A 28-year-old man presents to the emergency department 2 hours after sustaining a stab wound to the left anterior chest wall at the 5th intercostal space, mid-clavicular line. He is haemodynamically stable with a blood pressure of 128/82 mmHg, heart rate 92/min, and respiratory rate 18/min. Breath sounds are equal bilaterally. There is a small amount of blood oozing from the wound. On examination, the wound tract cannot be fully visualized due to depth. What is the most appropriate next step in management?

Explanation

## Clinical Assessment of Penetrating Chest Trauma ### Key Principle **Key Point:** Haemodynamically stable patients with penetrating chest wounds require imaging-based evaluation to determine the trajectory and depth of injury before deciding on operative versus conservative management. ### Rationale for Correct Answer The patient is **haemodynamically stable** with normal vital signs and no signs of tension pneumothorax, haemothorax, or cardiac tamponade. In such cases, **selective non-operative management** using serial clinical examination and imaging is the standard of care in modern trauma protocols. **High-Yield:** Triple contrast CT (IV, oral, and rectal) helps identify: - Depth of wound tract penetration - Involvement of mediastinum, heart, great vessels, or lungs - Presence of pneumothorax or haemothorax - Diaphragmatic injury ### Management Algorithm ```mermaid flowchart TD A[Penetrating chest wound]:::outcome --> B{Haemodynamically stable?}:::decision B -->|No| C[Immediate surgical exploration]:::urgent B -->|Yes| D{Signs of tension pneumothorax<br/>or tamponade?}:::decision D -->|Yes| E[Needle decompression/pericardiocentesis<br/>then OR]:::urgent D -->|No| F[Serial clinical exam<br/>+ Triple contrast CT]:::action F --> G{Imaging shows<br/>deep penetration?}:::decision G -->|Yes| H[Surgical exploration]:::action G -->|No| I[Continued observation<br/>+ serial exams]:::action ``` ### Serial Examination Protocol - Repeat vital signs every 15–30 minutes for first 2 hours - Auscultate for new breath sound changes - Assess for signs of evolving pneumothorax, haemothorax, or cardiac tamponade - Watch for subcutaneous emphysema (suggests pneumothorax) **Clinical Pearl:** The absence of haemodynamic instability, respiratory distress, or clinical signs of intrathoracic injury makes immediate exploration unnecessary and increases operative morbidity without benefit. [cite:Park 26e Ch 15]