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Qi J, Kong V, Ko J, Narayanan A, Wang J, Leow P, Bruce J, Laing G, Clarke D. Management of thoracoabdominal gunshot wounds - Experience from a major trauma centre in South Africa. Injury 2024; 55:111186. [PMID: 37989701 DOI: 10.1016/j.injury.2023.111186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 10/08/2023] [Accepted: 11/03/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION The management of thoracoabdominal (TA) gunshot wounds (GSW) remains challenging. This study reviewed our experience with treating such injuries over a decade. MATERIALS AND METHODS A retrospective study was conducted at a major trauma centre in South Africa over a ten-year period from December 2012 to January 2022. RESULTS Two hundred sixteen cases were included (male: 85 %, mean age: 33 years). Median RTS: 8 and median ISS: 17 (IQR: 10-19). The mean value of physiological parameters: Heart Rate (HR): 98/min, Systolic Blood Pressure (SBP): 119 mmHg, Temperature (T): 36.2 °C, pH: 7.35, Lactate 3.7 mmol/l. Ninety-nine (46 %) underwent a CT scan of the torso. One hundred fifty-four cases (69 %) were managed operatively: thoracotomy only [5/154 (3 %)], laparotomy only [143/154 (93 %)], and combined thoracotomy and laparotomy [6/154 (4 %)]. Those who had surgery following preoperative CT had a lower rate of dual cavity exploration (2 % vs 4 %, p = 0.51), although it did not reach statistical significance. The overall morbidity was 30 % (69). 82 % required intensive care (ICU) admission. The mean length of hospital stay was 14 days. The overall mortality was 13 % (28). Over the 10-year study period, there was a steady increase in the number of cases of TA GSWs managed at our institution. Over the study period, an increasing use of CT was noted, along with a steady reduction in the proportion of operations performed. CONCLUSIONS Thoraco-abdominal GSWs remain challenging to manage and continue to be associated with significant morbidity and mortality. The increased use of CT scans has reduced the degree of clinical confusion around which body cavity to prioritize, leading to an apparent decrease in dual cavity exploration, and has allowed for the increased use of minimalistic and non-operative approaches.
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Affiliation(s)
- Jonah Qi
- Department of Surgery, University of Auckland School of Medicine, Auckland, New Zealand
| | - Victor Kong
- Department of Surgery, University of the Witswatersrand, Johannesburg, South Africa; Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.
| | - Jonathan Ko
- Department of Surgery, University of Auckland School of Medicine, Auckland, New Zealand
| | - Anantha Narayanan
- Department of Surgery, University of Auckland School of Medicine, Auckland, New Zealand
| | - Jim Wang
- Department of Surgery, University of Auckland School of Medicine, Auckland, New Zealand
| | - Priscilla Leow
- Department of Surgery, University of Auckland School of Medicine, Auckland, New Zealand
| | - John Bruce
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Grant Laing
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Damian Clarke
- Department of Surgery, University of the Witswatersrand, Johannesburg, South Africa; Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
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Kong V, Ko J, Lee B, Leow P, Manchev V, Bruce J, Laing G, Clarke D. Double Jeopardy Injuries: Improved Clinical Outcomes With FAST Imaging and Subxiphoid Pericardial Window for Combined Cardiac and Abdominal Stab Wounds. Am Surg 2022:31348221093803. [PMID: 35512444 DOI: 10.1177/00031348221093803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND This study reviews our experience with combined cardiac and abdominal stab wounds over 12 years and reviews how changes in technology and clinical approaches have impacted our management of these patients. MATERIALS AND METHODS A retrospective cohort study was conducted from January 2008 to January 2020 at a major trauma centre in South Africa. All patients with concurrent SWs to the chest and the abdomen and required both a thoracotomy for cardiac injury and a laparotomy for an intra-abdominal injury at the same setting were included. RESULTS Twenty-two cases were identified (100% male, mean age: 27 years). Mean values of admission physiology: systolic blood pressure (SBP): 85 mmHg, pH: 7.2, base excess: -10.2 mmol/L and serum lactate 6.7 mmol/L. Thirty-two percent (7/22) of cases underwent a Focused Assessment with Sonography in Trauma (FAST) scan (5 positive and 2 negative). All 7 cases had intraoperatively confirmed cardiac injuries. The thoracotomy first approach was used in 18 cases (82%), and the laparotomy first approach was used in the remaining 4 cases (18%). Nineteen (86%) of the 22 laparotomies were positive. A total of 6 patients (27%) experienced one or more complications. The mean length of hospital stay was 9 days. The overall mortality was 18% (4/22) and all mortality occurred prior to 2013. DISCUSSION Double jeopardy is still associated with an increased risk of mortality. The use of FAST and Subxiphoid Pericardial Windows (SPWs) have reduced clinical uncertainty, decreasing the need for concomitant thoracotomy and laparotomy to be performed.
