Penetrating Trauma to the Mediastinal Vessels: a Taxing Injury

More than 90 % of thoracic great vessel injuries are due to penetrating trauma. The increased incidence of civilian penetrating (stab and low-velocity gunshot wounds) chest trauma and improved emergency medical services (EMS) have stemmed in an increasing number of seriously injured, but potentially salvageable patients, presenting to trauma centers. Penetrating mediastinal vascular injuries are associated with a high mortality. Unstable patients present a diagnostic and operative challenge to the surgeon, and require damage control resuscitation (DCR) and immediate surgery. DCR begins with the restrictive fluid administration, permissive hypotension, early blood product therapy that includes initiation of massive transfusion protocol (MTP), temporary hemostasis by balloon tamponade, tube thoracostomy, and/or resuscitative thoracotomy. Stable patients can undergo a rapid and aggressive workup with screening computerized tomographic angiography (CTA) followed by catheter angiography for unclear CTA findings, and when feasible, endovascular intervention.