Penetrating wounds to the heart: a wartime experience

Penetrating Heart Injury Repaired with Peripheral Cannulation: Case Report

Heart injuries usually occur due to penetrating or blunt traumas. High mortality rates are seen in heart injuries, owing to firearms and cutting/piercing tools. Factors such as the degree of injury, its localization, and the length of time to reach the hospital influence mortality rates. Despite the increase in imaging facilities and improvements in hospital transportation in today's conditions, high mortality rates are still observed, owing to causes such as sudden blood loss, cardiac arrest, or cardiac tamponade. The present study aimed to present the successful treatment of a 46-year-old male patient with injuries to the left atrium and posterior wall of the left ventricle due to a gunshot wound using the approach of median sternotomy and peripheral cannulation.

Emergency Resuscitative Thoracotomy in the Combat or Operational Environment

Resuscitative thoracotomy has been extensively described in the civilian trauma literature and has a high mortality rate, due largely to the nature of the injuries leading to arrest. The survival rates are generally highest (10-30%) for penetrating truncal injuries and patients who arrive with vital signs and proceed to arrest or who have impending arrest. They are significantly lower (less than 5%) for blunt trauma victims, particularly those who arrest in the field or during transport (1% or less). In addition, the likelihood of survival with intact neurologic function is significantly lower than the overall survival rates, particularly for blunt trauma victims and for prehospital arrest.

A Retained Bullet in Pericardial Sac: Penetrating Gunshot Injury of the Heart

Penetrating cardiac trauma is rarely seen but when present there is a short time lag to keep the patients alive. Cardiac gunshot injuries are exceptional and it occurs mostly during interpersonal disagreements casualties or a mistakenly fired gun nowadays. Here we present a case of cardiac gunshot injury from the war of Kobani, Syria. The patient was mistakenly diagnosed to have a sole bullet in the left shoulder while he had a penetrating cardiac trauma with a bullet in the heart and pericardial effusion possibly giving rise to pericardial tamponade. Luckily the cardiac gunshot injury was noticed one day later and the patient was referred to a tertiary hospital. Intrapericardial bullet was conservatively followed up. The patient was discharged one week later after resection of the bullet in the shoulder.

Longterm outcomes after combat casualty emergency department thoracotomy

BACKGROUND

The incidence, survival, and blood product use after emergency department thoracotomy (EDT) in combat casualties is unknown.

STUDY DESIGN

We performed a prospective and retrospective observational study of EDT at a combat support hospital in Iraq, evaluating the impact of injury mechanisms, blood product use, mortality, and longterm neurologic outcomes of survivors.

RESULTS

From November 2003 to December 2007, 12,536 trauma admissions resulted in 101 EDTs (0.01%). In patients undergoing EDT, penetrating trauma from explosions and firearms accounted for the majority of injuries (93%). There were no survivors after EDT for blunt trauma (n=7). The areas of primary penetrating injury were the abdomen (30%), thorax (40%), and extremities (22%). Twelve percent (12 of 101) of all patients survived until evacuation, with the overall survival rate (8 to 26 months) of US casualties at 11% (6 of 53). There was no difference in survival seen in either injury mechanism or primary injury location. Signs of life were present in all overall survivors. Cardiopulmonary resuscitation (CPR) was performed in 92% (93 of 101) of all patients, and in 75% (9 of 12) of those evacuated. Mean (+/-SD) transfusion requirements for all patients were 15.0+/-12.7 U of RBC and 7.3+/-8.7 U of fresh frozen plasma during the initial resuscitation. Survivors demonstrated higher fresh frozen plasma:RBC ratios. All survivors were neurologically intact.

CONCLUSIONS

In the combat casualty with penetrating injury, arriving with signs of life, receiving CPR, and undergoing EDT, longterm survival with normal neurologic outcomes is possible. CPR is not a contraindication to performance of EDT in penetrating injuries if signs of life are present. A large amount of blood products are used in the resuscitation of EDT patients.

Penetrating cardiac wounds: principles for surgical management

Stab wounds are the main type of penetrating cardiac injury in China and they have a fairly good prognosis when the patient receives expeditious and appropriate management. The objective of this study is to present the experience of managing the patients with penetrating cardiac injuries. A retrospective study involving 82 cases with penetrating wounds of the heart in the past 16 years was carried out. Stab wounds accounted for 86.58% of this series (71 of 82 patients). All 82 cases were treated operatively. The amount of preoperative infusion as fluid resuscitation for shock was less than 1,000 ml in 65.85% of the present study. Only in three patients was preoperative pericardiocentesis performed, yielding a false-negative result in one. Six patients sustaining cardiac arrest soon after arrival were subjected to emergency room thoracotomy (ERT), and five of them survived. The overall survival rate was 96.34%. One patient died of exsanguination due to injury of multiple chambers; of the remaining 2 deaths after operation 1 was associated with abdominal injuries and the other with failure of cerebral resuscitation. From the experience reported in this study, early establishment of diagnosis and prompt thoracotomy against time are the fundamental factors affecting the outcome of penetrating cardiac injuries. Preoperative massive transfusion and pericardiocentesis are not advocated.

