Penetrating cardiac trauma: management strategy based on 129 surgical emergencies over 2 years

Delayed presentation of penetrating cardiac injury successfully managed in resource limited setting: A case report

INTRODUCTION AND IMPORTANCE

Penetrating cardiac injury is rare and historically known to have very poor prognosis. Even today, 90 % of patients die before arriving to hospital. Even though patient presentations can be atypical, organized timely intervention can lead to survival.

CASE REPORT

A 21 years old arrived 5 h after stab injury to right anterior chest. He was hypotensive with a sucking wound bleeding on his right chest as well as hemothorax on the same side. Chest tube and pericardial window were both done with blood in pericardial space. Median sternotomy was done and revealed right atrial perforation. The perforation was repaired and the patient was discharged and continues to do well on follow up.

CLINICAL DISCUSSION

For most patients, time from injury to surgery is short. Focused and organized surveys as well as resuscitation are valuable for any patent with penetrating thoracic trauma. With a patient in hemorrhagic shock and a penetrating wound near the heart, a pericardial window is required regardless of the absence of pericardial fluid on ultrasound and in this case proved to be lifesaving. If there is a hole in the pericardium communicating with the pleural space the pericardial blood may decompress into the pleural cavity and not be visible on ultrasound.

CONCLUSION

Regardless of its rare prevalence, high index of suspicion for cardiac injury is extremely important in all patients with penetrating chest trauma in the cardiac box regardless of atypical presentations. With rapid diagnosis, capable surgeon availability, and availability of blood products, patients can survive this injury.

Predicting mortality in penetrating cardiac trauma in developing countries through a new classification: Validation of the Bogotá classification

Introduction

Penetrating chest trauma (PCT) represents 10% of worldwide mortality, with developing countries counting as some of the most affected by high mortality rates due to cardiac trauma. Colombia is considered one of the most violent countries due to the high mortality rate associated with war and crime, hence the validation of an own classification for penetrating cardiac injuries (PCI) is mandatory.

Methods

Retrospective cross-sectional study which included adult patients with PCIs at a level 4 trauma center in Colombia, between January 2018 and April 2020. We used our own system (Bogotá Classification) and compared it with traditional systems (e.g., Ivatury's, OIS-AAST), by analyzing the mechanism of injury (MOI), the hemodynamic status of the patient at admission, the inpatient management, the individual outcomes, and some demographic variables. Bivariate statistical analysis, spearman correlation, and logistic regression were performed.

Results

Four hundred and ninety-nine patients were included. Bivariate analysis demonstrated a significant relationship between mortality and hemodynamic state, MOI, its location and degree of lesion, cardiac/vessel injury, cardiac tamponade, time between injury and medical care, fluid reanimation, as well as the Ivatury's classification and the new classification (p < 0.005). The adequate correlation between Ivatury's and Bogotá classification supports the latter's clinical utility for patients presenting with PCI. Likewise, logistic regression showed a statistically significant association among mortality rates (p < 0.005).

Conclusions

The Bogotá classification showed similar performance to the Ivatury's classification, correlating most strongly with mortality. This scale could be replicated in countries with similar social and economic contexts.

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

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.

Anesthetic management of stab wound in right ventricle of heart

Stab wound in right ventricle of heart requires a prompt and focused surgical intervention. Cardiac tamponade is a common finding when dealing with stabbed hearts, which must be diagnosed and treated in a timely fashion. We report a case of 28-year-old man who presented in emergency department following accidental stab trauma during a religious ceremony. The challenges faced in the perioperative period were the management of impending cardiac tamponade and hemodynamic stability.

Case: Unusual Migration of Osteosynthetic Material

The authors present a rare and unusual case of complication, migration of osteosynthetic material for stabilization, titanium rod, which was used for stabilization of comminutive fracture of the first lumbar vertebra. This rod migrated from the retroperitoneal space to the pleural cavity. The removal of this rod was carried out by videothoracoscopy.

Thoracic Trauma: Injuries, Evaluation, and Treatment

Thoracic injury is common in high-energy and low-energy trauma, and is associated with significant morbidity and mortality. Evaluation requires a systematic approach prioritizing airway, respiration, and circulation. Chest injuries have the potential to progress rapidly and require prompt procedural intervention. For the diagnosis of nonemergent injuries, a careful secondary survey is essential. Although medicine and trauma management have evolved throughout the decades, the basics of thoracic trauma care have remained the same.

