Penetrating cardiac injury and the significance of chest computed tomography findings

A rare complication of a thoracic wound: the pneumopericardium?

Pneumopericardium (PPC) is defined by the presence of gas in the pericardial cavity, often leading to cardiac tamponade and a high mortality rate. This report describes a case involving a 33-year-old man found deceased a few meters from a knife, his clothes intact, with no resuscitation attempt made. A knotted scarf was tightly fastened around his neck, without ligature mark. Post-mortem CT revealed 271 ml of gas in the pericardial cavity, with "flattened heart". The forensic examination revealed two thoracic stab wounds, one penetrated the pericardium without penetrating the heart chamber, while the second remained superficial. In the absence of resuscitation or exsanguination, and in the presence of some non-specific signs observed in the context of asphyxia, the hypothesis of death by compressive PPC was supported. This first French case report of PPC highlights the rarity of this entity in forensic settings, and comparison with other cases described in the literature which did not present the same characteristics points out the diagnostic difficulties it presents and the importance of post-mortem CT in diagnosis.

Computed Tomography Scan of the Chest Is a Reliable Screening Investigation for Structural Cardiac and Pericardial Injury in Patients With Trauma

Background The objective of this study was to assess the efficacy of a computed tomography (CT) scan of the chest in detecting structural cardiac and pericardial injuries. Methods We retrospectively analyzed data from a data registry at a trauma center between January 2015 and June 2022. This study included individuals with severe chest trauma (defined as an Abbreviated Injury Scale score of ≥3 for the chest). The assessment of cardiac injury from chest CT scans relied on the information provided in the official radiological reports. Definitive diagnoses of structural cardiac injury were confirmed on the basis of surgical findings or the diagnosis upon discharge. Results The chest CT scans revealed 11 cases of pericardial abnormalities: 10 (90.9%) cases of pericardial effusion in patients with blunt trauma and one (9.1%) case of pneumopericardium in a patient with a stab wound. Among these 11 cases, surgical exploration identified four structural cardiac and pericardial injuries, and three died during hospitalization. The remaining seven cases underwent nonsurgical intervention, and none exhibited any cardiac and pericardial abnormalities. The chest CT for traumatic structural cardiac and pericardial injuries had a sensitivity of 4/4 (100.0%), a specificity of 402/411 (97.8%), a positive predictive value of 4/11 (36.4%), and a negative predictive value of 404/404 (100.0%). Conclusion This study highlighted a high mortality rate among patients diagnosed with structural cardiac injuries, underscoring the critical importance of accurate and timely diagnostic investigations in such cases. Our findings confirmed that chest CT is a reliable screening tool for detecting structural cardiac injuries in patients with both blunt and penetrating chest trauma. However, given the relatively low positive predictive value of chest CT for structural cardiac injuries, additional diagnostic imaging or prompt surgical intervention may be necessary in cases where pericardial abnormalities are identified on chest CT to address potential occult cardiac injuries.

ACR Appropriateness Criteria® Penetrating Torso Trauma

This document assesses the appropriateness of various imaging studies for acute penetrating trauma to the torso. Penetrating trauma most commonly occurs from gunshots and stabbings, although any object can impale the patient. Anatomic location, type of penetrating trauma, and hemodynamic status are among the many important factors when deciding upon if, what, and when imaging is needed to further evaluate the patient. Imaging plays a critical role in the management of these patients. CT, in particular, aids in identifying and predicting internal injuries based upon trajectory of the object. Clinical variants are distinguished by ballistic versus nonballistic injuries, hemodynamic status, and compartment of the body injured. Ballistic trauma trajectory is less predictable, and imaging recommendations are adjusted for this unpredictability. Excluded from this document are penetrating traumatic injuries to pediatric patients and specific recommendations when the genitourinary system is clinically suspected to be injured, the latter of which is more specifically discussed in other Appropriateness Criteria documents. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are documented annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer documented journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer documented literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Blunt and Penetrating Cardiac Trauma

Patients with traumatic cardiac injuries can present with wide variability in their severity of illness. The most severe will present in cardiac arrest, whereas the most benign may be altogether asymptomatic; most will fall somewhere in between. Management of cardiac injuries largely depends on mechanism of injury and patient physiology. Understanding the spectrum of injuries and their associated manifestations can help providers react more quickly and initiate potentially life-saving therapies more efficiently when time is critical. This article discusses the workup and management of both blunt and penetrating cardiac injuries.

Thinking outside the box: re-evaluating the approach to penetrating cardiac injuries

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.

[Possibilities of videothoracoscopy for penetrating thoracic injuries]

It was analyzed the medical reports of 596 victims with thoracic injuries including 360 cases with following conventional therapeutic approach and 236 patients who underwent videothoracoscopy. We estimated condition severity in case of injuries of thoracic wall, lungs, pericardium and heart. Hemodynamic disorders were estimated according to Allgower-Burri shock index. Intrapleural bleeding was calculated using volume of hemothorax and time before injury and operation. Severity of physiological damages was determined using RTS criterion, anatomic--using ISS criterion. We estimated possibility for videothoracoscopy in patients with conventional therapeutic approach comparing severity of injuries, severity of condition in both groups and volume of surgery. Retrospective analysis revealed possibility of videothoracoscopy in 86.7% of victims with pulmonary injury, in 83.3% with bleeding at the muscular vessels of thoracic wall, in 40.3% with intercostal vessels injury, in 31.2% with heart injury, in 27.3% with damage of pericardium and in 18.8% with internal thoracic vessels injury. Our investigation revealed that videothoracoscopy may be used more widely in case of thoracic injury.

Penetrating Thoracic Injury

This article discusses the role of radiology in evaluating patients with penetrating injuries to the chest. Penetrating injuries to the chest encompass ballistic and nonballistic injuries and can involve superficial soft tissues of the chest wall, lungs and pleura, diaphragm, and mediastinum. The mechanism of injury in ballistic and nonballistic trauma and the impact the injury trajectory has on imaging evaluation of penetrating injuries to the chest are discussed. The article presents the broad spectrum of imaging findings a radiologist encounters with penetrating injuries to the chest, with emphasis on injuries to the lungs and pleura, diaphragm, and mediastinum.

A concealed atriopleural fistula resulting from a cardiac stab wound

A young male presented with a right parasternal stab wound. The chest radiography was normal and transthoracic echocardiography ruled out pericardial tamponade. He remained hemodynamically stable until three hours later when signs of progressive anemia were observed. Chest computed tomography showed massive right-sided hemothorax. The patient underwent surgery, which revealed an active bleeding atriopleural fistula connecting the right atrium and draining into the right pleura resulting from the negative pressure generated during respiration. This mechanism prevented cardiac tamponade and maintained initial hemodynamically stability.