of injury, aiming at reducing the incidence of negative and non-therapeutic interventions and their potential complications. METHODS: A retrospective audit of results of patients who underwent immediate surgical exploration at the Chris Hani Baragwanath Academic Hospital in Soweto between January 2010 and December 2015 was performed. RESULTS: One-hundred and forty-five (145) patients, with a median age of 28 years (range 18-67 years), predominantly males (93.8%), underwent immediate exploration. Most injuries were caused by stab wounds (92.4%) and affected zone 2 (54.1%) on the left side of the neck (69.6%). The most common presentations were active haemorrhage (29.4%), shock (24.1%) and expanding haematoma (15.1%). A major vascular injury was found in 40%, and aero-digestive organ injury in 19.3%. The rate of negative-non-therapeutic exploration in this cohort was 4.1%. Complications were recorded in 7.6%, and the overall mortality was 9.6% secondary to early uncontrolled haemorrhage, sepsis and occlusive strokes. CONCLUSIONS: The utilisation of SNOM with strict criteria for selection of patients who require immediate surgical exploration versus investigations with CTA results in a low rate of non-therapeutic interventions.

Role of laparoscopy in management of patients with anterior abdominal stab wounds.

BACKGROUND: In this retrospective cohort study, we assessed the utility of laparoscopic surgery for diagnostic and therapeutic purposes in patients with anterior abdominal stab wounds (AASWs). We also investigated patient characteristics that might suggest a greater suitability of laparoscopic interventions. METHODS: Over a 25-year span, we analyzed AASW patients who had operations, categorizing them based on the presence of significant intra-abdominal injuries and whether they received laparoscopic surgery or laparotomy. We compared variables such as preoperative conditions, surgical details, and postoperative outcomes. We further evaluated the criteria indicating the necessity of direct laparotomies and traits linked to overlooked injuries in laparoscopic surgeries. RESULTS: Of 142 AASWs surgical patients, laparoscopic surgery was conducted on 89 (62.7%) patients. Only 2 (2.2%) had overlooked injuries after the procedure. Among patients without significant injuries, those receiving laparoscopic surgery had less blood loss than those receiving laparotomy (30.0 vs. 150.0 ml, p = 0.004). Patients who underwent laparoscopic surgery also had shorter hospital stays (significant injuries: 6.0 vs. 11.0 days, p < 0.001; no significant injuries: 5.0 vs. 6.5 days, p = 0.014). Surgical complications and overlooked injury rates were comparable between both surgical methods. Bowel evisceration correlated with higher laparotomy odds (odds ratio = 16.224, p < 0.001), while omental evisceration did not (p = 0.107). CONCLUSIONS: Laparoscopy is a safe and effective method for patients with AASWs, fulfilling both diagnostic and therapeutic needs. For stable AASW patients, laparoscopy could be the preferred method, reducing superfluous nontherapeutic laparotomies.

Is diagnostic laparoscopy necessary in the management of left thoracoabdominal stab wounds?

BACKGROUND: The diagnosis of a diaphragmatic rupture and the identification of patients for surgical repair is challenging despite current diagnostic algorithms and imaging technologies. Unless treated on time, acute traumatic diaphragmatic injury due to stab wounds has a high mortality and morbidity rate, with an increasing trend in the presence of organ herniation. In this study, we aimed to investigate the efficacy of diagnostic laparoscopy in patients with an anterior thoracoabdominal stab wound and to compare the follow-up outcomes of cases. METHODS: We retrospectively reviewed our institutional database of patients who were admitted with stab wounds between Oc-tober 2012 and 2022. Patients who underwent diagnostic laparoscopy were divided into two groups depending on the presence of a diaphragmatic injury. We analyzed demographics, the success of computed tomography (CT) imaging in the diagnosis, the presence of hemomediastinum, pneumomediastinum, tube thoracostomy application, associated organ injury, type of surgery, duration of surgery, complications, and the length of stay between the groups. RESULTS: Of the 39 patients with penetrating left thoracoabdominal injury underwent diagnostic laparoscopy, CT had a diagnostic sensitivity of 63.16% (95% Confidence interval [CI] 38.36-83.71%), and a specificity of 100% (95% CI 82.35-100.00%). We could not find a statistically significant difference between the groups in terms of studied variables, while operation time was significantly higher in the diaphragmatic injury group (P<0.01). Fourteen patients had accompanied visceral injuries. CONCLUSION: Diagnostic laparoscopy is still the gold standard particularly in the ER setting, particularly in the absence of an experienced radiologist for 24 h and when the close monitoring of the patient by the same team cannot be provided.

