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

Cardiac Trauma: A Review of Penetrating and Blunt Cardiac Injuries

Cardiac injuries pose challenging diagnostic and management dilemmas. Cardiac trauma can be classified by mechanism into blunt and penetrating injuries. Penetrating trauma has an overall higher mortality and is more likely to require operative intervention. Due to the lethality of any cardiac injury, prompt diagnosis and treatment is critical for survival. The initial management of suspected cardiac injury should start with Advanced Trauma Life Support (ATLS) protocols followed shortly by directed diagnosis and management, which usually begins with a focused assessment with sonography in trauma (FAST) examination. In contrast to traditional ATLS protocols, some centers have adopted an assessment of "circulation before "airway" and "breathing"; however, this is an evolving concept. In this article, we provide an overview on the management of penetrating and blunt cardiac injuries, including use of physical exam, laboratory tests, imaging, and surgery.

Penetrating cardiac injuries: What you need to know

ABSTRACT

Despite significant advances in trauma surgery in recent years, patients sustaining penetrating cardiac injuries still have an overall survival rate of 19%. A substantial number of deaths occur at the scene, while approximately 40% of those reaching trauma centers survive. To increase survival, the key factor is timely intervention for bleeding control, pericardial tamponade release, and definitive repair. Asymptomatic patients sustaining precordial wounds or mediastinal gunshot wounds should be assessed with chest ultrasound to rule out cardiac injuries. Shock on admission is an immediate indication of surgery repair. Patients admitted in posttraumatic cardiac arrest may benefit from resuscitative thoracotomy. The surgical team must be assured that appropriate personnel, equipment, instruments, and blood are immediately available in the operating room. A left anterolateral thoracotomy, which can be extended to a clamshell incision, and sternotomy are the most common surgical incisions. Identification of cardiac anatomical landmarks during surgery is vital to avoid complications. There are several technical options for bleeding control, and the surgeon must be trained to use them to obtain optimal results. Ultimately, prioritizing surgical intervention and using effective resuscitation strategies are essential for improving survival rates and outcomes.

Cardiac Arrhythmias in Trauma Patients Undergoing Pericardiotomy: A Retrospective Analysis

INTRODUCTION

Pericardiotomy is performed in the setting of trauma to diagnose and treat cardiac injury. The frequency of cardiac arrhythmia after pericardiotomy for trauma is poorly described in the literature. We sought to identify the frequency of and risk factors for the development of postpericardiotomy arrhythmia in trauma patients.

MATERIALS AND METHODS

We performed a retrospective single-center cohort study of patients >16 y of age, querying our institutional trauma database (Jan 2011-Dec 2020) for International Classification of Diseases-9 and -10 codes involving pericardiotomy (i.e., pericardial window, sternotomy). Operative details and postoperative course were collected for patients surviving >24 h. Sinus bradycardia and tachycardia were not included as arrhythmias.

RESULTS

We identified 252 trauma patients who underwent pericardiotomy. One hundred fifty-four patients survived >24 h. Of these, 12.3% experienced arrhythmia. Patients developing arrhythmia were older, had higher injury severity score, were more likely to have a blunt mechanism of injury, and had higher in-hospital mortality. On multiple logistic regressions, increasing age, blunt mechanism, and concomitant laparotomy were associated with arrhythmia development, while operative characteristics were not.

CONCLUSIONS

At our institution, trauma patients undergoing pericardiotomy have a risk of arrhythmia of 12.3%, which is associated with multiple nonmodifiable risk factors. Further study is warranted to identify potential mechanisms to reduce arrhythmias in this population.

Point of care ultrasound and sub-xiphoid window reduce uncertainty in the management of potential dual-cavity injuries in patients with torso stab wounds

INTRODUCTION

This paper reviews our experiences with the management of patients with torso stab wounds and potential injuries in both the chest and abdomen over the last decade. The aim of the project is to clarify our approach and provide an evidence base for clinical algorithms. We hypothesize that there is room for our clinical algorithms to be further refined in order to address the diverse, life threatening injuries that can result from stab wounds to the torso.

METHODS

Patients with one or more torso stab wounds, and a potential injury in both the chest and the abdomen were identified from a local database for the period December 2012 to December 2020.