Penetrating cardiac injuries: predictive model for outcomes based on 2016 patients from the National Trauma Data Bank

BACKGROUND

Penetrating cardiac injuries are uncommon and lethal. The objectives of this study are to examine the national profile of cardiac injuries, identify independent predictors of outcome, generate, compare and validate previous predictive models for outcomes. We hypothesized that National Trauma Data Bank (NTDB) given its large number of patients, would validate these models.

METHODS

The NTDB was queried for data on cardiac injuries, using survival as the main outcome measure. Statistical analysis was performed utilizing univariate and stepwise logistic regression. The stepwise logistic regression model was then compared with other predictive models of outcome.

RESULTS

There were 2016 patients with penetrating cardiac injuries identified from 1,310,720 patients. Incidence: 0.16%. Mechanism of injury: GSWs-1264 (63%), SWs-716 (36%), Shotgun/impalement-19/16 (1%). Mean RTS 1.75, mean ISS 27 ± 23. Overall survival 675 (33%). 830 patients (41%) underwent ED thoracotomy, 47 survived (6%). Survival stratified by mechanism: GSWs 114/1264 (10%), SWs 564/717 (76%). Predictors of outcome for mortality-univariate analysis: vital signs, RTS, ISS, GCS: Field CPR, ED intubation, ED thoracotomy and aortic cross-clamping (p < 0.001). Stepwise logistic regression identified cardiac GSW's (p < 0.001; AOR 26.85; 95% CI 17.21-41.89), field CPR (p = 0.003; AOR 3.65; 95% CI 1.53-8.69), the absence of spontaneous ventilation (p = 0.008; AOR 1.08, 95% CI 1.02-1.14), the presence of an associated abdominal GSW (p = 0.009; AOR 2.58, 95% CI 1.26-5.26) need for ED airway (p = 0.0003 AOR 1386.30; 95% CI 126.0-15251.71) and aortic cross-clamping (p = 0.0003 AOR 0.18; 95% CI 0.11-0.28) as independent predictors for mortality. Overall predictive power of model-93%.

CONCLUSION

Predictors of outcome were identified. Overall survival rates are lower than prospective studies report. Predictive model from NTDB generated larger number of strong independent predictors of outcomes, correlated and validated previous predictive models.

Penetrating nail-gun injury of the heart managed by adenosine-induced asystole in the absence of a heart-lung machine

During his work, an 18-year-old carpenter-in-training overbalanced and shot himself in the left median thorax with a nail gun. The patient was delivered to our thoracic surgery unit with a tentative diagnosis of penetrating lung trauma. An emergent computed tomogram showed a heart-penetrating nail injury. The patient was taken to the operating room, where he underwent emergency surgery that included sternotomy, pericardiotomy, extraction of the nail, and trauma treatment of the heart injury. The surgery was performed in a unit without a heart-lung machine. For that reason, asystole was chemically induced by the intravenous administration of adenosine. The surgery was successful, and the patient was discharged from the hospital on the 10th postoperative day. In cases of penetrating injuries of the heart, especially those with a foreign body retained in situ, we believe that the intravenous administration of adenosine is an elegant solution for the rapid provocation of asystole. In contrast to other methods, adenosine-induced asystole enables relatively safe myocardial manipulation in the absence of a cardiac surgical unit and a heart-lung machine.

Sternotomy or drainage for a hemopericardium after penetrating trauma: a randomized controlled trial

OBJECTIVE

To determine if stable patients with a hemopericardium detected after penetrating chest trauma can be safely managed with pericardial drainage alone.

BACKGROUND

The current international practice is to perform a sternotomy and cardiac repair if a hemopericardium is detected after penetrating chest trauma. The experience in Cape Town, South Africa, on performing a mandatory sternotomy in hemodynamically stable patients was that a sternotomy was unnecessary and the cardiac injury, if present, had sealed.

METHODS

A single-center parallel-group randomized controlled study was completed. All hemodynamically stable patients with a hemopericardium confirmed at subxiphoid pericardial window (SPW), and no active bleeding, were randomized. The primary outcome measure was survival to discharge from hospital. Secondary outcomes were complications and postoperative hospital stay.