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Affiliation(s)
- Victor Kong
- Department of Surgery,37707University of the Witwatersrand, Johannesburg, South Africa
- Trauma Service, Department of Surgery, 1415Auckland City Hospital, Auckland New Zealand
| | - Jonathan Ko
- Department of Surgery, 1415University of Auckland, Auckland, New Zealand
| | - Bogo Lee
- Department of Surgery, 1415University of Auckland, Auckland, New Zealand
| | - Priscilla Leow
- Department of Surgery, 3718Waikato Hospital, Hamilton, New Zealand
| | - Vasil Manchev
- Department of Surgery, 56394University of KwaZulu Natal, Durban, South Africa
| | - John Bruce
- Department of Surgery, 56394University of KwaZulu Natal, Durban, South Africa
| | - Grant Laing
- Department of Surgery, 56394University of KwaZulu Natal, Durban, South Africa
| | - Damian Clarke
- Department of Surgery,37707University of the Witwatersrand, Johannesburg, South Africa
- Department of Surgery, 56394University of KwaZulu Natal, Durban, South Africa
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The Role of Pericardial Window Techniques in the Management of Penetrating Cardiac Injuries in the Hemodynamically Stable Patient: Where Does It Fit in the Current Trauma Algorithm. J Surg Res 2022; 276:120-135. [PMID: 35339780 DOI: 10.1016/j.jss.2022.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/21/2021] [Accepted: 02/12/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Penetrating cardiac injuries (PCIs) have high in-hospital mortality rates. Guidelines regarding the use of pericardial window (PW) for diagnosis and treatment of suspected PCIs are not universally established. The objective of this review was to provide a critical appraisal of the current literature to determine the effectiveness and safety of PW as both a diagnostic and therapeutic technique for suspected PCIs in patients with hemodynamic stability. METHODS A review was conducted using PubMed/MEDLINE, Google Scholar, and Embase to identify literature evaluating the accuracy and therapeutic efficacy of PW and its role in a hemodynamically stable patient with penetrating thoracic or thoracoabdominal trauma. RESULTS Eleven studies evaluating diagnostic PW and two studies evaluating therapeutic PW were included. These studies ranged from (y) 1977 to 2018. Existing literature indicates that PW is highly sensitive (92%-100%) and specific (96%-100%) for the diagnosis of suspected PCIs. PW and drainage, when compared with sternotomy, may be associated with decreased total hospital stay (4.1 versus 6.5 d; P < 0.001) and intensive care unit stay (0.25 versus 2.04 d; P < 0.001) along with similar mortality and complication rates after the management of hemopericardium. CONCLUSIONS In a hemodynamically stable patient presenting with penetrating cardiac trauma with a high suspicion for PCI, PWs can (1) facilitate prompt diagnosis in the event of equivocal ultrasonography findings and (2) serve as an effective therapeutic modality with the benefit of potentially avoiding more invasive procedures. Subxiphoid, transdiaphragmatic, and laparoscopic approaches for PW have been shown to have similar efficacy and safety.
