Penetrating Cardiac Injuries: A Historic Perspective and Fascinating Trip Through Time

Systematic Review of Penetrating Cardiac Injury by a Firearm: Forensic Implications

Penetrating injuries of the heart, named penetrating cardiac injury (PCI), may cause hemorrhagic shock as well as cardiac tamponade, leading to death if not treated immediately. This systematic review aims to highlight the main aspects of penetrating cardiac injuries after firearm wounds. The cases of 39 subjects (age 37.05 + 15.4) were selected (6 fatal cases). Specifically, 4/39 cases involved subjects under 18 y.o.; analyzing the entrance wound, in 30/39 cases it was located in the anterior chest, 4/39 in the posterior chest, 3/39 in the shoulder/axilla area, 1/39 in the neck, and 1/39 in the pelvis (gluteus). The exit wound was found in only 3/39 cases. Several factors may influence the prognosis: firstly, prompt intervention represents a crucial point, then considering the complications related to PCI, the most important are myocardial infarction, and projectile migration with embolization. The mortality rate is related to: (1) area and severity of the heart injury; (2) duration of transport and intervention; (3) contemporary lesion to other organ/s; (4) the quantity of blood lost; (5) and presence/absence of cardiac tamponade. Based on these findings, a correct approach in the management of PCI may be considered important from a forensic point of view, both as regards to medical liability and from the trial perspective.

Emergency Department Resuscitative Thoracotomy: Indications, surgical procedure and outcome. A narrative review

BACKGROUND

Emergency Department Thoracotomy (EDRT) after traumatic Cardio-pulmonary Arrest (CPR) can be used to salvage select critically injured patients. Indications of this surgical procedure are widely debated and changed during last decades. We provide the available literature about EDRT in the effort to provide a comprehensive synthesis about the procedure, likelihood of success and patient's outcome in the different clinical setting, accepted indications and technical details adopted during the procedure for different trauma injuries.

METHODS

Literature from 1975 to 2020 was retrieved from multiple databases and reviewed. Indications, contraindications, total number and outcome of patients submitted to EDRT were primary endpoints.

RESULTS

A total number of 7236 patients received EDRT, but only 7.8% survived. Penetrating trauma and witnessed cardiopulmonary arrest with the presence of vital signs at the trauma center are the most favorable conditions to perform EDRT.

CONCLUSIONS

EDRT should be reserved for acute resuscitation of selected dying trauma patient. Risks of futility, costs, benefits of the surgical procedure should be carefully evaluated before performing the surgical procedure.

An odyssey of suturing cardiac wounds: Lessons from the past

BACKGROUND AND AIM OF THE STUDY

Cardiac wounds have been described for centuries and still remain to be fatal. For a long period of time, the suturing of a myocardial laceration was thought to be absolutely impossible if not sacrilege.

METHODS

It is only at the end of the 19th century that pioneers decided to defy such a dogma in desperate cases.

RESULTS

Nowadays, it seems obvious that a cardiac stab wound requires emergent surgery whenever possible.

CONCLUSIONS

The story of cardiac wounds highlights nicely the change of mind that is required to accept progress and new procedures in medicine.

Delayed presentation of cardiac injury four weeks after stabbing

Penetrating trauma to the heart has a high associated mortality due to significant hemorrhage, coronary artery injury, and cardiac tamponade. Such sequelae progress rapidly, often leading to death before reaching hospital. We report a case of delayed presentation following a stab injury to the right ventricle. This case highlights the mechanisms that may facilitate a delayed presentation and the importance of appropriate investigation when suspicion of cardiac injury is high.

Fatal cardiac trauma in the city of Manaus, Amazonas state, Brazil

OBJECTIVE

to determine the frequency of fatal cardiac trauma in the city of Manaus, Brazil, between November 2015 and October 2016, and to clarify the mechanisms of trauma and death, previous hospital treatment, as well as the injuries associated with cardiac trauma.

METHODS

retrospective, observational, and cross-sectional study, which reviewed the necropsy reports of individuals whose cause of death was cardiac injury.