RESULTS

Fifty-five patients were randomized to sternotomy and 56 to pericardial drainage and wash-out only. Fifty-one of the 55 patients (93%) randomized to sternotomy had either no cardiac injury or a tangential injury. There were only 4 patients with penetrating wounds to the endocardium and all had sealed. There was 1 death postoperatively among the 111 patients (0.9%) and this was in the sternotomy group. The mean intensive care unit (ICU) stay for a sternotomy was 2.04 days (range, 0-25 days) compared with 0.25 days (range, 0-2) for the drainage (P < 0.001). The estimated mean difference highlighted a stay of 1.8 days shorter in the ICU for the drainage group (95% CI: 0.8-2.7). Total hospital stay was significantly shorter in the SPW group (P < 0.001; 95% CI: 1.4-3.3).

CONCLUSIONS

SPW and drainage is effective and safe in the stable patient with a hemopericardium after penetrating chest trauma, with no increase in mortality and a shorter ICU and hospital stay. (ClinicalTrials.gov Identifier: NCT00823160).

Cardiac trauma during teenage years

The spectrum of blunt cardiac trauma ranges from asymptomatic myocardial contusion to fatal cardiac arrhythmias and/or cardiac rupture. Although cardiac rupture is common in fatal traffic accidents, these patients rarely reach hospital care. Insignificant blunt cardiac injury during sports may cause fatal arrhythmia in teens. Penetrating cardiac trauma is fairly common in the United States, encountered frequently in major urban centers. Most cases are dead at the scene and never reach hospital. The incidence of cardiac sequelae in survivors is high, and these patients should be evaluated with early and late echocardiography to detect anatomic or functional cardiac involvement.

Transcatheter closure of a traumatic ventricular septal defect using an Amplatzer™ atrial septal occluder device

A relatively rare occurrence, the incidence of ventricular septal defect (VSD) complicating penetrating cardiac trauma has been reported at 4.5%. Closing such defects may be challenging especially in an unstable patient where cardiopulmonary bypass may exponentially increase the surgical risk. In such patients, catheter-based device closure is a reliable and effective alternative. We describe case of a 30 year old man who presented with a stab wound to his anterior mediastinum. His injuries involved laceration to right and left ventricles and a VSD. His lacerations were repaired on a beating heart and the VSD was not addressed due to patient hemodynamic instability. The VSD was semi-electively closed using a 24 mm Amplatzer™ device as the patient demonstrated significant left to right shunt. Post-device closure, the patient developed hemolysis attributed to an intra- device residual leak. The hemolysis resolved without any complications by conservative medical management. At latest follow-up the patient is in NYHA functional class I-II.

Traumatic ventricular septal defect

Traumatic ventricular septal defect (VSD) is an uncommon occurrence in cases of penetrating cardiac injury with an incidence of only 1% to 5%. The mainstay of diagnosis of VSDs is the transthoracic echocardiogram. We report a case of an occult traumatic VSD, which was not seen on echocardiography, but was later found on a high-resolution computed tomographic scan of the chest.

Penetrating cardiac injury: overcoming the limits set by Nature

Repair of cardiac wounds was considered impossible little over 100 years ago. Despite progress, penetrating cardiac injury remains a highly lethal form of trauma today. Cardiac tamponade and exsanguination are the greatest immediate and life-threatening risks. Clinical presentation is extremely variable and diagnosis may be highly deceptive. Unlike other forms of trauma, resuscitation is of limited value and urgent operative intervention is the only meaningful treatment. Refinements in cardiothoracic surgery and the simultaneous evolution of trauma care systems have both contributed to saving lives. However, mortality rates for this condition have changed little in the last century, due largely to the rising proportion of more lethal injuries caused by gunshot wounds.

Selective Use of Cardiopulmonary Bypass in Trauma Patients

The need for cardiopulmonary bypass (CPB) in the treatment of trauma patients is controversial, and not all level I trauma centers have CPB readily available. Our purpose was to review the selective use of CPB in the management of trauma victims at a level I trauma center in Los Angeles County. We reviewed the records of all patients for whom the CPB team was called in from 1994 to 2002. Perfusionists were present for the initial operative management of 24 patients, 22 (92%) of which were male. Twelve patients had penetrating and nine had blunt injuries, two were severely hypothermic, and the last suffered embolization of a bullet to the pulmonary artery. Overall survival was 75 per cent. Sixteen (67%) patients required CPB due to the life-threatening nature of their injuries and/or hemodynamic instability; 11 (69%) survived. The remaining 8 patients were operated on with the CPB team present but on standby; 7 (88%) survived. Cardiopulmonary bypass could be life-saving in select trauma patients with major chest injuries. Hypothermia, acidemia, and shock can be reversed earlier while allowing increased time to gain adequate exposure and perform quality repairs. Level I trauma centers should have CPB capabilities immediately available.