Intracardiac shrapnel in a polytraumatized child

Penetrating cardiac trauma is a life-threatening condition and presents a therapeutic challenge for the surgeon. Additional multiple organ-system injuries, as are common in the setting of war, further complicate the management of such patients. We present the case of a 9-year-old girl who sustained multiple injuries from an unexploded artillery shell, resulting in a retained intracardiac shrapnel. Her cardiac pathology consisted of a shrapnel located in the interventricular septum accompanied by a pneumopericardium and a right-sided hemopneumothorax. The presentation and management of this patient are the subjects of this report.

Survival after emergency department thoracotomy: review of published data from the past 25 years

BACKGROUND

Emergency department thoracotomy (EDT) has become standard therapy for patients who acutely arrest after injury. Patient selection is vitally important to achieve optimal outcomes without wasting valuable resources. The aim of this study was to determine the main factors that most influence survival after EDT.

STUDY DESIGN

Twenty-four studies that included 4,620 cases from institutions that reported EDT for both blunt and penetrating trauma during the past 25 years were reviewed. The primary outcomes analyzed were in-hospital survival rates.

RESULTS

EDT had an overall survival rate of 7.4%. Normal neurologic outcomes were noted in 92.4% of surviving patients. Factors reported as influencing outcomes were the mechanism of injury (MOI), location of major injury (LOMI), and signs of life (SOL). Survival rates for MOI were 8.8% for penetrating injuries and 1.4% for blunt injuries. When penetrating injuries were further separated, the survival rates were 16.8% for stab wounds and 4.3% for gunshot wounds. For the LOMI, survival rates were 10.7% for thoracic injuries, 4.5% for abdominal injuries, and 0.7% for multiple injuries. If the LOMI was the heart, the survival rate was the highest at 19.4%. The third factor influencing outcomes was SOL. If SOL were present on arrival at the hospital, survival rate was 11.5% in contrast to 2.6% if none were present. SOL present during transport resulted in a survival rate of 8.9%. Absence of SOL in the field yielded a survival rate of 1.2%. There was no clear single independent preoperative factor that could uniformly predict death.

CONCLUSIONS

The best survival results are seen in patients who undergo EDT for thoracic stab injuries and who arrive with SOL in the emergency department. All three factors-MOI, LOMI, and SOL-should be taken into account when deciding whether to perform EDT. Uniform reporting guidelines are needed to further elucidate the role of EDT taking into account the combination of MOI, LOMI, and SOL.

Cardiac murmur associated with an abnormal chest x-ray film

Investigation of a cardiac murmur and thrill in an asymptomatic 35-year-old man revealed a foreign body lying within the left ventricular cavity. Upon questioning, the man revealed that he had been shot in the chest years earlier. This is the first reported adult case of a retained intracardiac bullet causing a ventricular septal defect.

Penetrating cardiac injuries: a population-based study

BACKGROUND

Wide variances exist in reports of survival rates after penetrating cardiac injuries because most are hospital-based reports and thus are affected by the local trauma system. The objective of this study was to report population-based, as well as hospital-based, survival rates after penetrating cardiac injury.

METHODS

Retrospective cohort analysis was performed during a 7-year period of 20,181 consecutive trauma admissions to a regional Level I trauma center and 6,492 medical examiner's reports. A meta-analysis was performed comparing survival rates with available population-based reports.

RESULTS

There were 212 penetrating cardiac injuries identified, for an incidence of approximately 1 per 100,000 man years and 1 per 210 admissions. The overall survival rate was 19.3% (41 of 212) for the population studied, with survival rates of 9.7% (12 of 123) for gunshot wounds and 32.6% (29 of 89) for stab wounds. Ninety-six of the 212 patients were transported to the trauma center for treatment, resulting in an overall hospital survival rate of 42.7% (41 of 96), with a hospital survival rate of 29.3% (12 of 41) for gunshot wounds and 52.7% (29 of 55) for stab wounds.

CONCLUSION

Review of population-based studies indicates that there has been only a minor improvement in the survival rates for the treatment of penetrating cardiac injuries.

Penetrating cardiothoracic war wounds

OBJECTIVE

Penetrating cardiothoracic war wounds are very common among war casualties. Those injuries require prompt and specific treatment in an aim to decrease mortality and late morbidity. There are a few controversies about the best modality of treatment for such injuries, and there are not many large series of such patients in recent literature.