RESULTS

the cardiac trauma rate was of 5.98% (138 cases) out of 2,306 necropsies performed in the study period by Instituto Médico Legal (IML) de Manaus (IML is a Brazilian institute responsible for necropsies and cadaveric reports). Males accounted for 92% of the cases. The median age was 27 years (14-83). Gunshot wounds (GSW) was the trauma mechanism in 62.3% and stab wound (SW) in 29.7%. Exsanguination was responsible for most of the deaths and cardiac tamponade was present in second place. On-site death occurred in 86.2% of the cases. The ventricles were the most common site of cardiac injury. Hemothorax was identified in 90.6% of the individuals. Only 23 patients (16.7%) were taken to the hospital (Emergency Room), but six (26.2%) were submitted only to chest drainage, not to thoracotomy. The lung was unilaterally affected in 57% of the cases and bilaterally in 43%.

CONCLUSION

fatal cardiac trauma represented an index of 5.98% in the city of Manaus. Most patients die at the scene of the trauma, usually due to exsanguination caused by gunshot wound. About a quarter of patients who reached the hospital and died were not diagnosed with cardiac trauma in time.

Resuscitative thoracotomy

Resuscitative thoracotomy is often performed on trauma patients with thoracoabdominal penetrating or blunt injuries arriving in cardiac arrest. The goal of this procedure is to immediately restore cardiac output and to control major hemorrhage within the thorax and abdominal cavity. Only surgeons with experience in the management of cardiac and thoracic injuries should perform this procedure.

Delayed revascularization following complete transection of left anterior descending artery after a stab wound

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Complete coronary artery transection after a stab wound is survivable.

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At even slight suspicion, surgical exploration of pericardial sac and heart is always strongly justified.

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Off-pump coronary artery by-pass is a safe alternative for transected artery treatment.

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Examination and treatment of cardiac injuries in facility with “heart team” and cardiac surgical expertise is always strongly recommended.

Introduction

Penetrating heart injury as a consequence of a stab wound is usually considered fatal. Nevertheless, there are rare lucky cases with mild symptoms which deserve clinical suspicion and proper management.

Presentation of case

We report a penetrating cardiac trauma with left anterior descending coronary artery transection after a stab wound. Successful revascularization without cardiopulmonary bypass support was performed.

Discussion

Coronary artery injuries after penetrating cardiac trauma are mostly fatal. The standard approach has traditionally been coronary artery ligation with serious morbidity. We report a case of complete coronary artery transection with delayed revascularization validating the safety of off-pump approach. We add a short literature review of the management of traumatic coronary artery injury.

Conclusion

This adds to the world literature on coronary artery trauma with successful off-pump revascularization. Coronary artery transection stab-wound victims can have only mild symptoms. Slightest intimation of heart injury should provoke proper clinical examination and management.

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.

Pericardiocentesis in trauma: a systematic review

BACKGROUND

Pericardiocentesis (PCC) had been taught as a mandatory skill in the Advanced Trauma Life Support (ATLS®) course as a bridge to definitive surgical therapy for traumatic pericardial tamponade since its inception in 1978. Immediate thoracotomy for penetrating trauma to the heart and chest has resulted in the decreased use of PCC in trauma. PCC is now offered as an optional skill in the ninth edition of the ATLS®. A review of the literature regarding the use and effectiveness of PCC in traumatic pericardial tamponade in the modern era is necessary to better define its current role in trauma care.

METHODS

Scientific publications from 1970 to 2010 involving PCC after trauma were identified. The Preferred Reporting Items for Systematic reviews and Meta-Analyses was used. Human studies describing acute traumatic tamponade were included. Publications involving nontraumatic or chronic pericardial tamponade from effusions caused by inflammatory, infectious, or neoplastic etiology were excluded. Publications were categorized by level of evidence.

RESULTS

Of the 135 publications identified, 27 were included, composing of 2,094 trauma patients with suspected cardiac tamponade. The reported use of PCC decreased from 45.9% of patients in the period 1970 to 1979 down to 6.4% of patients in the period between 2000 and 2010 (p < 0.05). Reported rates describing the use of PCC as the sole intervention decreased from 13.7% in the period 1970 to 1979 to 2.1% in the period 2000 to 2010 (p < 0.05). Survival analysis after PCC was possible for 380 patients. Overall survival following PCC was 83.4% (n = 317) and 91.8% (n = 145) when used as the sole intervention. In patients who received PCC then thoracotomy, survival rate was 79.5% (n = 178).

CONCLUSION

Studies on the use of PCC for trauma are limited and biased toward survivors. The reported survival rate is high. There remains a limited role for PCC in nontrauma centers where definitive surgical management is not immediately available and transport time to a higher level of care facility supports the use of temporary decompression by PCC.