Penetrating knife injury to the heart

A 39-year-old man attempted to kill himself using a small knife to penetrate the left anterior chest wall because of trouble at work and with his girlfriend. On arrival at the emergency room, his consciousness was not clear and vital signs were unstable. The knife remained vertically located in the left anterior chest wall. A large left hemothorax was identified by chest X-ray, and moderate cardiac tamponade was detected by echocardiography. Left-sided chest drainage was performed by inserting a chest drainage tube, and about 2500 ml of hemorrhagic effusion was drained. An emergency operation was performed to relieve the cardiac tamponade and repair the penetrating cardiac injury. About an hour after arrival at the emergency room, a median sternotomy was performed in the operating room. The knife had injured the surface of the right ventricular outflow tract, the left lung, and the 3rd intercostal artery and vein. Cardiopulmonary bypass was immediately prepared for the repair of the cardiac injury. The wounds were successfully repaired with pledgeted sutures under cardiac beating. The postoperative course was uneventful with no sign of infection. The patient was discharged at 9 days after the operation. Here we have reported a case of successful surgical repair of a penetrating knife injury to the heart, which was managed by immediate resuscitation and emergency surgery.

Current evaluation of cardiac stab wounds

BACKGROUND

Patients with penetrating cardiac injuries may be stable or only mildly shocked, especially if the laceration has sealed off and the patient has been aggressively resuscitated. Clinical signs, chest roentgenograms, pericardiocentesis, and subxiphoid window are not always helpful in establishing the diagnosis. We reflect on the current evaluation based on 128 patients.

METHODS

There were four groups of patients, ranging from lifeless (group I) to stable (group IV). Patients in groups I and II were prepared immediately for operation. Those in groups III and IV were often investigated further (chest roentgenogram and cardiac ultrasound).

RESULTS

Mortality was 8%. Significant findings were a precordial stab, central venous pressure of more than 15 cm of water, one or more clinical signs of tamponade, and initial shock. Cardiac ultrasound was performed in 5 patients in group II (15%), 14 patients in group III (48%), and 37 patients in group IV (86%). There were no false positives, and 6 false negatives (11%). Thirty-one patients (24%) had clotted lacerations. There were no negative sternotomies.

CONCLUSIONS

Efficient fluid resuscitation and rapid confirmation of diagnosis with cardiac ultrasound should decrease mortality. Stable patients with a precordial wound should undergo cardiac ultrasound or echocardiogram. Diagnosis may be reliably confirmed in these patients whose clinical signs often fluctuate (or rapidly deteriorate).

The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study

BACKGROUND

Ultrasound is quickly becoming part of the trauma surgeon's practice, but its role in the patient with a penetrating truncal injury is not well defined. The purpose of this study was to evaluate the accuracy of emergency ultrasound as it was introduced into five Level I trauma centers for the diagnosis of acute hemopericardium.

METHODS

Surgeons or cardiologists (four centers) and technicians (one center) performed pericardial ultrasound examinations on patients with penetrating truncal wounds. By protocol, patients with positive examinations underwent immediate operation. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded.

RESULTS

Pericardial ultrasound examinations were performed in 261 patients. There were 225 (86.2%) true-negative, 29 (11.1%) true-positive, 0 false-negative, and 7 (2.7%) false-positive examinations, resulting in sensitivity of 100%, specificity of 96.9%, and accuracy of 97.3%. The mean time from ultrasound to operation was 12.1+/-5 minutes.

CONCLUSION

Ultrasound should be the initial modality for the evaluation of patients with penetrating precordial wounds because it is accurate and rapid.

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.

Survival following cardiac tamponade and arrest in a paediatric patient with penetrating trauma to pulmonary artery

A seven-year-old child with an airgun pellet injury to the upper part of the anterior chest wall was transported in a state of shock from a nearby hospital to this trauma centre. The nature and site of injury associated with engorged neck veins, hypotension, pulsus paradoxus and an enlarged liver suggested the possibility of acute pericardial tamponade. On arrival in the emergency room the child had a brief period of cardiac arrest revived by basic resuscitation procedures. Pericardiocentesis was negative in the emergency room. Emergency median sternotomy with pericardiotomy was done to relieve the tamponade which was peroperatively diagnosed to be due to a tear in the pulmonary artery close to its origin. Early clinical diagnosis, rapid surgical intervention in the operating room and efficient anaesthetic management within the 'Golden Hour' saved life. It is believed that this is the first report of survival of a paediatric patient with a gunshot penetrating trauma to the pulmonary artery leading to cardiac tamponade and a brief period of cardiac arrest.

