ECMO-/ECLS

Stab wounds or projectiles that violate the thoracic cavity can potentially
lead to lung, heart, major vessel, or mediastinal injury. Fortunately, the majority
of stab wounds to the chest in children do not go beyond the muscle wall.
Thoracic bullet penetration injuries can result in significant tissue damage from
direct missile penetration or secondary missiles from bone fragments.
Furthermore, bullets may travel in an unpredictable trajectory, necessitating
complete evaluation of intrathoracic structures, including the mediastinum.
A chest X-ray is obtained to assess for pneumothorax,
hemopneumothorax, or mediastinal air. It can also verify the location of the
projectile and its potential trajectory. Tube thoracostomy should be placed for
pneumothorax or hemothorax, and a persistent air leak should prompt further
evaluation for tracheobronchial tree injury. Cardiac injury should be evaluated
with a FAST exam or echocardiogram. If the patient is hemodynamically
stable, a CT angiogram of the chest may be considered to efficiently inventory
all the intrathoracic injuries.
Bleeding from bullet penetrating lung injury may require operative
intervention. Operative criteria for bleeding include > 20 mL/kg blood loss on
initial tube placement or persistent bleeding at a rate of 3cc/kg per hour. In
cases where significant bleeding occurs from a missile tract through the lung
parenchyma, a pulmonary tractotomy should be performed. The entry and exit
wounds on the lung are first identified, and a penrose drain is subsequently
placed through the tract to assist with retraction. A gastrointestinal anastomosis
stapler is then placed into the tract and fired to complete the tractotomy. This