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Muratov A, Tuibayev Z, Arynov Z, Abdykalykov K, Kurbanbayev O, Khashimov B, Matkasymov M, Abdullaeva Z. Combined thoracoabdomial injury: Case report. Ann Med Surg (Lond) 2020; 56:149-151. [PMID: 32637091 PMCID: PMC7330147 DOI: 10.1016/j.amsu.2020.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/22/2020] [Accepted: 06/22/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Combined thoracoabdominal injuries are the most severe case in the medical practice. Bilateral injuries are rare case in patients and just few cases reported in literature. Diaphragm traumas and pneumothorax are defined as severe trauma leading to injuries of thoracic and abdominal organs. We are describing multiple injuries of abdominal tract and chest causing internal bleeding and hemothorax in patient. Surgical operation was carried out on the right side thoracotomy including revision of the pleural cavity and subphrenic space, closure of the wound, removal of the blood clot and drainage of the pleural with abdominal cavities. Presentation of case A 24-years old man was admitted in Emergency Department after penetrating knife wounds of abdominal cavity. Discussion X-ray of the tracheobronchial tree (bronchography) showed closed chest injuries, post traumatic hemopneumothorax of the right side. Conclusion Surgical repair was conducted by displacing of the organs in chest cavity with lamellar T-shaped retractor, and hemostatic Billroth, Kocher clamps to stop bleeding in the wound.
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Affiliation(s)
- A Muratov
- Osh State University, Department of General Surgery, Kurmanjan Datka Street 157, 723500, Osh, Kyrgyzstan
| | - Z Tuibayev
- Osh City Clinical Hospital, Surgery Department, Kurmanjan Datka Street 157, 723500, Osh, Kyrgyzstan
| | - Z Arynov
- Osh State University, International Medical Faculty, Department of Surgical Disciplines and Traumatology, Jolon Mamytov Campus, 723500, Osh, Kyrgyzstan
| | - K Abdykalykov
- Jalal-Abad Regional Hospital, Department of Surgery, Pushkin Str. 92, 715609, Jalal-Abad, Kyrgyzstan
| | - O Kurbanbayev
- Osh State University, Department of General Surgery, Kurmanjan Datka Street 157, 723500, Osh, Kyrgyzstan
| | - B Khashimov
- Tumen Regional Clinical Hospital, Department of Thoracoabdominal Surgery, Russian Federation
| | - M Matkasymov
- Department of Thoracoabdominal Surgery, Osh Interregional Clinical Hospital, Osh, Kyrgyzstan
| | - Z Abdullaeva
- Osh State University, International Medical Faculty, Department of Anatomy, Histology and Normal Physiology, Jolon Mamytov Campus, 723500, Osh, Kyrgyzstan
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Selective Operative Management of Penetrating Chest Injuries. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0233-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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García A. Enfoque inicial del paciente estable con trauma precordial penetrante: ¿es tiempo de un cambio? REVISTA COLOMBIANA DE CIRUGÍA 2019. [DOI: 10.30944/20117582.93] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Management of pericardial fluid in blunt trauma: Variability in practice and predictors of operative outcome in patients with computed tomography evidence of pericardial fluid. J Trauma Acute Care Surg 2017; 82:733-741. [PMID: 28129264 DOI: 10.1097/ta.0000000000001386] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The objectives of this study were to assess current variability in management preferences for blunt trauma patients with pericardial fluid, and to identify characteristics associated with operative intervention for patients with pericardial fluid on admission computed tomography (CT) scan. METHODS This was a mixed-methods study of blunt trauma patients with pericardial fluid. The first portion was a research survey of members of the Eastern Association for the Surgery of Trauma conducted in 2016, in which surgeons were presented with four clinical scenarios of blunt trauma patients with pericardial fluid. The second portion of the study was a retrospective evaluation of all blunt trauma patients 14 years or older treated at our Level I trauma center between January 1, 2010, and November 1, 2015, with pericardial fluid on admission CT scan. RESULTS For the survey portion of our study, 393 surgeons responded (27% response rate). There was significant variability in management preferences for scenarios depicting trace pericardial fluid on CT with concerning hemodynamics, and for scenarios depicting hemopericardium intraoperatively. For the separate retrospective portion of our study, we identified 75 blunt trauma patients with pericardial fluid on admission CT scan. Seven underwent operative management; six of these had hypotension and/or electrocardiogram changes. In multivariable analysis, pericardial fluid amount was a significant predictor of receiving pericardial window (relative risk for one category increase in pericardial fluid amount, 3.99, 95% confidence interval, 1.47-10.81) but not of mortality. CONCLUSION There is significant variability in management preferences for patients with pericardial fluid from blunt trauma, indicating a need for evidence-based research. Our institutional data suggest that patients with minimal to small amounts of pericardial fluid without concerning clinical findings may be observed. Patients with moderate to large amounts of pericardial fluid who are clinically stable with normal hemodynamics may also appear appropriate for observation, although confirmation in larger studies is needed. Patients with hemodynamic instability should undergo operative exploration. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.