One hundred five penetrating cardiac injuries: a 2-year prospective evaluation

OBJECTIVES

To analyze the parameters measured in the field, during transport, and upon arrival of the physiologic condition of patients sustaining penetrating cardiac injuries, along with the Cardiovascular Respiratory Score (CVRS) component of the Trauma Score, the mechanism and anatomical site of injury, operative characteristics, and cardiac rhythm as predictors of outcome. We also set out to identify a set of patient characteristics that best predict mortality outcome and to correlate cardiac injury grade as determined by the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) with mortality.

METHODS

This report was a prospective study at American College of Surgeons Level I urban trauma center. Interventions included thoracotomy, sternotomy, or both, for resuscitation and definitive repair of cardiac injury. The main outcome measures used were those parameters measuring physiologic condition of patients, CVRS, mechanism and anatomical site of injury, mortality, and grade of injury.

RESULTS

A total of 105 patients sustained penetrating cardiac injuries: 68 injuries (65%) were gunshot wounds and 37 injuries (35%) were stab wounds. The mean Injury Severity Score was 36. Of the 105 wounds, 23 wounds (22%) involved multiple-chamber injuries. The overall survival was 35 of 105 patients (33%): survival of gunshot wound victims was 11 of 68 patients (16%); survival of stab wound victims was 24 of 37 patients (65%). Emergency department thoracotomy was performed in 71 of the 105 patients (68%) with 10 survivors (14%). CVRS: 94% mortality (50 of 53) when CVRS = 0, 89% mortality (57 of 64) when CVRS = 0 to 3, and 31% mortality (12 of 39) when CVRS 4 to 11 (p < 0.001). The presence of sinus rhythm when pericardium was opened predicted survival (p < 0.001). Anatomical site of injury (injured chamber) and the presence of tamponade did not predict survival. Stepwise logistic regression analysis identified gunshot wound, exsanguination, and restoration of blood pressure as most predictive variables of mortality. AAST-OIS injury grade and mortality: grade I, 0 of 1 (0%); grade II, 1 of 2 (50%); grade III, 2 of 3 (66%); grade IV, 28 of 50 (56%); grade V, 29 of 38 (76%); grade VI, 10 of 11 (91%). Overall incidence: grades IV-VI, 99 of 105 (94%).

CONCLUSIONS

Parameters measuring physiologic condition, CVRS, and mechanism of injury are significant predictors of outcome in penetrating cardiac injuries. AAST-OIS injury grades I-III are rare in penetrating cardiac trauma. AAST-OIS Injury grades IV-VI are common in penetrating cardiac trauma and accurately predict outcome.

Management of combined penetrating cardiac and abdominal trauma

This is a retrospective review of patients with combined penetrating cardiac and abdominal trauma. Clinical presentation patterns are described and a management strategy is outlined. The series comprises 25 patients. On the basis of the mechanism of injury and the prognosis, the patients were divided into two groups: 'low risk' (single high epigastric stab wound) and 'high risk' (multiple stabs, single or multiple gunshot wounds). There were six patients in the low-risk group. Their intra-abdominal injuries were moderately severe. None of this group died. There were 19 patients in the high-risk group. Three underwent emergency-room thoracotomy and died. Of the remaining patients, four underwent a thoracotomy first for cardiac tamponade or massive haemothorax and 12 underwent a laparotomy first because of massive haemoperitoneum. The mortality in this group was 63 per cent. It is essential to recognize the cardiac injury in low-risk patients; the cardiorrhaphy must be performed before the laparotomy. In high-risk patients, the sequence of operations depends on the clinical presentation. Obvious cardiac tamponade or massive haemothorax mandate a thoracic approach first, while severe hypovolaemic shock with a massive haemoperitoneum justifies the performance of a laparotomy first; a transdiaphragmatic pericardiotomy is useful, in these cases, before proceeding to median sternotomy.