RESULTS

A total of 899 patients were identified. The mean age was 29 years (SD = 9) and 93% of patients were male. Amongst all patients, 686 (76%) underwent plain radiography, 207 (23%) a point of care ultrasound assessment, and 171 (19%) a CT scan. Following initial resuscitation, assessment and investigation, a total of 527 (59%) patients proceeded to surgery. A total of 185 patients (35%) underwent a semi elective diagnostic laparoscopy to exclude an occult diaphragm injury. Of the 342 who underwent an emergency operation, 9 patients (1%) required thoracotomy or sternotomy exclusively, 299 patients (33%) required a laparotomy exclusively and 34 patients (4%) underwent some form of dual cavity exploration. In total, there were 16 deaths, a mortality rate of 2%. The use of laparoscopy, point of care ultrasound and subxiphoid pericardial window increased over the period of this study.

CONCLUSIONS

Patients with torso stab wounds and potential injuries above and below the diaphragm are challenging to manage. The highly structured clinical algorithm of the ATLS course should be complemented by the use of point of care ultrasound and sub-xiphoid window to assess the pericardium. These adjuncts reduce the likelihood of negative exploration and incorrect operative sequencing.

Role of extracorporeal life support for traumatic hemopericardium: A single level I trauma center review

BACKGROUND

Traumatic hemopericardium may lead to cardiac tamponade, arrhythmia, arrest, or death and requires emergency surgery. We reviewed cases of traumatic hemopericardium in our center and the role of extracorporeal life support in these cases.

METHODS

From November 2011 to January 2022, 28 patients with significant hemopericardium and suspected cardiac injury were enrolled. In our center, surgery is the primary treatment of choice; however, if the patient is in an unstable condition, extracorporeal life support is administered in the emergency room prior to surgery.

RESULTS

Preoperative extracorporeal life support was applied to 10 patients (36 %). Two patients (20 %) were converted from extracorporeal life support to cardiopulmonary bypass during operation. After surgery, 2 patients (20 %) needed postoperative extracorporeal membrane oxygenation support. Overall, 21 patients (75 %) survived; of these, 6 (29 %) received extracorporeal life support. Meanwhile, 7 patients (25 %) died; of these, 4 patients (57 %) received extracorporeal life support.

CONCLUSION

Resuscitation method is the most crucial survival strategy in patients with severe chest trauma. Extracorporeal life support in cases of traumatic hemopericardium may be beneficial and efficient in stabilizing patients prior to surgery.

Management of Penetrating Cardiac Injuries With Pericardial Window and Drainage in Select Patients

BACKGROUND

Management of penetrating chest injuries with a positive pericardial window (PW) are presumed cardiac injuries and traditionally result in sternotomy. However, there is some evidence in the literature that select patients can be managed with PW, lavage, and drainage (PWLD).

METHODS

All patients with penetrating chest trauma who underwent PW and/or sternotomy over a 5-year period were identified. Patients were stratified by operative intervention [PW + sternotomy vs PWLD] and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of therapeutic sternotomy.

RESULTS

Of the 146 patients who underwent PW and/or sternotomy included in the study, 126 patients underwent PW, 39 underwent sternotomy, and 10 underwent PWLD. There was no difference in demographics, LOS, ICU LOS, vent days, or mortality in patients who underwent PW + sternotomy, compared to patients who underwent PWLD. In the PWLD group, one patient returned to the OR for recurrent pericardial effusion and no patients required sternotomy. Multivariable logistic regression identified ISS as an independent predictor of therapeutic sternotomy (OR 1.160; 95% CI 1.006-1.338, P = .0616). Interestingly, positive FAST, significant CT findings, and trajectory were not predictors of therapeutic sternotomy. There were 7 patients with a left hemothorax and negative FAST found to have a positive PW and cardiac injury mandating sternotomy and repair.

CONCLUSION

Penetrating cardiac injury can be managed with PWLD in select patients. Positive FAST, significant findings on CT, and trajectory do not mandate sternotomy. A negative FAST in the setting of a hemothorax does not rule out a cardiac injury.

Evidence-Based Pearls

The challenge in caring for patients who sustain traumatic chest injuries centers on their complex needs from high acuity and the potential for multisystem effects and complications. Hemorrhage and respiratory compromise are common sequela of thoracic trauma. Patients must be resuscitated and their injuries managed with the primary goals of restoring cardiopulmonary structural integrity and preventing complications. There are evolving strategies for the management of the thoracic trauma victim including damage control resuscitation and surgery, endovascular repairs, and assessments implementing severity scores to aid in planning interventions.

Gunshot Wound to the Right Superior Pulmonary Vein With Bullet Embolization to the Aortic Bifurcation: Emergent Surgical Repair

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.