Penetrating cardiac injuries: a population-based study

Management of a Traumatic Penetrating Cardiac Injury in a Low-Resource Center Without a Cardiothoracic Surgery Department

Traumatic penetrating cardiac injury is a rare pathology with a high mortality rate, more commonly occurring in a military setting or during violent assaults in a civilian environment. Given the anatomy, these injuries are often managed by cardiothoracic surgeons. However, in an institute that lacks these specialists, the responsibility for managing this condition falls on the shoulders of the general surgeon on call. We herein report a case where a penetrating cardiac injury was managed successfully by general surgeons in the absence of cardiothoracic surgeons. This case serves two educational purposes. The first is that Caribbean hospitals possess the potential to match a developed country's medical standard if additional resources can be obtained from their respective governing bodies. The second is that a general surgeon's role is not yet finished in the modern era of sub-specialization, especially in a setting that lacks dedicated specialists.

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.

An unusual foreign body ricocheting into the pericardium after a penetrating thoracic injury: A case report

INTRODUCTION AND IMPORTANCE

Injuries to the thorax are common in trauma patients, among whom cardiac injuries are most lethal, particularly in the setting of penetrating trauma.

CASE PRESENTATION

In this case report, the foreign body was visualized to be lodged in between the left atrium and ventricle. After that, an emergency open heart surgery was performed. Post-intervention, the patient was shifted to the intensive care unit without ionotropic support and with stable haemodynamics.

CLINICAL DISCUSSION

Cardiac foreign bodies are rarely seen because most patients with penetrating cardiac injuries die from hemorrhagic shock or cardiac tamponade.

CONCLUSION

We report a case of a penetrating injury into the thorax with the foreign body being lodged into the pericardium and then managed surgically. The patient was discharged subsequently and followed up after a few days with progressive recovery.

Shot through the heart: A 17-year analysis of pre-hospital and hospital deaths from penetrating cardiac injuries

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.

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.

Penetrating Heart Injury Repaired with Peripheral Cannulation: Case Report

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

Myocardial Injury and Stroke after Attempted Suicide

Self-stabbing is an uncommon method of suicide and attempt of suicide, mostly chosen by young men and people with a psychiatric history. A curious case of suicide attempt by self-stabbing with a huge pointed knife in a 56-year-old man is presented which resulted in a myocardial injury and was evaluated with a stroke after cardiorrhaphy.

Selective use of pericardial window and drainage as sole treatment for hemopericardium from penetrating chest trauma

Background

Penetrating cardiac injuries (PCIs) are highly lethal, and a sternotomy is considered mandatory for suspected PCI. Recent literature suggests pericardial window (PCW) may be sufficient for superficial cardiac injuries to drain hemopericardium and assess for continued bleeding and instability. This study objective is to review patients with PCI managed with sternotomy and PCW and compare outcomes.

Methods

All patients with penetrating chest trauma from 2000 to 2016 requiring PCW or sternotomy were reviewed. Data were collected for patients who had PCW for hemopericardium managed with only pericardial drain, or underwent sternotomy for cardiac injuries grade 1-3 according to the American Association for the Surgery of Trauma (AAST) Cardiac Organ Injury Scale (OIS). The PCW+drain group was compared with the Sternotomy group using Fisher's exact and Wilcoxon rank-sum test with P<0.05 considered statistically significant.

Results

Sternotomy was performed in 57 patients for suspected PCI, including 7 with AAST OIS grade 1-3 injuries (Sternotomy group). Four patients had pericardial injuries, three had partial thickness cardiac injuries, two of which were suture-repaired. Average blood drained was 285 mL (100-500 mL). PCW was performed in 37 patients, and 21 had hemopericardium; 16 patients proceeded to sternotomy and 5 were treated with pericardial drainage (PCW+drain group). All PCW+drain patients had suction evacuation of hemopericardium, pericardial lavage, and verified bleeding cessation, followed by pericardial drain placement and admission to intensive care unit (ICU). Average blood drained was 240 mL (40-600 mL), and pericardial drains were removed on postoperative day 3.6 (2-5). There was no significant difference in demographics, injury mechanism, Revised Trauma Score exploratory laparotomies, hospital or ICU length of stay, or ventilator days. No in-hospital mortality occurred in either group.

