Transmediastinal Gunshot Wounds

This is a complex problem because of the variety of injuries that may occur in the chest from vascular or cardiac injury, aeroesophageal injury, or spinal injury. Priority lies with life-threatening cardiac and vascular injuries. After the initial resuscitation, if the patient remains stable, he should be transported to the an-giography suite for arteriogram of the aortic arch vessels and ascending aorta (Table 19.1). If this is negative and the patient is still stable, he should go to the operating room for endotracheal intubation followed by flexible bronchoscopy and rigid esophagoscopy. If these are negative, the patient is taken back to the radiology suite for a Gastrograffin swallow to rule out esophageal injury, and if this is negative then an esophageal swallow with barium if there is still high suspicion for esophageal injury. The reason that a radiologic swallow study should generally be done after a negative rigid esophageal endoscopy is that the radiologic study is actually more sensitive than the endoscopic study. Of course if at the time of surgery esophageal endoscopy reveals an injury then it should be managed op-eratively either by a right or left thoracotomy, or if in the cervical region a cervical approach. Tracheobronchial injuries are likewise managed depending on the location of the injury.

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