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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, Narayan A, Hassan S, Leow P, Lim J, Bruce J, Laing G, Clarke D. Serum lactate level is an independent predictor of mortality in stab wounds to the heart. SURGERY IN PRACTICE AND SCIENCE 2023. [DOI: 10.1016/j.sipas.2023.100157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
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McNicoll CF, McNickle AG, Vanderet D, Patel PP, Souchon P, Kuhls DA, Fraser DR, Chestovich PJ. Shot through the heart: A 17-year analysis of pre-hospital and hospital deaths from penetrating cardiac injuries. Injury 2023; 54:1349-1355. [PMID: 36764901 DOI: 10.1016/j.injury.2023.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 01/03/2023] [Accepted: 01/25/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Penetrating cardiac injuries (PCI) are often fatal despite rapid transport and treatment in the prehospital setting. Although many studies have identified risk factors for mortality, few studies have included non-transported field mortalities. This study analyzes penetrating cardiac injuries including hospital and coroner reports in the current era. METHODS Seventeen years of data were reviewed, including the trauma center (TC) registry, medical records, and coroner reports from 2000-2016. PCI were graded using American Association for the Surgery of Trauma (AAST) cardiac organ injury score (COIS). Subjects were divided into three groups: field deaths, hospital deaths, and survivors to hospital discharge. The primary outcome is survival to hospital discharge overall and among those transported to the hospital. RESULTS During the study period, 643 PCI patients were identified, with 52 excluded for inadequate data, leaving 591 for analysis. Mean age was 38.1 ± 17.5 years, and survivors (n=66) were significantly younger than field deaths (n=359) (32.6 ± 14.4 vs 41.1 ± 18.5, p<0.001). Stab wounds had higher survival than gunshot wounds (26.6% vs. 4.3%, p<0.001). COIS grades 4 to 6 (n=602) had lower survival than grades 1 to 3 (n=41) (8.3% vs. 39.0%, p<0.001). Survivors (n=66) had lower median COIS than patients who died in hospital (n=218) (4 vs. 5, p<0.001). Single chamber PCI had higher survival than multiple chamber PCI (13% vs. 5%, p=0.004). The left ventricle is the most injured (n=177), and right ventricle PCI has the highest survival (p<0.001). Of field deaths, left ventricular injuries had the highest single chamber mortality (60%), equaling multi-chamber PCI (60%). CONCLUSIONS Survival to both TC evaluation and hospital discharge following PCI is influenced by many factors including age, mechanism, anatomic site, and grade. Despite advances in trauma care, survival has not appreciably improved.
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Affiliation(s)
- Christopher F McNicoll
- Department of Surgery, Division of Acute Care Surgery, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, 1701 West Charleston Blvd., Suite 490, Las Vegas, NV, 89102, United States
| | - Allison G McNickle
- Department of Surgery, Division of Acute Care Surgery, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, 1701 West Charleston Blvd., Suite 490, Las Vegas, NV, 89102, United States
| | - Danielle Vanderet
- Department of Surgery, Division of Acute Care Surgery, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, 1701 West Charleston Blvd., Suite 490, Las Vegas, NV, 89102, United States
| | - Purvi P Patel
- Department of Surgery, Division of Acute Care Surgery, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, 1701 West Charleston Blvd., Suite 490, Las Vegas, NV, 89102, United States
| | - Patricia Souchon
- Department of Surgery, Division of Acute Care Surgery, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, 1701 West Charleston Blvd., Suite 490, Las Vegas, NV, 89102, United States
| | - Deborah A Kuhls
- Department of Surgery, Division of Acute Care Surgery, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, 1701 West Charleston Blvd., Suite 490, Las Vegas, NV, 89102, United States
| | - Douglas R Fraser
- Department of Surgery, Division of Acute Care Surgery, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, 1701 West Charleston Blvd., Suite 490, Las Vegas, NV, 89102, United States
| | - Paul J Chestovich
- Department of Surgery, Division of Acute Care Surgery, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, 1701 West Charleston Blvd., Suite 490, Las Vegas, NV, 89102, United States.