Epidemiology, repair technique, and predictors of stroke and mortality in penetrating carotid artery injuries.

OBJECTIVE: Penetrating carotid artery injuries (PCAI) are significantly morbid and deadly, often presenting in extremis with associated injuries and central nervous system deficit. Repair may be challenging with arterial reconstruction vs ligation role poorly defined. This study evaluated contemporary outcomes and management of PCAI. METHODS: PCAI patients in the National Trauma Data Bank from 2007 to 2018 were analyzed. Outcomes were compared between repair and ligation groups after additionally excluding external carotid injuries, concomitant jugular vein injuries, and head/spine Abbreviated Injury Severity score of ≥3. Primary end points were in-hospital mortality and stroke. Secondary end points were associated injury frequency and operative management. RESULTS: There were 4723 PCAI (55.7% gunshot wounds, 44.1% stab wounds). Gunshot wounds more frequently had associated brain (73.8% vs 19.7%; P < .001) and spinal cord (7.6% vs 1.2%; P < .001) injuries; stab wounds more frequently had jugular vein injuries (19.7% vs 29.3%; P < .001). The overall in-hospital mortality was 21.9% and the stroke rate was 6.2%. After exclusion criteria, 239 patients underwent ligation and 483 surgical repair. Ligation patients had lower presenting Glasgow Coma Scale (GCS) than repair patients (13 vs 15; P = .010). Stroke rates were equivalent (10.9% vs 9.3%; P = .507); however, in-hospital mortality was higher after ligation (19.7% vs 8.7%; P < .001). In-hospital mortality was higher in ligated common carotid artery injuries (21.3% vs 11.6%; P = .028) and internal carotid artery injuries (24.5% vs 7.3%; P = .005) compared with repair. On multivariable analysis, ligation was associated with in-hospital mortality, but not with stroke. A history of neurological deficit before injury lower GCS, and higher Injury Severity Score (ISS) were associated with stroke; ligation, hypotension, higher ISS, lower GCS, and cardiac arrest were associated with in-hospital mortality. CONCLUSIONS: PCAI are associated with a 22% rate of in-hospital mortality and a 6% rate of stroke. In this study, carotid repair was not associated with a decreased stroke rate, but did have improved mortality outcomes compared with ligation. The only factors associated with postoperative stroke were low GCS, high ISS, and a history of neurological deficit before injury. Beside ligation, low GCS, high ISS, and postoperative cardiac arrest were associated with in-hospital mortality.

Relationship of Obesity and Severe Penetrating Thoracic and Abdominal Injuries in Adolescent Patients.

BACKGROUND: Over 20% of United States adolescents are obese. A thicker layer of subcutaneous adiposity might provide a protective "armor" layer against penetrating wounds. We hypothesized that adolescents with obesity presenting after isolated thoracic and abdominal penetrating trauma have lower rates of severe injury and mortality than adolescents without obesity. METHODS: The 2017-2019 Trauma Quality Improvement Program database was queried for patients between 12 and 17 years old presenting with knife or gunshot wounds. Patients with body mass index (BMI) ≥30 (obese) were compared to patients with BMI <30. Sub-analyses were performed for adolescents with isolated abdominal trauma and isolated thoracic trauma. Severe injury was defined as an abbreviated injury scale grade >3. Bivariate analyses were performed. RESULTS: 12,181 patients were identified; 1603 (13.2%) had obesity. In isolated abdominal gunshot or knife wounds, rates of severe intra-abdominal injuries and mortality were similar (all P > .05) between groups. In isolated thoracic gunshot wounds, adolescents with obesity had a lower rate of severe thoracic injury (5.1% vs 13.4%, P = .005) but statistically similar mortality (2.2% vs 6.3%, P = .053) compared to adolescents without obesity. In isolated thoracic knife wounds, rates of severe thoracic injuries and mortality were similar (all P > .05) between groups. DISCUSSION: Adolescent trauma patients with and without obesity presenting after isolated abdominal or thoracic knife wounds had similar rates of severe injury, operative intervention, and mortality. However, adolescents with obesity presenting after an isolated thoracic gunshot wound had a lower rate of severe injury. This may impact the future work-up and management of adolescents sustaining isolated thoracic gunshot wounds.

