Penetrating Thoracic Stab Wounds and The Cardiac Box: A Single-Center Experience of in-hospital Treatment and Outcome in Germany

Background Thoracic stab injuries (TSI) remain uncommon in emergency care settings in Germany despite being potentially life-threatening events. The cardiac box concept has been proposed as a method of assessing cardiac injuries caused by penetrating injuries. This study aims to assess the in-hospital management of TSI to further evaluate the association between treatment and outcome, as well as the cardiac box as a predictor of major injuries in these patients.

Methods & Materials The study retrospectively collected data of all patients with TSI in the context of an assault or self-harm who were primarily admitted to the University Hospital of Leipzig (Level 1 certified Trauma Centre) from January 2020 to June 2024. Therefore, prehospital and inhospital parameters were analyzed descriptively.

Results 56 patients with TSI were enrolled (male: 100%, median age 28.5 years). 16 patients sustained injuries within the cardiac box (CB), while 39 patients had injuries outside the cardiac box (NCB). The admission rate to our ER was 100% in the CB group and 95% in the NCB group. The proportion of ER visits ranged from 1.4% to 2.4% per year. The median injury severity score (ISS) was 6 and higher in the CB group (9.5 vs. 3; p = 0.045). The range of intrathoracic injuries did not differ significantly between the groups as well as the hemodynamic situation in the ER (MAP (mmHg) CB 93 (IQR 81, 110) vs. NCB 97 (IQR 88, 105), p=0.925). 2 patients (NCB n=2) received a chest tube by emergency doctors. In the ER a chest tube was placed in 13 patients (23.2%) with no significant difference between the groups. The interval between arrival and transferral was shorter for the CB group (38 min (IQR 38.5, 104) vs. 67 min (IQR 46.5, 130.5). VATS was performed in 8 patients (14.3%) (CB: n = 4, 25%; NCB: n = 4, 10.3%; p = 0.241), whereas in one patient in each group an open procedure was applied. The CB group had a higher incidence of major complications (≥ grade II Clavien-Dindo classification: CB: 50.1%, NCB: 25.7%; p = 0.018). The overall mortality rate was 3.6% (CB n = 2).

Conclusion TSI are rare but life-threatening injuries. A minimal-invasive approach can be performed in hemodynamically stable patients. The low rate of prehospital chest drain placement needs further investigation to elucidate the underlying reasons. The cardiac box concept appears to be overly simplistic and may lead to the underestimation of injuries outside the box that often show a similar pattern of clinical features and intrathoracic injuries.

 

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Publication History

Article published online:
25 August 2025