METHODS

We analysed a group of 259 patients with penetrating cardiothoracic war wounds admitted to our institutions between May 1991 and October 1992.

RESULTS

There were 235 (90.7%) patients with thoracic wounds, 14 (5.4%) patients with cardiac, wounds and in 10 (3.7%) patients both heart and lungs were injured. The cause of injury was shrapnel in 174 patients (67%), bullets in 25 patients (9.7%), cluster bomb particles in 45 patients (17.3%) and other (blast etc.) in 15 patients (6%). Patients, 69, had concomitant injuries of various organs. The initial treatment in 164 operated patients was chest drainage in 76 (46.3%) patients, thoracotomy and suture of the lung in 71 (43.2%) patients, lobectomy in 12 (7.3%) patients and pneumonectomy in 5 (3%) patients. Complications include pleural empyema and/or lung abscess in 20 patients (8.4%), incomplete reexpansion of the lung in 10 patients (4.2%), osteomyelitis of the rib in 5 patients (2.1%) and bronchopleural fistula in 1 patient (0.4%). Secondary procedures were decortication in 12 patients, rib resection in 5 patients, lobectomy in 2 patients, pneumonectomy in 4 patients, reconstruction of the chest wall in 2 patients and closure of the bronchopleural fistula in 1 patient. The cardiac chamber involved was right ventricle in 12 patients, left ventricular in 6 patients, right atrium in 7 patients, left atrium in 3 patients, ascending aorta in 2 patients and 1 patient which involved descending aorta, right ventricle and coronary artery (left anterior descending) and inferior vena cava, respectively. The primary procedure was suture in 17 patients (in 10 patients with the additional suture of the lung), suture + extraction of the foreign body in 4 patients, 2 of them with cardiopulmonary bypass. Complications were pericardial effusion in 6 patients, arrhythmia in 2 patients, myocardial infraction in 1 patient and migration of the foreign body in 1 patient. Patients, 7, died, five of the group with concomitant injuries, two of thoracic and one of cardiac injuries (5, 1.2 and 4.2%, respectively).

CONCLUSIONS

Penetrating cardiothoracic wounds are among the most serious injuries in war, either in combat or among civilians. In spite of their nature, they can be treated successfully with relatively low mortality and morbidity.

Emergency department echocardiography improves outcome in penetrating cardiac injury

STUDY OBJECTIVES

To determine the effect of immediate two-dimensional echocardiography on the time to diagnosis, survival rate, and neurologic outcome of patients with penetrating cardiac injury.

DESIGN

A ten-year retrospective review.

SETTING

Regional trauma center serving a population base of 1.25 million with 85,000 visits yearly.

TYPE OF PARTICIPANTS

All patients presenting to the emergency department with penetrating cardiac injury.

MEASUREMENTS AND MAIN RESULTS

The records of 49 patients with penetrating cardiac injury were reviewed. Of these, 28 received immediate two-dimensional echocardiography in the ED (echo group) and 21 did not (nonecho group). The probability of survival was derived using TRISS methodology. Differences between groups were determined using either the two sample t-test for parametric data or the Mann-Whitney test for nonparametric data. The overall probability of survival was 33.2%, and the actual survival rate was 81.6%. The probability of survival was 34.2% and 31.8% for the echo group and nonecho group, respectively. The actual survival was 100% in the echo group and 57.1% in the nonecho group. The average time to diagnosis and disposition for surgical intervention was 15.5 +/- 11.4 minutes for the echo group and 42.4 +/- 21.7 minutes for the nonecho group (P less than .001). The Glasgow Outcome Score was 5.0 for the echo group and 4.2 for the nonecho group (P = .007).

CONCLUSION

Since the introduction of immediate ED two-dimensional echocardiography, the time to diagnosis of penetrating cardiac injury has decreased and both the survival rate and neurologic outcome of survivors has improved.

Emergency arteriography in the assessment of penetrating trauma to the lower limbs

One hundred emergency arteriographies (EA) were performed in 87 patients with lower limb trauma due to high-velocity missiles. Thirteen patients had bilateral injuries. In 79 cases, EA findings were positive and led to emergency surgery. In 76 cases an arterial injury was found and treated, a positive predictive value of 96% (76/79). In the other 3 cases, no arterial lesion was found (3 false positives). Among the 21 patients with normal findings from angiography, 10 had surgical exploration because of high clinical suspicion of vascular injury. Arterial injury was found in 2 cases (2 false negatives). In 8 patients, arteriography modified the surgical procedure. In the 11 remaining patients, clinical and echo Doppler follow-up results were normal, a negative predictive value of 90% (19/21). Sensitivity was 97%, specificity 86%, and accuracy 95%. These data show that arteriography in stable patients is a safe and accurate procedure. It permits avoidance of unnecessary surgical exploration in selected patients and helps modify the surgical procedure.