Conclusions

Hemodynamically stable patients with penetrating chest trauma and hemopericardium may be safely managed with PCW, lavage and drainage with documented cessation of bleeding, and postoperative ICU monitoring.

Level of evidence

Therapeutic study, level IV.

Cardiac Injuries at Estonian Major Trauma Facilities: A 23-year Perspective

BACKGROUND AND AIMS

Cardiac injuries are highly lethal lesions following trauma and most of the patients decease in pre-hospital settings. However, studies on cardiac trauma in Estonia are scarce. Thus, we set out to study cardiac injuries admitted to Estonian major trauma facilities during 23 years of Estonian independence.

MATERIALS AND METHODS

After the ethics review board approval, all consecutive patients with cardiac injuries per ICD-9 (861.0 and 861.1) and ICD-10 codes (S.26) admitted to the major trauma facilities between 1 January 1993 and 31 July 2016 were retrospectively reviewed. Cardiac contusions were excluded. Data collected included demographics, injury profile, and in-hospital outcomes. Primary outcome was mortality. Secondary outcomes were cardiac injury profile and hospital length of stay.

RESULTS

During the study period, 37 patients were included. Mean age was 33.1 ± 12.0 years and 92% were male. Penetrating and blunt trauma accounted for 89% and 11% of the cases, respectively. Thoracotomy and sternotomy rates for cardiac repair were 80% and 20%, respectively. Most frequently injured cardiac chamber was left ventricle at 49% followed by right ventricle, right atrium, and left atrium at 34%, 17%, and 3% of the patients, respectively. Multi-chamber injury was observed at 5% of the cases. Overall hospital length of stay was 13.5 ± 16.7 days. Overall mortality was 22% (n = 8) with uniformly fatal outcomes following left atrial and multi-chamber injuries.

CONCLUSION

Overall, 37 patients with cardiac injuries were hospitalized to national major trauma facilities during the 23-year study period. The overall in-hospital mortality was 22% comparing favorably with previous reports. Risk factors for mortality were initial Glasgow Coma Scale < 9, pre-hospital cardiopulmonary resuscitation, and alcohol intoxication.

Penetrating cardiac injuries: A 36-year perspective at an urban, Level I trauma center

BACKGROUND

This study evaluates patterns of injuries and outcomes from penetrating cardiac injuries (PCIs) at Grady Memorial Hospital, an urban, Level I trauma center in Atlanta, Georgia, over 36 years.

METHODS

Patients sustaining PCIs were identified from the Trauma Registry of the American College of Surgeons and the Emory Department of Surgery database; data of patients who died prior to any therapy were excluded. Demographics and outcomes were compared over three time intervals: Period 1 (1975-1985; n = 113), Period 2 (1986-1996; n = 79), and Period 3 (2000-2010; n = 79).

RESULTS

Two hundred seventy-one patients (86% were male; mean age, 33 years; initial base deficit = -11.3 mEq/L) sustained cardiac stab (SW, 60%) or gunshot wounds (GSW, 40%). Emergency department thoracotomy was performed in 67 (25%) of 271 patients. Overall mortality increased in the modern era (Period 1, 27%, vs. Period 2, 22%, vs. Period 3, 42%; p = 0.03) along with GSW mechanisms (Period 1, 32%, vs. Period 2, 33%, vs. Period 3, 57%; p = 0.001), GSW mortality (Period 1, 36%, vs. Period 2, 42%, vs. Period 3, 56%; p = 0.04), and multichamber injuries (Period 1, 12%, vs. Period 2, 10%, vs. Period 3, 34%; p< 0.001). In Period 3, GSWs (n = 45) resulted in multichamber injuries in 28 patients (62%) and multicavity injuries in 19 patients (42%). Surgeon-performed ultrasound accurately identified pericardial blood in 55 of 55 patients in Period 3.

CONCLUSIONS

Increased frequency of GSWs in the past decade is associated with increased overall mortality, multichamber injuries, and multicavity injuries. Ultrasound is sensitive for detection of PCI.

