1. Perform a chest radiograph followed by computed tomography angiography in stable patients.
   
2. Proceed directly to the operating room for left posterolateral thoracotomy.
   
3. A median sternotomy is preferred for obtaining proximal arterial control.
   
4. A supraclavicular exploration is recommended for unstable patients.
   
5. Covered stents have now completely replaced open repair techniques for left subclavian transections.

A patient with a stab wound to the chest should first be evaluated with a chest radiograph to rule out pneumothorax. In a patient with a suspected left subclavian artery injury, a radiograph may also show a first rib fracture, widened mediastinum, apical pleural hematoma, or opacification along the expected course of the subclavian artery. In a hemodynamically stable patient or those without “hard signs” of vascular trauma, the next step in the evaluation would be a multi‐slice computed tomography angiography (CTA) to diagnose the injury and aid the preoperative plan (choice A). There are no indications for a rush to the operating room in this case as the patient is stable (choice B). The safe approach to achieve proximal control for a left subclavian artery injury is a left anterolateral thoracotomy (choice C). Supraclavicular exploration is not advised particularly in unstable patients with hard signs of vascular injury because of the potential for uncontrolled surgical bleeding and the time to expose the artery with this approach is longer even in the best of hands (choice D). The subclavian artery is easily visible through the chest and control is fast and simple. Right subclavian artery injuries, however, are best approached with a median sternotomy. Endovascular repairs are becoming more frequent but require a stable patient with suitable anatomy (choice E). Transactions are the most challenging to repair with an endovascular strategy and may require added challenges such as retrograde trans‐brachial access and trans‐femoral snaring for stent deployment. Preservation of the left vertebral artery remains an important consideration and may ultimately determine the best approach.

Answer: A

Waller CJ, Cogbill TH, Kallies KJ, Ramirez LD, Cardenas JM, Todd SR, Chapman KJ, Beckman MA, Sperry JL, Anto VP, Eriksson EA, Leon SM, Anand RJ, Pearlstein M, Capano‐Wehrle L, Cothren Burlew C, Fox CJ, Cullinane DC, Roberts JC, Harrison PB, Berg GM, Haan JM, Lightwine K. Contemporary management of subclavian and axillary artery injuries‐A Western Trauma Association multicenter review. J Trauma Acute Care Surg. 2017; 83(6):1023–1031.

Ganapathy A, Khouqeer AF, Todd SR, Mills JL, Gilani R. Endovascular management for peripheral arterial trauma: The new norm? Injury. 2017; 48(5):1025–1030.

1. Place a chest tube followed by an open repair of the aortic injury.
   
2. Place a chest tube and move to a hybrid room for thoracic endovascular aortic repair.
   
3. Place a chest tube with nonoperative management of the aortic and splenic injuries.
   
4. Place a chest tube followed by exploratory laparotomy.
   
5. Systemic anticoagulation and nonoperative management for the aortic injury.

Several multicenter trials have demonstrated survival benefit for thoracic endovascular aortic repair (TEVAR) when compared to open aortic repair (choice A). An intimal flap is considered a mild blunt aortic injury and can be managed with medical therapies (blood pressure parameters and antiplatelet) and repeat imaging in several days to determine injury progression and the need for intervention (choice B). The pneumothorax is addressed early in accordance with advanced trauma life support (ATLS) guidelines (choice C). The splenic injury does not necessitate immediate exploration or intervention in a stable patient (choice D). Systemic anticoagulation is contraindicated in the setting of a traumatic brain injury and is not a good substitute for antiplatelet therapy that is recommended when the other injuries are stable, and the bleeding risk is lower (choice E).

Answer: C

Demetriades D, Velmahos GC, Scalea TM, Jurkovich GJ, Karmy‐Jones R, Teixeira PG, Hemmila MR, O’Connor JV, McKenney MO, Moore FO, London J, Singh MJ, Lineen E, Spaniolas K, Keel M, Sugrue M, Wahl WL, Hill J, Wall MJ, Moore EE, Margulies D, Malka V, Chan LS ; American Association for the Surgery of Trauma Thoracic Aortic Injury Study Group. Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study. J Trauma. 2008; 64(3):561–570; discussion 570‐1.

Quiroga E, Starnes BW, Tran NT, Singh N. Implementation and results of a practical grading system for blunt thoracic aortic injury. J Vasc Surg. 2019; 70(4):1082–1088.