[Gunshot Wounds and Penetrating Injuries]. / Schusswaffenverletzungen und penetrierende Traumata.

The acute medical care in Germany after gunshot and stab wounds in the pre-hospital and in-hospital setting is a rarity in an international comparison. The resulting lack of routine in the acute care of critically injured people after penetrating trauma should therefore be countered with regular theoretical and practical training. In addition to standardized care algorithms for the care of severely injured people, knowledge of kinetics and wound ballistics is required for focused treatment. The article focuses mainly on the early treatment phase.

A Rare Self-Inflicted Stabbing to the Neck Injuring the Distal Trachea and Proximal Esophagus.

Penetrating neck trauma poses a significant risk to multiple vital structures, which if not treated immediately may lead to devastating consequences. Our patient presented after sustaining self-inflicted stab wounds to the neck. He was taken to the operating room for a left neck exploration and median sternotomy, revealing a distal tracheal injury. Following repair of the tracheal injury, an intraoperative esophagogastroduodenoscopy demonstrated a full-thickness esophageal injury 15 cm proximal to the tracheal injury. Both injuries were the result of separate stab entries originating from the same external midline wound. To our knowledge, this case report is unique in bringing this circumstance to the literature, demonstrating the importance of full intraoperative examination to assess for concomitant wounds in stab injuries after the initial pathology has been found and the initial stab trajectory understood.

Accuracy of CT Scan for Detecting Hollow Viscus Injury in Penetrating Abdominal Trauma.

BACKGROUND: In penetrating abdominal trauma, computed tomography (CT) is routinely performed to evaluate stable patients for selective non-operative management (SNOM). Triple-contrast CT (oral, rectal, and IV) has traditionally been used. However, due to its disadvantages, most trauma centres, including our unit at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), now perform single-contrast intravenous-only CT scans. We performed a retrospective review to determine the accuracy of single-contrast CT scans for detecting hollow viscus injuries (HVI) in penetrating abdominal trauma. METHODS: A retrospective review of all patients who presented to CMJAH with penetrating abdominal injuries was performed between 01 August 2017 and 31 August 2019 and were evaluated for SNOM with CT (IV contrast only). Patient records were reviewed to determine pertinent demographics, mechanism, and site of injury, as well as metabolic parameters. CT findings were compared to findings at laparotomy. RESULTS: A total of 437 patients met the inclusion criteria. The majority were male (92.7%), with a mean age of 31.5 yrs (SD 8.7). Injuries were predominantly due to stab wounds (72,5%, n = 317). CT scan was negative in 342 patients, of which 314 completed SNOM successfully. A total of 93 patients proceeded to laparotomy. CT had a sensitivity of 95.1%, specificity of 44.2%, positive predictive value of 57.4%, and negative predictive value of 92%. CONCLUSION: Single-contrast CT in penetrating abdominal trauma is a valuable investigative tool in identifying patients for SNOM. Features of HVI on single-contrast CT are not very specific and should be interpreted along with other clinical factors including wound trajectory and serial abdominal examinations. Other associated injuries such as diaphragmatic and solid organ injuries should be considered in the final management plan.

Overview of stab injuries in Far North Queensland: A new insight into the demographics, injury patterns and management.