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Rizzo AN, Epstein DA, Salamon T, Beery PR. Gunshot Wound to the Right Superior Pulmonary Vein With Bullet Embolization to the Aortic Bifurcation: Emergent Surgical Repair. Vasc Endovascular Surg 2022; 57:75-78. [PMID: 36065845 DOI: 10.1177/15385744221124295] [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: 11/17/2022]
Abstract
Bullet embolization is a rare complication of gunshot wound injuries with most of the literature consisting of case reports. We report a case regarding bullet embolization to the distal aorta following entry into the right superior pulmonary vein as a result of a gunshot wound to the posterior chest. The patient presented with signs of lower extremity ischemia. Imaging revealed an intrabdominal bullet at the level of L4 and laparatomy identified the bullet to be within the aorta at the bifurcation. Successful repair of the cardiac injury and removal of the intra-aortic bullet were achieved by sternotomy and laparatomy.
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Affiliation(s)
- Anthony N Rizzo
- 465072Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA
| | - David A Epstein
- Vascular Surgery, 24594OhioHealth Grant Medical Center, Columbus, OH, USA
| | - Thomas Salamon
- Thoracic and Cardiac Surgery, 24594OhioHealth Grant Medical Center, Columbus, OH, USA
| | - Paul R Beery
- Surgical Critical Care, 24594OhioHealth Grant Medical Center, Columbus, OH, USA
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Williams BM, Mulima G, Charles A. Chest Trauma Management in Low- and Middle-Income Countries. Thorac Surg Clin 2022; 32:329-336. [PMID: 35961741 DOI: 10.1016/j.thorsurg.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Trauma is a leading cause of death and disability worldwide and disproportionately affects those in low- and middle-income countries (LMICs). Globally, two-thirds of injured patients sustain trauma to the thoracic cavity. Further research, capacity building, and increased awareness are needed to limit the high thoracic trauma-associated morbidity and mortality in LMICs.
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Affiliation(s)
| | | | - Anthony Charles
- Department of Surgery, University of North Carolina-Chapel Hill; Kamuzu Central Hospital, Lilongwe, Malawi.
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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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Sarquis LM, Brunet-Schultze AC, Gazola BB, Collaço IA, Aguiar AJDE, Fontes H. Epidemiological analysis of cardiac trauma victims at a referral trauma hospital: a 5 year case series. Rev Col Bras Cir 2022; 49:e20223120. [PMID: 35239854 PMCID: PMC10578789 DOI: 10.1590/0100-6991e-20223120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 10/06/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to describe, analyze, and trace the epidemiological profile for cardiac trauma victims on a referral trauma hospital of a major urban center. METHODS a case series study to review, describe, compile and analyze medical records of all patients sustaining traumatic cardiac injuries, from January 2015 to January 2020 admitted to the referral trauma hospital of Curitiba, Brazil. Patients sustaining traumatic heart injuries were identified using the hospitals database. Patients who died prior to reaching hospital care were excluded. RESULTS all 22 cases were urban victims, mostly penetrating injuries (12 stab wounds, 9 gunshot wounds); 82% were male; mean age, 37.1 years. 17 cases (77%) occurred during night hours, 15 between Friday and Sunday, and 15 were admitted hemodynamically stable. Only 27% were diagnosed with FAST, the remainder requiring other imaging exams. About incisions, 14 had thoracotomies, 6 median sternotomies and in 2 cases both. Of injuries, 8 affected the right ventricle, 3 right atrium, 9 left ventricle, 1 right coronary sulcus and 1 anterior wall. All had cardiorrhaphy repair. 3 patients died, 17 were discharged and 2 were transferred. 17 received postoperative echocardiograms, revealing ejection fractions ranging 55.1% to 75%. Patients spent a mean of 9.6 days on ICU and a mean of 15.2 days of total hospital stay. The mortality rate was 14%. CONCLUSIONS cardiac traumas predominantly occurred in adult males, due to violent causes, during night hours on weekends. The overall mortality rate found (14%), as well as total hospital stay, accords with the literature.