LEVEL OF EVIDENCE

Systematic review, level III.

Penetrating cardiac trauma: 20-y experience from a university teaching hospital

BACKGROUND

Penetrating traumas, including gunshot and stab wounds, are the major causes of cardiac trauma. Our aim was to describe and compare the variables between patients with penetrating cardiac trauma in the past 20 y in a university hospital, identifying risk factors for morbidity and death.

METHODS

Review of trauma registry data followed by descriptive statistical analysis comparing the periods 1990-1999 (group 1, 54 cases) and 2000-2009 (group 2, 39 cases). Clinical data at hospital admission, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and Revised Trauma Score (RTS) were recorded.

RESULTS

The incidences of penetrating cardiac injuries were steady within the period of study in the chosen metropolitan area. The two groups were similar regarding age, mechanism of trauma (gunshot × stab), and ISS. Group 1 showed lower systolic blood pressure at admission (mean 87 versus 109 mm Hg), lower GCS (12.9 versus 14.1), lower RTS (6.4 versus 7.3), higher incidence of grade IV-V cardiac lesions (74% versus 48.7%), and were less likely to survive (0.83 versus 0.93). The major risk factor for death was gunshot wound (13 times higher than stab wound), systolic blood pressure < 90 mm Hg, GCS < 8, RTS < 7.84, associated injuries, grade IV-V injury, and ISS > 25. We observed a tendency in mortality reduction from 20.3% to 10.3% within the period of observation.

CONCLUSIONS

Several associated factors for mortality and morbidity were identified. In the last decade, patients were admitted in better physiological condition, perhaps reflecting an improvement on prehospital treatment. We observed a trend toward a lower mortality rate.

Retrospective study of heart injuries occurred in Manaus - Amazon

OBJECTIVE

To evaluate the forms of treatment employed to heart injuries and the main aspects related to their morbidity and mortality.

METHODS

A retrospective study of 102 patients with cardiac injuries treated in the two emergency rooms in Manaus (Dr. John Lucio Pereira Machado Emergency Hospital and August 28 County Emergency Hospital) from January 1998 to June 2006.

RESULTS

Of the 102 patients, 95.1% were men; mean age was 27 years; stab wounds accounted for 81.4% of cases and gunshot wounds for 18.6%; cardiorrhaphy was performed in 98.1% of cases. The heart chambers affected were: Right Ventricle (RV): 43.9% (36.2% isolated and 7.7% associated with other chambers); Left Ventricle (LV): 37.2%; Right Atrium (RA): 8.5%; and Left Atrium (LA): 10.4%; specific mortalities were of 21%, 23%, 22% and 45%, respectively. The mortality injuries to two associated chambers was 37.5%, 20% being for RA + RV, 100% for RV + LV, and zero for RV + LA. The lung accounted for 33.7% of the 89 associated lesions. Mean time of surgery and hospital stay were 121 minutes and 8.2 days, respectively. About 22.5% of patients displayed 41 complications. The mortality rate was 28.4%. Lesions grade IV and V corresponded to 55% and 41% of cases, with specific mortality of 26% and 15%, respectively. All patients with grade injuries VI died.

CONCLUSION

Cardiac stab wounds were associated with lower mortality, cardiac lesions grade IV were associated with higher mortality and a shorter operative time was associated with greater severity and mortality.

How to mend a broken heart: a major stab wound of the left ventricle

A 28-year-old male admitted with a stab wound under his left nipple, underwent emergency surgery because of confusion, a decreasing blood pressure and increasing tachycardia. A median sternotomy incision was made and after establishing cardiopulmonary bypass, a 7 cm wound in the left ventricle and a smaller wound in the left atrium were repaired. An injured segment of lung was resected and the left anterior descending and circumflex arteries were grafted after weaning from cardiopulmonary bypass was initially unsuccessful. Although the patient suffered a stroke, probably due to prehospital hypoperfusion, he eventually recovered without major sequelae. In addition to the case report we present a literature review of the last 15 years pertaining the management of penetrating cardiac injury.

Unraveling the paradox of cardiac tamponade: case presentation and discussion of physiology

A 53-year-old man on warfarin for postoperative pulmonary embolism presented with chest pain and was found to be in cardiac tamponade due to an atraumatic haemopericardium. Findings of tamponade and a novel approach to the pathophysiology of pericardial disease to explain these finding are presented.