BACKGROUND: Cairns Hospital is the northernmost tertiary referral hospital in Far North Queensland (FNQ) and manages trauma from a large catchment area. A large burden of stab injuries occurs in at-risk patient groups, such as Indigenous and mental health patients, in this region. This research aims to present an overview of the demographics, injury patterns, management and outcomes for stabbings injuries in FNQ. METHODS: A five-year retrospective single-centre study of all patients treated for neck, torso or junctional stab wounds in Far North Queensland was performed searching for all patients with a coded diagnosis of stabbing or knife injury from 1 March 2016 to 31 March 2021. RESULTS: 214 knife injuries were identified and 50.5% of those injured identified as Aboriginal and/or Torres Strait Islander. Stabbing injury locations were most commonly the abdomen/flank/pelvis (n = 81) and the chest/thorax (n = 77). Two-thirds of injuries that breached abdominal fascia had concurrent intra-abdominal injury. Hollow viscus injury commonly involved the small bowel (n = 8), colon (n = 5) and stomach (n = 2), whilst the liver was the most frequently injured solid organ (n = 6). There were 19 vascular injuries, excluding the extremities. 89.2% received diagnostic imaging in the emergency department. FAST scan had 76% sensitivity and 100% specificity for intra-abdominal injury at operation. Overall, 35% of patients required an operation. There were only two in-hospital deaths. CONCLUSION: Stab injuries annually in FNQ are comparable to other centres in Australia. Overall injury severity was low, with excellent survival rates and outcomes for patients who reached hospital. Operative intervention rates for abdominal stab wounds were low in FNQ compared to available data and imaging again appears protective against negative laparotomy rate.

Abdominal stab wounds with retained knife: 15 years of experience from a major trauma centre in South Africa.

INTRODUCTION: This study reviews our cumulative experience with the management of patients presenting with a retained knife following an abdominal stab wound (SW). METHODS: A retrospective study was conducted at a major trauma centre in South Africa over a 15-year period from July 2006 to December 2020 including all patients who presented with a retained knife in the abdomen following a SW. RESULTS: A total of 42 cases were included: 37 males (93%) with a mean age of 26 years. A total of 18 knives (43%) were in the anterior abdomen and 24 were posterior abdomen. Plain radiography was performed in 88% (37/42) of cases and computed tomography was performed in 81% (34/42); 90% (38/42) underwent extraction in the operating theatre. Laparotomy was performed in 62% (26/42). Of all the laparotomies performed, 77% (20/26) were positive for intra-abdominal organ or visceral injury. Overall morbidity was 31%. There were two mortalities (5%). Laparotomy was less commonly required for the posterior abdomen (33% (8/24) vs 100% (18/18), p<0.001). For retained knives in the anterior abdomen, 72% (13/18) of the laparotomies were positive for intra-abdominal organ or visceral injury. For the posterior abdomen, 7 of the 8 (88%) were positive for intra-abdominal organ or visceral injury. There were no differences in the need for intensive care unit admission, length of hospital stay, morbidities or mortalities. CONCLUSIONS: Uncontrolled extraction of a retained knife in the abdomen outside of the operating theatre must be avoided. Retained knives in the anterior abdomen usually require formal laparotomy, but this is generally not required for posterior abdomen.

Laparotomy for Abdominal Stab Wound With Combined Omental and Organ Evisceration: 10-Year Experience From a Major Trauma Centre in South Africa.

INTRODUCTION: Combined omental and organ evisceration following anterior abdominal stab wound (SW) is uncommon and there is a paucity of literature describing the management and spectrum of injuries encountered at laparotomy. METHODS: A retrospective study was undertaken on all patients who presented with anterior abdominal SW involving combined omental and organ evisceration who underwent laparotomy over a 10-year period from January 2008 to January 2018 at a major trauma centre in South Africa. RESULTS: A total of 61 patients were eligible for inclusion and all underwent laparotomy: 87% male, mean age: 29 years. Ninety-two percent (56/61) had a positive laparotomy whilst 8% (5/61) underwent a negative procedure. Of the 56 positive laparotomies, 91% (51/56) were considered therapeutic and 9% (5/56) were non-therapeutic. In addition to omental evisceration, 59% (36/61) had eviscerated small bowel, 28% (17/61) had eviscerated colon and 13% (8/61) had eviscerated stomach. A total of 92 organ injuries were identified. The most commonly injured organs were small bowel, large bowel and stomach. The overall complication rate was 11%. Twelve percent (7/61) required intensive care unit admission. The mean length of hospital stay was 9 days. The overall mortality rate for all 61 patients was 2%. CONCLUSIONS: The presence of combined omental and organ evisceration following abdominal SW mandates laparotomy. The small bowel, large bowel and stomach were the most commonly injured organs in this setting.