1. Placement of a lumbar drain prior to endovascular repair of the traumatic aortic injury.
   
2. This is a known complication that cannot be prevented.
   
3. Preservation of the left subclavian artery.
   
4. Use of a larger diameter and longer covered stent graft.
   
5. Open repair.

Placement of lumbar drain preoperatively is typically done for elective treatment of aneurysms in the setting of atherosclerosis but is not routinely recommended or performed for the trauma patient (choice A). Spinal cord ischemia is a dreaded complication but can be prevented with careful preoperative planning and precise TEVAR delivery (choice B). For example, intentional preservation of the left subclavian artery may reduce posterior circulation strokes and spinal cord ischemia (choice C). Limited subclavian artery coverage or revascularization strategies can be achieved with fenestration of the polyester thoracic graft, parallel stenting, or carotid subclavian artery bypass. Diameters are slightly oversized to the aortic wall and increased diameters risk dissection. Longer grafts sacrifice more intercostal arteries and therefore correlate with an increased risk of spinal cord ischemia (choice D). Open repair and endovascular repair continue to carry a measurable risk of spinal cord injury and paralysis (choice E).

Answer: C

Sobocinski J, Patterson BO, Karthikesalingam A, Thompson MM. The effect of left subclavian artery coverage in thoracic endovascular aortic repair. Ann Thorac Surg. 2016; 101(2):810–817.

Stafforini NA, Singh N, Hemingway J, Starnes B, Tran N, Quiroga E. Re‐evaluating the need for routine coverage of the left subclavian artery in thoracic blunt aortic injury. Ann Vasc Surg. 2020; 31:S0890–5096(20)31110‐9.

1. 33‐year‐old with a stab wound to the right ventricle.
   
2. 23‐year‐old with a gunshot to the left atrium.
   
3. 42‐year‐old with a stab wound to the left atrium.
   
4. 36‐year‐old with stab wound to the left ventricle.
   
5. 27‐year‐old with a gunshot wound to the intra‐pericardial aorta.

In penetrating cardiac injuries, the mechanism of injury, physiologic status at presentation, and the anatomic site of injury can all determine the prognosis. For example, gunshot wounds carry higher mortality than stab wounds and left heart injuries are worse than right heart injuries due to higher pressure gradients (choices A–D). The thinner atrial myocardium may be a factor for a ventricular injury having a better prognosis. The intra‐pericardial great vessel injuries have the worst prognosis of all injury patterns due to thin high‐pressure walls (choice E). Multiple‐chamber injuries, especially with great vessel involvement, were associated with the highest mortality rate. In addition to the location of injury, physiologic status and presence of tamponade impact outcome.

Answer: E

Morse BC, Mina MJ, Carr JS, Jhunjhunwala R, Dente CJ, Zink JU, Nicholas JM, Wyrzykowski AD, Salomone JP, Vercruysse GA, Rozycki GS, Feliciano DV. Penetrating cardiac injuries: A 36‐year perspective at an urban, Level I trauma center. J Trauma Acute Care Surg. 2016; 81(4):623–631.

Tyburski JG, Astra L, Wilson RF, Dente C, Steffes C. Factors affecting prognosis with penetrating wounds of the heart. J Trauma. 2000; 48(4):587–590; discussion 590‐1.

Rhee PM, Foy H, Kaufmann C, Areola C, Boyle E, Maier RV, Jurkovich G. Penetrating cardiac injuries: A population‐based study. J Trauma. 1998; 45(20):366–370.

1. Surgical fixation of rib fracture after failure of medical management.
   
2. Multimodal therapy including the use of regional anesthesia to permit chest physiotherapy.
   
3. Mechanical ventilation to optimize tidal volumes.
   
4. Limiting narcotic pain medication to prevent depression of the respiratory drive.
   
5. Fluid restriction and steroids.

Surgical stabilization of rib fractures are believed to improve chest wall stability leading to both better pain control and pulmonary mechanics. The sooner this stability is achieved, the less time the patient is exposed to secretion accumulation, atelectasis, and hypoventilation. Proponents of rib fixation suggest the greatest outcome is observed with early fixation by not allowing the patient the “opportunity” to fail medical management (choice A). Multimodal analgesia, including the use of narcotics and anti‐inflammatory medications will permit chest physiotherapy and ensure the best outcome with improved pain control, pneumonia prevention, and a decreased need for mechanical ventilation (choice B). Mechanical ventilation is reserved for patients with respiratory failure and those who require mechanical ventilation have worse outcomes and higher mortality (choice C). The management of flail chest includes analgesia and aggressive chest physiotherapy but is not accomplished by limiting narcotic pain medication (choice D). Judicious fluid resuscitation is recommended in these patients to assure adequate tissue perfusion. However, steroids should be avoided in the management of pulmonary contusion (choice E).

Answer: B

Brasel KJ, Moore EE, Albrecht RA, deMoya M, Schreiber M, Karmy‐Jones R, Rowell S, Namias N, Cohen M, Shatz DV, Biffl WL. Western Trauma Association Critical Decisions in Trauma: Management of rib fractures. J Trauma Acute Care Surg. 2017; 82(1):200–203.

Pieracci FM, Coleman J, Ali‐Osman F, Mangram A, Majercik S, White TW, Jeremitsky E, Doben AR. A multicenter evaluation of the optimal timing of surgical stabilization of rib fractures. J Trauma Acute Care Surg. 2018; 84(1):1–10.