Comparison of staples and sutures for cardiorrhaphy in traumatic puncture wounds of the heart

The purpose of this study was to compare the traditional method for repair of cardiac lacerations using sutures and pledgets (S/P) with repair using a skin stapling device (SSD) performed by emergency medicine residents. In a prospective, randomized, non-blinded animal study, 20 anesthetized mongrel dogs were instrumented and underwent left lateral thoracotomy, pericardiotomy, and cardiac exposure. In set 1, a standardized 8-mm right ventricular stab wound was made with a #10 scalpel; emergency medicine residents then immediately performed emergent cardiorrhaphy by either S/P (n = 5) or SSD (n = 5) technique. In set 2, 10 dogs received standardized 8-mm right ventricular stab wounds followed by repair and then received a second stab wound to the same right ventricle that was subsequently repaired by the same operator using the alternate technique. All dogs were observed for 60 min for gross blood loss, hemodynamic instability, and integrity of repair. The results demonstrate that SSD cardiorrhaphy was significantly faster (29 +/- 11 sec in set 1; 14 +/- 6 sec in set 2) than S/P repair (201 +/- 10 sec in set 1; 196 +/- 59 sec in set 2). No appreciable differences in blood loss or repair integrity were noted in either group. Two operators in the S/P group suffered needle puncture injuries. In conclusion, cardiorrhaphy by SSD is faster to perform, has similar repair integrity, and has less risk of accidental contaminated needle injury than does traditional S/P repair when performed by emergency medicine residents.

The role of surgeon-performed ultrasound in patients with possible cardiac wounds

OBJECTIVE

The authors evaluate surgeon-performed ultrasound in determining the need for operation in patients with possible cardiac wounds.

BACKGROUND DATA

Ultrasound quickly is becoming part of the surgeon's diagnostic armamentarium; however, its role for the patient with penetrating injury is less well-defined. Although accurate for the detection of hemopericardium, the lack of immediate availability of the cardiologist to perform the test may delay the diagnosis, adversely affecting patient outcome. To be an effective diagnostic test in trauma centers, ultrasound must be immediately available in the resuscitation area and performed and interpreted by surgeons.

METHODS

Surgeons performed pericardial ultrasound examinations on patients with penetrating truncal wounds but no immediate indication for operation. The subcostal view detected hemopericardium, and patients with positive examinations underwent immediate operation by the same surgeon. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded.

RESULTS

During 13 months, 247 patients had surgeon-performed ultrasound. There were 236 true-negative and 10 true-positive results, and no false-negative or false-positive results; however, the pericardial region could not be visualized in one patient. Sensitivity, specificity, and accuracy were 100%; mean examination time was 0.8 minute (246 patients). Of the ten true-positive examinations, three were hypotensive. The mean time (8 patients) from ultrasound to operation was 12.1 minutes; all survived. Operative findings (site of cardiac wounds) were: left ventricle (4), right ventricle (3), right atrium (2), right atrium/superior vena cava (1), and right atrium/inferior vena cava (1).

CONCLUSIONS

Surgeon-performed ultrasound is a rapid and accurate technique for diagnosing hemopericardium. Delay times from admission to operating room are minimized when the surgeon performs the ultrasound examination.

Cardiopulmonary bypass for resuscitation after penetrating cardiac trauma

Cardiopulmonary bypass is only occasionally required acutely in the management of penetrating cardiac injuries, usually to allow coronary grafting. We describe a case of penetrating trauma in which cardiopulmonary bypass was used to resuscitate a patient whose cardiac lacerations were controlled in the emergency department.

[Management of suspected heart injuries]

Penetrating cardiac injury has to be ruled out in any patients with penetrating thoracic injuries, even in those with no alterations in vital functions. Undelayed echocardiography should be performed to screen for the presence of pericardial effusion. The first case underlines the risk of cardiac tamponade if the diagnosis is missed. Echocardiography was not performed because no echocardiographist was present at the time, and a high suspicion of a neck vascular injury existed. Sudden deterioration due to the onset of acute tamponade was only reversed by an immediate pericardiocentesis followed by surgical haemostasis. The second patient, although stable, had a large echographic pericardial effusion. Emergent sternotomy revealed a large amount of blood in the pericardial space and two cardiac wounds with one on a coronary artery. Penetrating wounds in proximity to the heart, even in a stable patient, require aggressive attempts at ruling out a cardiac injury. Immediate echocardiography should be systematically performed to screen for pericardial fluid.

Penetrating cardiac injuries: clinical classification and management strategy

The management of penetrating cardiac injury is controversial. To facilitate decision making, a simple clinical classification of patients with such an injury is proposed. Five categories are considered: (1) lifeless, (2) critically unstable, (3) cardiac tamponade, (4) thoracoabdominal injury and (5) benign presentation. Investigation, if indicated, and the timing and setting of surgical intervention are discussed for each category.