CT after emergency surgery in penetrating trauma: a seven-year experience in a level I Nordic trauma center.

BACKGROUND: Patients with severe penetrating trauma may require emergency surgery on arrival, and postoperative computed tomography (CT) can reveal significant additional injuries. PURPOSE: To determine the utility of postoperative CT performed within 48 h of emergency surgery after penetrating trauma. MATERIAL AND METHODS: Trauma registry data were retrieved over a seven-year period at a single level 1 trauma center. All patients aged ≥17 years, admitted with penetrating injury, who underwent urgent surgery and postoperative CT imaging within 48 h, were included. Pre- and intraoperative medical records were compared to CT findings. Age, sex, Injury Severity Score (ISS), New Injury Severity Score (NISS), 30-day mortality, injury mechanism, surgical intervention, and intensive care unit length of stay were extracted. RESULTS: Out of 1262 patients, 38 fulfilled the study criteria (36 men [94.7%], 2 women [5.3%]; mean age = 31.5 years. Stab wound (SW) was the most common injury mechanism (26/38, 68.4%) followed by gunshot wound (GSW; 10/38, 26.3%). Patients with GSWs were more severely injured than SW victims (median NISS = 34 [range = 3-75]; for GSWs = 34; for SWs = 26; P = 0.045). Out of 38 patients, 20 (52.6%) had additional findings at postoperative CT. Six patients (15.8%) had unidentified or underestimated findings at CT that were severe enough to warrant additional surgery or angiography. CONCLUSION: Postoperative CT imaging after emergency surgery in penetrating trauma is an important tool in evaluating the injury panorama. Out of 38 patients, 6 (15.8%) had findings at postoperative CT that warranted additional surgical or angiographic intervention.

Double Jeopardy Injuries: Improved Clinical Outcomes With FAST Imaging and Subxiphoid Pericardial Window for Combined Cardiac and Abdominal Stab Wounds.

BACKGROUND: This study reviews our experience with combined cardiac and abdominal stab wounds over 12 years and reviews how changes in technology and clinical approaches have impacted our management of these patients. MATERIALS AND METHODS: A retrospective cohort study was conducted from January 2008 to January 2020 at a major trauma centre in South Africa. All patients with concurrent SWs to the chest and the abdomen and required both a thoracotomy for cardiac injury and a laparotomy for an intra-abdominal injury at the same setting were included. RESULTS: Twenty-two cases were identified (100% male, mean age: 27 years). Mean values of admission physiology: systolic blood pressure (SBP): 85 mmHg, pH: 7.2, base excess: -10.2 mmol/L and serum lactate 6.7 mmol/L. Thirty-two percent (7/22) of cases underwent a Focused Assessment with Sonography in Trauma (FAST) scan (5 positive and 2 negative). All 7 cases had intraoperatively confirmed cardiac injuries. The thoracotomy first approach was used in 18 cases (82%), and the laparotomy first approach was used in the remaining 4 cases (18%). Nineteen (86%) of the 22 laparotomies were positive. A total of 6 patients (27%) experienced one or more complications. The mean length of hospital stay was 9 days. The overall mortality was 18% (4/22) and all mortality occurred prior to 2013. DISCUSSION: Double jeopardy is still associated with an increased risk of mortality. The use of FAST and Subxiphoid Pericardial Windows (SPWs) have reduced clinical uncertainty, decreasing the need for concomitant thoracotomy and laparotomy to be performed.