Aortic transection occurs quite commonly, particularly following high-speed vehicle accidents in which there is sudden deceleration. Only 10-20% of patients reach hospital alive but in these patients the rupture is contained and surgical repair is feasible. The diagnosis is suspected primarily from the widening of the mediastinum seen on the chest X-ray and a definitive diagnosis is made by arch aortography. There is some urgency about aortic repair as these patients are not stable and delayed rupture does occur. However, a balance must be struck between over hasty intervention and delay and some experts now favour a semi-urgent operation in cases where there is benefit to be gained from a more prolonged period of stabilisation of other injuries.
Blunt thoracic injury may also rupture the oesophagus or diaphragm or cause myocardial contusion. The latter may present with hypotension, dysrhythmia or sudden arrest. Penetrating injuries may also damage any of these viscera. While knife tracks are usually predictable, those of missiles are often less so. This makes the surgical approach to the chest difficult to plan as, unlike the abdomen, the incision greatly influences the access obtained. In certain gunshot injuries, further imaging may help to plan surgery but this is, of course, only feasible in the stable patient. Penetrating injuries also account for the great majority of pericardial tamponades (see above). On occasion thoracotomy will be necessary in the resuscitation room to save life. This rule only applies to patients who have sustained penetrating wounds (usually stab injuries) to the chest and who arrive with signs of life. If these patients undergo cardiac arrest within the resuscitation room, then opening the chest will permit haemorrhage, usually from the heart, to be controlled digitally until the operating theatre can be reached, sutures can be placed or expert help arrives. Opening the chest of patients with blunt thoracic trauma outwith the operating theatre is not usually associated with survival.
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