LEVEL OF EVIDENCE

Therapeutic study, level IV; epidemioligc study, level III.

Intracardiac Penetrating Injury with Right Femoral Artery Embolism due to Blast Injury

Embolization due to blast injury with projectiles entering the bloodstream from the heart is a rare event that is unlikely to be suspected during the initial assessment of trauma patients. We report a case in which a missile penetrating the heart chambers managed to embolize and occlude the right common femoral artery. This was successfully managed by means of a multidisciplinary approach that included exploration, cardiorrhaphy, and embolectomy.

Traumatic cardiac injury: Experience from a level-1 trauma centre

PURPOSE

Traumatic cardiac injury (TCI) is a challenge for trauma surgeons as it provides a short thera- peutic window and the management is often dictated by the underlying mechanism and hemodynamic status. The current study is to evaluate the factors influencing the outcome of TCI.

METHODS

Prospectively maintained database of TCI cases admitted at a Level-1 trauma center from July 2008 to June 2013 was retrospectively analyzed. Hospital records were reviewed and statistical analysis was performed using the SPSS version 15.

RESULTS

Out of 21 cases of TCI, 6 (28.6%) had isolated and 15 (71.4%) had associated injuries. Ratio be- tween blunt and penetrating injuries was 2:1 with male preponderance. Mean ISS was 31.95. Thirteen patients (62%) presented with features suggestive of shock. Cardiac tamponade was present in 12 (57%) cases and pericardiocentesis was done in only 6 cases of them. Overall 19 patients underwent surgery. Perioperatively 8 (38.1%) patients developed cardiac arrest and 7 developed cardiac arrhythmia. Overall survival rate was 71.4%. Mortality was related to cardiac arrest (p = 0.014), arrhythmia (p = 0.014), and hemorrhagic shock (p =0.04). The diagnostic accuracy of focused assessment by sonography in trauma (FAST) was 95.24%.

CONCLUSION

High index of clinical suspicion based on the mechanism of injury, meticulous examination by FAST and early intervention could improve the overall outcome.

New device for temporary hemorrhage control in penetrating injuries to the ventricles

Background

The best way to control hemorrhage from cardiac injuries is through digital occlusion followed by suture. However, this is difficult to accomplish in the emergency department (ED) setting. Generally, temporary control is obtained in advance of definitive treatment in the operating room. Despite safety and efficacy concerns, balloon Foley catheter insertion through the injury is still an option following ED thoracotomies. We developed a new device for temporary hemorrhage control in cardiac injuries and compared it to the Foley.

Methods

6 adult swine (n=6) underwent full-thickness (1.5 cm) injury along the longitudinal axis of the right ventricle (RV). After 5 s of bleeding, hemorrhage control was attempted with either the device or the Foley, and blood loss quantified. Subsequently, the wound was sutured and mean arterial pressure was restored to baseline with lactated Ringer's infusion. Subsequently, another injury 2 cm apart in the same ventricle was managed with apparatus not employed in the first injury. The same followed in the LV totaling 4 injuries per animal, 2 in each ventricle. Intraoperative echocardiogram, laboratory test and final wound sizes assessed.

Results

The device resulted in less bleeding than the Foley; RV 58.7±11.3 vs 147.7±30.9 mL, LV 81.7±11.9 vs 187.5±40.3 mL (p<0.05). Percent change in tricuspid regurgitation was less with the device than FO, 66.6% vs 400%. Mitral regurgitation increased 16% with Foley, but remained unchanged with the device. Changes in stroke volume and LV ejection fraction were less with the device than with Foley; SV 2.09% vs 12.48%, left ventricular ejection fraction 0.46% vs 5.45%. Foley insertion enlarged the wounds. Platelet count, complete blood count, prothrombin time, activated prothrombin time and fibrinogen decreased, whereas troponin and lactate increased compared with baseline, underscoring the magnitude of shock.

Conclusions

Cardiac hemorrhage was effectively controlled with the new device. The low-profile collapsible blocking membrane interfered less with cardiac function than did the balloon of the Foley, an important asset in the context of shock.