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Affiliation(s)
| | | | | | - Mike Faurie
- Edendale Hospital, Pietermaritzburg, South Africa
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Getting a better look: Outcomes of laparoscopic versus transdiaphragmatic pericardial window for penetrating thoracoabdominal trauma at a Level I trauma center. J Trauma Acute Care Surg 2016; 81:1035-1038. [PMID: 27879614 DOI: 10.1097/ta.0000000000001173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In penetrating thoracoabdominal trauma, it is necessary to evaluate both the pericardial fluid and the diaphragm directly. Transdiaphragmatic pericardial windows (TDWs) provide direct access to the pericardium and diaphragm but expose the patient to the risks of laparotomy. We hypothesize that transabdominal laparoscopic pericardial windows (LPWs) are a safe and effective alternative to TDWs in stable patients. METHODS This is a retrospective observational study of stable patients with thoracoabdominal penetrating trauma at a level I trauma center between January 2007 and June 2015, comparing outcomes after TDW versus LPW. RESULTS A total of 99 patients with penetrating trauma had a diagnostic pericardial window, 33 of which were laparoscopic. Stab wounds were most common (80, 80.8%) compared with gunshot wounds (19, 19.2%). Of 11 patients who had a positive pericardial window, 10 (90.9%) were associated with a cardiac injury. There was no difference in the ratio of positive pericardial windows for patients who had TDW versus LPW (8/66, 12.1% vs. 3/33, 9.1%; p = 0.651). One patient had a complication related to a negative pericardial window in the laparoscopic group. There was no difference in complication rates between TDW and LPW (p = 0.155). Mean length of stay was longer in TDW compared with LPW (12 vs. 5 days, p = 0.046). One patient died during index admission in the TDW group, but there was no difference in mortality rates between TDW and LPW during the index admission (p = 0.477). Median length of follow-up was 29 days (range, 0-2,709). On long-term follow-up, there was also no difference in mortality rates between TDW and LPW (2/66, 3.0% vs. 2/33, 6.1%; p = 0.470). CONCLUSION In hemodynamically stable patients with thoracoabdominal injuries, LPW is a safe and effective technique in evaluating both pericardial fluid and the diaphragm. LPW is a viable alternative to exploratory laparotomy and TDWs. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Ghods K, Razavi MR, Forozeshfard M. Performance, pain, and quality of life on use of central venous catheter for management of pericardial effusions in patients undergoing coronary artery bypass graft surgery. J Pain Res 2016; 9:887-892. [PMID: 27826210 PMCID: PMC5096756 DOI: 10.2147/jpr.s116483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Different pericardial catheters have been suggested as an effective alternative method for drainage of pericardial effusion. The aim of this study was to determine the performance, pain, and quality of life on use of central venous catheter (CVC) for drainage of pericardial effusion in patients undergoing open heart surgery. Fifty-five patients who had developed pericardial effusion after an open heart surgery (2012-2015) were prospectively assessed. Triple-lumen central catheters were inserted under echocardiographic guidance. Clinical, procedural, complication, and outcome details were analyzed. Intensity of pain and quality of life of patients were assessed using the numerical rating scale and Short-Form Health Survey. CVC was inserted for 36 males and 19 females, all of whom had a mean age of 58.5±15 years, and the mean duration of the open heart surgery was 8±3.5 hours. The mean central venous pressure catheter life span was 14.6 days. No cases of recurrent effusion and complication were reported. The technical success rate of procedure was 100%. Intensity of pain and quality of life of patients had improved during follow-up. CVC insertion is a safe and effective technique for the management of pericardial effusion in patients after open heart surgery.