1. Place another right‐sided chest tube.
   
2. Obtain a supine chest radiograph.
   
3. Increase the wall suction on the right chest tube.
   
4. Proceed to the operating room for an emergent thoracotomy.
   
5. Correct coagulopathy and continue monitoring vital signs.

Patient physiology rather than numbers should be the primary indication for thoracotomy after penetrating chest trauma. Regardless, an initial chest tube output >1500 mL or persistent bleeding of 200 mL/hour for 4 or more hours should prompt consideration for surgical intervention (choice D) versus continued monitoring in the setting of shock (choice E). The guidelines for thoracotomy in most textbooks are for when thoracotomy should be considered or when a trauma surgeon should be informed. When assessing and managing hemothorax, the two questions need to be answered. The first is how much has bled into the chest and the second is, are they still bleeding. Large amounts of blood out of the chest tube initially in a stable patient with no further bleeding may not need surgery. An unstable patient with bright red bleeding that continues may need surgery before a certain amount of blood has been collected. Chest tubes do not always reliably fully evacuate the hemothorax and the chest x‐ray helps determine the effectiveness of the chest tube. A large amount of blood may be missed when viewing portable supine images and is not a reliable tool for managing this condition (choice B). A persistent air leak or retained hemothorax or when the bleeding seems to be “slowing” after chest tube placement can be managed with early video‐assisted thoracoscopic surgery (VATS). Delays for further monitoring, extra suction (choice C), or placing additional tubes may increase the risk of complications. Blood in the chest always causes clotted residual blood to a relative degree. Blood clot in the chest does not come out of any sized chest tube but unclotted blood comes out of smaller bore chest tubes. Thus, although some trauma centers have advocated for second chest tubes if a certain amount comes out of the initial chest tube or if the diaphragm is not well visualized on chest X ray, this is no longer the standard (choice A). Retained clot is evaluated with CT scan and early VATS has become the standard.

Answer: D

Mowery NT, Gunter OL, Collier BR, Diaz JJ Jr, Haut E, Hildreth A, Holevar M, Mayberry J, Streib E. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma. 2011; 70(2):510–518.

Karmy‐Jones R, Namias N, Coimbra R, Moore EE, Schreiber M, McIntyre R Jr, Croce M, Livingston DH, Sperry JL, Malhotra AK, Biffl WL. Western trauma association critical decisions in trauma: Penetrating chest trauma. J Trauma Acute Care Surg. 2014; 77(6):994–1002.

Ahmed N, Jones D. Video‐assisted thoracic surgery: State of the art in trauma care. Injury. 2004; 35(5):479–489.

1. Retained hemothorax; video‐assisted thoracoscopy surgery.
   
2. Intraparenchymal chest tube; upright chest radiographs.
   
3. Intraparenchymal chest tube; chest computed tomography (CT).
   
4. Tracheobronchial injury; thoracotomy.
   
5. Tracheobronchial injury; bronchoscopy.

Air leaks are a common finding after traumatic injury to the chest and may be due to a leak in the drainage system or an intraparenchymal tube and can be excluded once serious injuries are ruled out (choices B, C). The associated severity of a missed tracheobronchial injury should prompt the diagnosis when a significant air leak, subcutaneous emphysema, hemoptysis, or pneumomediastinum is discovered. A CT scan is may be appropriate; however, a bronchoscopy will both diagnose and precisely localize the tracheobronchial injury for preoperative planning (choice E). Small injuries without leak can be managed nonoperatively. Most thoracic tracheal injures are approached via right posterolateral fourth intercostal thoracotomy and repaired with simple interrupted absorbable sutures although for trauma patients an anterior lateral thoracotomy is more commonly performed and is a viable option once the diagnosis is established (choice D). Distal air leaks will often seal with a tube thoracostomy, provided the suction is managed appropriately. VATS is appropriate for treating a retained hemothorax (choice A), but management of the tracheobronchial injury must take priority.

Answer: E

Karmy‐Jones R, Wood DE. Traumatic injury to the trachea and bronchus. Thorac Surg Clin. 2007; 17(1):35–46.

Chouliaras K, Bench E, Talving P, Strumwasser A, Benjamin E, Lam L, Inaba K, Demetriades D. Pneumomediastinum following blunt trauma: Worth an exhaustive workup? J Trauma Acute Care Surg. 2015; 79(2):188–192; discussion 192‐3.

1. Electrocardiogram (ECG) is an appropriate screening tool in hemodynamically stable patients.
   
2. Males age older than 55 are the highest risk.
   
3. BCI can only be ruled out by transesophageal echocardiogram.
   
4. There is no role for cardiac enzyme testing in BCI.
   
5. Nuclear medicine studies can be useful and should be routinely used in suspected BCI.

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