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Affiliation(s)
| | | | | | | | | | - Hector Fontes
- - Hospital do Trabalhador, General Surgery - Curitiba - PR - Brasil
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Ahmadinejad M, Ahmadinejad I, Maghsoudi LH, Soltanian A, Safari M. Complications in Patients with Cardiac Penetrating Trauma. Cardiovasc Hematol Disord Drug Targets 2021; 21:212-216. [PMID: 34906065 DOI: 10.2174/1871529x21666211214155349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/15/2021] [Accepted: 11/26/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cardiac penetrating trauma is a medical emergency that mostly affects young people. Based on the type of injury and associated complications, it can present as a surgical challenge and can lead to mortality. OBJECTIVE The aim of this study is to evaluate the complications of penetrating heart trauma among patients referred to Shahid Madani Hospital. METHODS In this retrospective descriptive study, the data of penetrating cardiac trauma patients referred to Shahid Madani hospital, Karaj, Tehran, from 2016-2019, were investigated. Information, including age, sex, cause of trauma, traumatized area and complications, was extracted and recorded in a data collection form. The data were evaluated statistically using SPSS v18. RESULTS A total of 44 patients were included in the study, where the mean age of the patients was 25 years. 73.3% of these patients were men and 26.7% were women. Knife stab wounds were the most prevalent cause of the trauma, present in 93.3% of patients. 73.3% of the patients had cardiac tamponade and 20% had a pneumothorax. The right ventricle was the most common site of the injury in 46.7% of the patients. A mortality rate of 3.4% was reported in this study. CONCLUSION The results of this study showed that the highest penetrating heart rate trauma occurred among young people, and the most common cause of the trauma was a knife stab. The most common area of the injury was the right ventricular, and cardiac tamponade was the most common complication.
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Affiliation(s)
- Mojtaba Ahmadinejad
- Department of Surgery, School of Medicine, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj. Iran
| | | | - Leila Haji Maghsoudi
- Department of Surgery, School of Medicine, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj. Iran
| | - Ali Soltanian
- Department of Surgery, School of Medicine, Alborz University of Medical Sciences, Karaj. Iran
| | - Mehdi Safari
- Student Research Committee, Alborz University of Medical Sciences, Karaj. Iran
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Abdominal Aorta Bullet Embolism: Presentation and Management. Ann Vasc Surg 2021; 74:524.e17-524.e21. [PMID: 33836233 DOI: 10.1016/j.avsg.2021.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 11/23/2022]
Abstract
Penetrating cardiac injury (PCI) secondary to a gunshot wound presents with several complications and a mortality rate of 94% before reaching the hospital. Current literature search reveals that embolism of bullet fragments after gunshot wounds are exceptionally rare. Additionally, no reported case was found regarding bullet embolism following left atrium penetration at the time of this case report. This case describes a 34-year-old male who presented to a level I trauma center after sustaining a gunshot wound to the posterior torso. Imaging demonstrated several fragments in the mid-thoracic region in addition to the primary bullet fragment located within the aorta at the bifurcation of the iliac arteries likely due to left atrial penetration and subsequent embolization.
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Zoltowska DM, Agrawal Y, Kalavakunta JK, Gupta V. Nail to the heart: no big deal. A rare case of post-traumatic pericarditis. BMJ Case Rep 2018; 2018:bcr-2017-223220. [DOI: 10.1136/bcr-2017-223220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Gratton R, Olaussen A, Hassan M, Thaveenthiran P, Fitzgerald MC, Mitra B. Diagnostic performance of the cardiac FAST in a high-volume Australian trauma centre. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2017. [DOI: 10.5339/jemtac.2017.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background: Cardiac injury is uncommon, but it is important to diagnose, in order to prevent subsequent complications. Extended focused assessment with sonography in trauma (eFAST) allows rapid evaluation of the pericardium and thorax. The objective of this study was to describe cardiac injuries presenting to a major trauma centre and the diagnostic performance of eFAST in detecting haemopericardium as well as broader cardiac injuries. Methods: Data of patients with severe injuries and diagnosed cardiac injuries (Injury Severity Score >12 and AIS 2008 codes for cardiac injuries) were extracted from The Alfred Trauma Registry over a four-year period from July 2010 to June 2014. The initial eFAST results were compared to those of the final diagnosis, which were determined after analysing imaging results and intraoperative findings. Results: Thirty patients who were identified with cardiac injuries met the inclusion criteria. Among these, 22 patients sustained injuries under the scope of eFAST, of which a positive eFAST scan in the pericardium was reported in 13 (59%) patients, while nine (41%) patients had a negative scan. This resulted in a sensitivity of 59% (95% CI: 36.7%–78.5%). The sensitivity of detecting any cardiac injuries was lower at 43.3% (95% CI: 26.0–62.3). Conclusions: The low sensitivities of eFAST for detecting cardiac injuries and haemopericardium demonstrate that a negative result cannot be used in isolation to exclude cardiac injuries. A high index of suspicion for cardiac injury remains essential. Adjunct diagnostic modalities are indicated for the diagnosis of cardiac injury following major trauma.