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Affiliation(s)
- Kamran Ghods
- Clinical Research Development Unit (CRDU), Department of Cardiovascular Surgery, Kowsar Hospital
| | | | - Mohammad Forozeshfard
- Cancer Research Center, Department of Anesthesiology, Semnan University of Medical Sciences, Semnan, Iran
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Barbois S, Abba J, Guigard S, Quesada J, Pirvu A, Waroquet P, Reche F, Risse O, Bouzat P, Thony F, Arvieux C. Management of penetrating abdominal and thoraco-abdominal wounds: A retrospective study of 186 patients. J Visc Surg 2016; 153:69-78. [DOI: 10.1016/j.jviscsurg.2016.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Stranch EW, Zarzaur BL, Savage SA. Thinking outside the box: re-evaluating the approach to penetrating cardiac injuries. Eur J Trauma Emerg Surg 2016; 43:617-622. [PMID: 27194248 DOI: 10.1007/s00068-016-0680-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/02/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Penetrating cardiac injuries are infrequent but highly lethal. To address these injuries, cardiopulmonary bypass and cardiothoracic surgery availability are required for Level I trauma center verification. However, acute care surgeons are more readily available for this time-sensitive injury. The purpose of this study was to review an acute care surgery-based experience with penetrating cardiac trauma at an urban Level 1 trauma center. Our hypothesis was that care provided solely by acute care surgeons was both safe and effective for this patient population. METHODS All patients with injuries to the 'cardiac box' following penetrating thoracic trauma were identified from 2005-2010. Demographic and injury related data were obtained. The types and location of cardiac injury, as well as patient outcomes, were determined from operative reports. RESULTS 1701 patients with penetrating chest trauma were admitted during the study period. 260 patients were identified as having high-risk injuries and were included in the review. 37 patients underwent resuscitative thoracotomy, with a survival rate of 8 %. 76 patients (29 %) suffered a cardiac injury. 72 % of these patients had a preoperative FAST exam, which had a sensitivity and specificity of 56.5 and 82.5 % respectively. 82 % underwent a pericardial window, which had a positive predictive value of 81.4 %. 61 % (n = 46) of the patients with a cardiac injury survived, while the overall death rate in this cohort was 21 %. No patients in the cohort required cardiopulmonary bypass for emergent repair of cardiac injury and acute care surgeons performed all cases. CONCLUSION Penetrating injury to the heart is highly lethal and time-sensitive. Increasingly, FAST and subxyphoid pericardial window are relied upon to make the diagnosis in patients arriving in varying stages of shock to the resuscitation room. Acute care surgeons are the most appropriate surgeons to care for these injuries and provide safe and effective care.
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Affiliation(s)
- E W Stranch
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - B L Zarzaur
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - S A Savage
- Indiana University School of Medicine, Indianapolis, IN, USA.
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Bamous M, Abdessamad A, Tadili J, Kettani A, Faroudy M. Evaluation of penetrating cardiac stab wounds. Scand J Trauma Resusc Emerg Med 2016; 24:6. [PMID: 26801618 PMCID: PMC4724072 DOI: 10.1186/s13049-015-0190-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 12/10/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to identify factors associated with unfavourable outcome following stab wounds to the heart in order to improve selection of patients who may benefit from resuscitative effort. METHODS From February to March, variables were collected from medical records of patients sustaining cardiac trauma. The inclusion criterion was the presence of a penetrating cardiac injury confirmed intraoperatively. RESULTS Ninety-eight patients were admitted with penetrating cardiac injury. The mortality rate was 60 %. Fifty-seven patients had unrecordable blood pressure at admission and emergency department thoracotomy was done in twelve patients. The AAST-OIS score was higher in non survivors group (4,21 vs 4,49). Multivariate analysis identified tamponade, associated injuries, right ventricular laceration as the most predictive variables for mortality. DISCUSSION Stab wounds should be separated from gunshots wounds as the former mechanism has different pathophysiological issue. Patients arriving without signs of life may benefit from aggressive resuscitative efforts depending on transport time. CONCLUSION Penetrating cardiac injuries are highly lethal condition. Cardiac tamponade, right ventricle lacerations and associated extra-cardiac injuries are independent risk factors of death.
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Affiliation(s)
- Mehdi Bamous
- Department of Cardiac Surgery, Mohamed V Military Hospital, Mohamed V University, Rabat, Morocco.
| | - Abdou Abdessamad
- Department of Cardiac Surgery, Mohamed V Military Hospital, Mohamed V University, Rabat, Morocco.
| | - Jawad Tadili
- Department of Anesthesiology, Trauma Unit, Ibn Sina Hospital, Mohamed V University, Rabat, Morocco.
| | - Ali Kettani
- Department of Anesthesiology, Trauma Unit, Ibn Sina Hospital, Mohamed V University, Rabat, Morocco.
| | - Mamoun Faroudy
- Department of Anesthesiology, Trauma Unit, Ibn Sina Hospital, Mohamed V University, Rabat, Morocco.
