Management of Penetrating Torso Trauma

Initial Assessment and Hemodynamic Stratification

Hemodynamic stability is defined as systolic blood pressure ≥ 90 mm Hg and heart rate 50-110 beats per minute, which determines the management pathway for penetrating torso trauma, according to the American College of Radiology 1, 3
The American College of Radiology recommends that hemodynamic stability be assessed before any imaging is performed, as it dictates all subsequent management decisions 1

Gunshot wounds are high-energy injuries with mortality rates of 13.7 deaths per 100,000 people and overall survival after emergency thoracotomy of only 4.3%, as reported by the MMWR Recommendations and Reports 2, 4
Stab wounds are low-energy injuries with significantly better outcomes, including 15.2% survival after emergency thoracotomy, and may not require advanced imaging depending on wound depth, according to the American College of Radiology 2, 4

The priority for hypotensive patients is early and aggressive hemostatic resuscitation, prompt diagnosis of life-threatening injuries, and early control of ongoing bleeding, not imaging, as recommended by the American College of Radiology 1, 3
FAST examination is the primary triage tool to identify hemopericardium, pneumothorax, and free intraperitoneal fluid, which have direct implications for immediate surgical intervention, according to the American College of Radiology 1, 3

Contrast-enhanced CT with multiplanar reformations is the standard imaging tool for stable patients, due to fast acquisition and excellent resolution, as recommended by the American College of Radiology 2, 3
The American College of Radiology recommends CT chest, abdomen, and pelvis with IV contrast as the primary modality for stable patients 3, 6

Non-operative management can be performed at specialized centers only when all resources are available, including serial clinical examinations, continuous vital signs monitoring, prompt operating room access, and ICU admission capability, as reported by the World Journal of Emergency Surgery 7, 8
Local wound exploration must be performed to rule out peritoneal violation, and if peritoneum is breached, non-operative management can still be utilized but requires higher clinical suspicion and lower threshold for intervention, according to the World Journal of Emergency Surgery 7, 8

FAST examination requires approximately 620 mL of free fluid to be detected, and intra-abdominal free fluid is non-specific for intestinal injury, as reported by the World Journal of Emergency Surgery 5
Bowel injury is missed on initial CT in 20% of cases, and patients with equivocal or non-specific findings require admission for observation with serial clinical examinations, according to the World Journal of Emergency Surgery 5