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Affiliation(s)
| | - Alexander Olaussen
- 2Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
- 3Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- 4Trauma Service, The Alfred Hospital, Melbourne, Australia
- 5National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | - Mariam Hassan
- 5National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | | | - Mark C. Fitzgerald
- 4Trauma Service, The Alfred Hospital, Melbourne, Australia
- 5National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | - Biswadev Mitra
- 3Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- 5National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
- 6Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
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Pol MM, Prasad KSK, Deo V, Uniyal M. Penetrating cardiac injury: sustaining health by building team resilience in growing civilian violence. BMJ Case Rep 2016; 2016:bcr-2016-216293. [PMID: 27591038 DOI: 10.1136/bcr-2016-216293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Penetrating cardiac injury (PCI) is gradually increasing in developing countries owing to large-scale manufacturing of illegal country-made weapons. These injuries are associated with significant morbidity and mortality. Logistically it is difficult to have all organ-based specialists arrive together and attend every critically injured patient round-the-clock in developing countries. It is therefore important for doctors (physicians, surgeons and anaesthetists) to be trained for adequate management of critically injured patients following trauma. We report the approach towards 2 cases of haemodynamically unstable PCI managed by a team of trauma doctors. Time lag (duration between injury and arrival at hospital) and quick horizontal resuscitation are important considerations in the treatment. By not referring these patients to different hospitals the team actually reduced the time lag, and a quick life-saving surgery by trauma surgeons (trained in torso surgery) offered these almost dying patients a chance of survival.
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Affiliation(s)
| | - K Shiv Krishna Prasad
- Surgery (Surgical Disciplines) All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Vishant Deo
- Surgery (Surgical Disciplines) All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Madhur Uniyal
- Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
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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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Reyna-Sepúlveda F, Cueto-Ramos R, Vásquez-Fernández F, Hernández-Guedea M, Guevara-Charles A, Muñoz-Maldonado G. Self-inflicted wound with a nail in the heart: Case report. MEDICINA UNIVERSITARIA 2016. [DOI: 10.1016/j.rmu.2016.03.002] [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] Open
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16
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The accuracy of physical examination in identifying significant pathologies in penetrating thoracic trauma. Eur J Trauma Emerg Surg 2014; 41:647-50. [PMID: 26038008 DOI: 10.1007/s00068-014-0484-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 11/30/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Accurate physical examination (PE) remains a key component in the assessment of penetrating thoracic trauma (PTT), despite the increasing availability of advanced radiological imaging. Evidence regarding the accuracy of PE in identifying significant pathology following PTT is limited. MATERIALS AND METHODS A retrospective review of 405 patients was undertaken over a twelve-month period to determine the accuracy of PE in identifying significant pathology (SP) subsequently confirmed on chest radiographs (CXRs) in patients who sustained stab injuries to the thorax. RESULTS Ninety-seven per cent (372/405) of patients were males, and the mean age was 24 years. The weapons involved were knives in 98 % (398/405), screwdrivers in 1 % (3/405) and unknown in the remaining 1 %. Fifty-nine per cent (238/405) of all injuries were on the left side. There were 306 (76 %) SPs identified on CXR. Ninety-nine (24 %) CXRs were entirely normal. Based on PE alone, 223 (55 %) patients were thought to have SPs present, 182 (45 %) patients were thought to have no SPs. The overall sensitivity of PE in identifying SPs was 68 % (63-73, 95 % CI), with a specificity of 86 % (77-92, 95 % CI). The PPV of PE was 94 % (90-97, 95 % CI) and the NPV was 47 % (39-54, 95 % CI). The sensitivity of PE for identifying a pneumothorax was 59 % (51-66, 95 % CI), with a specificity of 96 % (89-99, 95 % CI) and the sensitivity of PE for identifying a haemothorax was 79 % (72-86, 95 % CI), with a specificity of 96 % (89-99, 95 % CI). CONCLUSIONS PE is inaccurate in identifying SPs in PTT. The increased reliance on advanced radiological imaging and the subsequent reduced emphasis on PE may have contributed to rapid deskilling amongst surgical residents. The importance of PE must be repeatedly re-emphasised.
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