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Sánchez ÁI, García AF, Velsquez M, Puyana JC. Predictors of Positive Subxiphoid Pericardial Window in Stable Patients with Penetrating Injuries to the Precordial Region. PANAMERICAN JOURNAL OF TRAUMA, CRITICAL CARE & EMERGENCY SURGERY 2016; 5:43-51. [PMID: 36196358 PMCID: PMC9529016 DOI: 10.5005/jp-journals-10030-1142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Subxiphoid pericardial window (SPW) remains a valuable diagnostic tool for patients at risk of occult cardiac injuries. However, how to select patients that could benefit from this procedure remains unclear. We aimed to identify clinical predictors of positive SPW in patients with penetrating precordial injuries. MATERIALS AND METHODS Prospective data collection of 183 patients who underwent SPW for the exclusion of penetrating cardiac injuries during 2002 - 2004 at a level I trauma centre in Cali, Colombia. Patient's demographics, clinical characteristics, and injury information were obtained. Independent predictors of positive SPW were assessed using stepwise logistic regressions. RESULTS There were 41 positive SPW (22.4%). Unadjusted analyses demonstrated that stab/knife wounds (OR 2.48, 95% CI 1.17-5.25, p = 0.017), single wound (OR 14.61, 95% CI 1.9-110, p = 0.009), and clinical signs of pericardiac tamponade (OR 8.52, 95% CI 3.92-18.4, p < 0.001) were associated with increased odds of positive SPW. Conversely, systolic blood pressure (0.98, 95% CI 0.96-0.99) and stable physiological index (OR 0.31, 95% CI 0.14-0.65, p = 0.002) were associated with decreased odds. In multivariable analyses, signs of pericardiac tamponade (OR 6.37, 95% CI 2.78-14.6, p < 0.001), and single injuries (OR 12.99, 95% CI 1.6-102.7, p = 0.015) remained as independent predictors of positive SPW. CONCLUSION Emphasis on early recognition of the clinical signs of pericardiac tamponade could be the most important factor for the identification of occult cardiac injuries. Patients with multiple wounds to the precordial region who reached the hospital may not benefit from a SPW. However, high level of awareness is important because the incidence of occult cardiac injuries is not negligible.
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Affiliation(s)
- Álvaro I Sánchez
- Universidad CES – Fundación Valle del Lili, Carrera 98 No. 18-49, Cali, Colombia
| | - Alberto F García
- Department of Surgery, Universidad del Valle, Calle 5 No. 36-08, 4th floor, Cali, Colombia. Research Associate, CISALVA Institute, Universidad del Valle, Calle 4B No. 36-00, Edificio 100, Oficina 114, Cali, Colombia. Trauma and Acute Care Surgeon, Department of Surgery, Fundación Valle del Lili, Carrera 98 No. 18-49, Cali, Colombia
| | - Mauricio Velsquez
- Department of Surgery, Fundación Valle del Lili, Carrera 98 No. 18-49, Cali, Colombia
| | - Juan Carlos Puyana
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Ingraham A, Sperry J. Operative Management of Cardiac Injuries: Diagnosis, Technique, and Postoperative Complications. CURRENT TRAUMA REPORTS 2015. [DOI: 10.1007/s40719-015-0032-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Soto VG, Dandin O, Soto AV. Evaluation of pericardial effusion by contrast echocardiography after gunshot injury. ANZ J Surg 2015; 88:E69-E70. [PMID: 26183937 DOI: 10.1111/ans.13235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Victor G Soto
- Department of Cardiology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Ozgur Dandin
- Division of Trauma Center Miami, Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Ana V Soto
- Zen and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Pericardioscopy for Diagnosing Penetrating Cardiac Trauma. Ann Thorac Surg 2015; 99:e115-6. [DOI: 10.1016/j.athoracsur.2015.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 01/15/2015] [Accepted: 02/06/2015] [Indexed: 11/22/2022]
