International Association of Trauma and Surgical Intensive Care Symposium: Penetrating Trauma. Update on Penetrating Trauma

Significant advances in the management of penetrating trauma have taken place over the past decade. Military experience has demonstrated the benefits of changes in our prehospital management and resuscitation strategies, and improving technology has allowed an evolution in diagnostic and therapeutic paradigms. In the end, however, there are fundamental principles that continue to guide how we approach the patient with penetrating injury. The trauma victim who suffers cardiopulmonary arrest is likely to die without immediate intervention. Dr. Civil and colleagues provide an overview of resuscitative thoracotomy in penetrating trauma, including indications, technical considerations, and outcomes. In addition, they discuss issues such as training, personnel, and location— pointing out that the capabilities in urban trauma centers in the US are not necessarily duplicated in hospitals worldwide. This is certainly a consideration in designing an institutional protocol for managing patients in extremis. Penetrating neurotrauma can be immediately lethal or leave the victim with devastating disability. Rosenfeld and colleagues provide an overview of penetrating and blast injury to the central nervous system. Blast injury and its sequelae are being seen with increasing frequency in the aftermath of military conflict. The authors emphasize the importance of aggressive resuscitation and correction of coagulopathy, and highlight the need for early operative intervention in order to optimize outcomes. On the other hand, they offer criteria for nonoperative management of penetrating injuries to the brain and spinal cord. Finally, the importance of early decompression for blast injuries is highlighted. In his paper on penetrating cervical trauma, Dr. Feliciano reviews the signs and symptoms of significant vascular or aerodigestive injury, and emphasizes that early operative intervention is most appropriate in symptomatic patients. Among patients without symptoms, he points out that serial clinical evaluation is accurate and that CT scanning does not improve on the accuracy. On the other hand, as he points out, CT scanning is likely to obviate the need for invasive testing in the patient with ‘‘soft’’ signs or equivocal exam findings. Finally, he offers valuable technical tips for the surgical management of cervical injuries. In ‘‘Laparoscopy in penetrating abdominal trauma,’’ Uranues and colleagues describe the benefits of employing technological advances in the diagnosis and management of abdominal trauma. As surgeons gain experience with laparoscopy, it can be relied upon to facilitate diagnosis of significant abdominal and thoracoabdominal injuries— particularly diaphragmatic lacerations, small intestinal perforation, and mesenteric hemorrhage. The reduced surgical morbidity and length of stay, and cost-effectiveness of this approach compared with laparotomy, make a compelling argument for laparoscopy as the preferred approach in the stable patient. This paper highlights the importance of trauma surgeons’ acquisition and maintenance of skills in the elective surgical realm, so that they may be applied in the emergency situation. A different, even less-invasive, approach to penetrating abdominal trauma is described by Biffl and Leppaniemi. The authors offer evidence that, in patients with anterior abdominal stab wounds, performing additional testing & Walter L. Biffl walter.biffl@dhha.org