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The peril of thoracoabdominal firearm trauma: 984 civilian injuries reviewed. J Trauma Acute Care Surg 2014; 77:684-691. [PMID: 25494418 DOI: 10.1097/ta.0000000000000436] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thoracoabdominal firearm injuries present major diagnostic and therapeutic challenges because of the risk for potential injury in multiple anatomic cavities and the attendant dilemma of determining the need for and correct sequencing of cavitary intervention. Injury patterns, management strategies, and outcomes of thoracoabdominal firearm trauma remain undescribed across a large population. METHODS All patients with thoracoabdominal firearm injury admitted to a major Level I trauma center during a 16-year period were reviewed. RESULTS The 984 study patients experienced severe injury burden; 25% (243 of 984) presented in cardiac arrest, and 75% (741 of 984) had an Abbreviated Injury Scale (AIS) score of 3 or greater in both the chest and the abdomen. Operative management occurred in 86% (638 of 741). Of the patients arriving alive, 68% (507 of 741) underwent laparotomy alone, 4% (27 of 741) underwent thoracotomy alone, and 14% (104 of 741) underwent dual-cavitary intervention. Negative laparotomy occurred in 3%. Diaphragmatic injury (DI) occurred in 63%. Seventy-five percent had either DI or hollow viscus injury. Cardiac injury was present in 33 patients arriving alive. Despite the use of trauma bay ultrasound, 44% of the patients with cardiac injury underwent initial laparotomy. In half of this group, ultrasound did not detect pericardial blood. The need for thoracotomy, either alone or as part of dual-cavitary intervention, was the strongest independent risk factor for mortality in those arriving alive. CONCLUSION Greater kinetic destructive potential drives the peril of thoracoabdominal firearm trauma, producing clinical challenges qualitatively and quantitatively different from nonfirearm injuries. Severe injury, on both sides of the diaphragm, generates high operative need with low rates of negative exploration. The need for emergent intervention and a high incidence of DI or hollow viscus injury limit opportunity for nonoperative management. Even with ultrasound, emergent preoperative diagnosis remains challenging, as the complex combination of intra-abdominal, thoracic, and diaphragmatic injuries can provoke misinterpretation of both radiologic and clinical data. Successful emergent management requires thorough assessment of all anatomic spaces, integrating ultrasonographic, radiologic, and clinical findings. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Kong VY, Oosthuizen G, Sartorius B, Bruce J, Clarke DL. Penetrating cardiac injuries and the evolving management algorithm in the current era. J Surg Res 2014; 193:926-32. [PMID: 25438953 DOI: 10.1016/j.jss.2014.09.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 09/04/2014] [Accepted: 09/23/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Penetrating cardiac injuries carry a significant mortality, especially if operative intervention is delayed because of diagnostic difficulties. METHODS AND MATERIALS We reviewed our experience of 134 consecutive cases over a 6 year period. For the initial 5 years, the diagnosis was based on clinical grounds only. During the final year of study, focused ultrasound focused abdominal sonar for trauma (FAST) and subxiphoid pericardial window were introduced. RESULTS Ninety-six per cent (128/134) were males and the overall mean age was 27 y. Eighty-four per cent (112/134) sustained isolated cardiac injury and the remaining sixteen per cent (22/134) had concurrent injuries elsewhere. A total of 10 FAST's were performed and the sensitivity was 20%. Fifteen subxiphoid pericardial window were performed (8 had diagnostic uncertainty, 2 with double jeopardy, and 5 with delayed tamponade) and had a sensitivity of 100%. The survival rate for the 109 patients from the pre-adjunct period was 83% and 88% for the 25 patients in the post-adjunct period, which was not statistically significant (P value = 0.765). There was no significant difference in the complication rate, mean intensive care unit stay, or mean total hospital stay. CONCLUSIONS Penetrating cardiac injuries are highly lethal. A high index of suspicion, coupled with early operative intervention remains the key in securing the survival of these patients.
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Affiliation(s)
- Victor Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu Natal, Pietermaritzburg, South Africa.
| | - George Oosthuizen
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu Natal, Pietermaritzburg, South Africa
| | - Benn Sartorius
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - John Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu Natal, Pietermaritzburg, South Africa
| | - Damian L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu Natal, Pietermaritzburg, South Africa
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