Cardiac Injuries: A Review of Multidetector Computed Tomography Findings

Trauma is the leading cause of death in United States in the younger population. Cardiac trauma is common following blunt chest injuries and is associated with high morbidity and mortality. This study discusses various multidetector computed tomography (MDCT) findings of cardiac trauma. Cardiac injuries are broadly categorized into the most commonly occurring blunt cardiac injury and the less commonly occurring penetrating injury. Signs and symptoms of cardiac injury can be masked by the associated injuries. Each imaging modality including chest radiographs, echocardiography, magnetic resonance imaging and MDCT has role in evaluating these patients. However, MDCT is noninvasive; universally available and has a high spatial, contrast, and temporal resolution. It is a one stop shop to diagnose and evaluate complications of cardiac injury. MDCT is an imaging modality of choice to evaluate patients with cardiac injuries especially the injuries capable of causing hemodynamic instability.

Sharp Force Injuries at the University Hospital of the West Indies, Kingston, Jamaica: A Seventeen-year Autopsy Review

OBJECTIVES

This study aimed to ascertain the prevalence and patterns of fatal sharp force injuries, victims' demographics, cause of death and average survival time at the University Hospital of the West Indies (UHWI), Kingston, Jamaica.

METHODS

The autopsy records for 1990-2010 were searched for fatal cases of sharp force injuries. The records for 1998-2001 were not located. A 17-year retrospective analysis was therefore performed and findings for the two periods, 1990-1997 and 2002-2010 were compared. All data were obtained from the provisional anatomical diagnoses (PAD) autopsy reports.

RESULTS

During the 17-year period, 57/4264 autopsies were performed for sharp force injuries, yielding an overall autopsy prevalence rate of 1.34% (1.25%, 26/2086 (95% CI 0.77, 1.73) in Period 1 and 1.42%, 31/2178 (95% CI 0.92, 1.92) in Period 2). The majority were males (91.1%), in the age group 15-39 years (77%), mean age of 30.9 years (range = 17─65 years). Stab wounds predominated (91.3%) and the chest was the area most frequently stabbed (42.1%). In the 24 fatalities due to chest injuries only, eight (33.3%) had injuries to the heart alone. Forty-five patients (79.0%) died within 24 hours from exsanguination. Injury documentation at autopsy was deficient.

CONCLUSION

Stabbing was the most common sharp force injury, mainly involving the chest and young men were at greatest risk. Most patients died from exsanguination within 24 hours of admission. Introduction of synoptic-type reports for both clinical and autopsy examination may improve documentation.

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).

Western Trauma Association critical decisions in trauma: resuscitative thoracotomy

BACKGROUND

In the past three decades, there has been a significant clinical shift in the performance of resuscitative thoracotomy (RT), from a nearly obligatory procedure before declaring any trauma patient deceased to a more selective application of RT. We have sought to formulate an evidence-based guideline for the current indications for RT after injury in the patient.

METHODS

The Western Trauma Association Critical Decisions Committee queried the literature for studies defining the appropriate role of RT in the trauma patient. When good data were not available, the Committee relied on expert opinion.

RESULTS

There are no published PRCT and it is not likely that there will be; recommendations are based on published prospective observational and retrospective studies, as well as expert opinion of Western Trauma Association members. Patients undergoing cardiopulmonary resuscitation (CPR) on arrival to the hospital should be stratified based on injury and transport time. Indications for RT include the following: blunt trauma patients with less than 10 minutes of prehospital CPR, penetrating torso trauma patients with less than 15 minutes of CPR, patients with penetrating trauma to the neck or extremity with less than 5 minutes of prehospital CPR, and patients in profound refractory shock. After RT, the patient's intrinsic cardiac activity is evaluated; patients in asystole without cardiac tamponade are declared dead. Patients with a cardiac wound, tamponade, and associated asystole are aggressively treated. Patients with an intrinsic rhythm following RT should be treated according to underlying primary pathology. Following several minutes of such treatment as well as generalized resuscitation, salvageability is reassessed; we define this as the patient's ability to generate a systolic blood pressure of greater than 70 mm Hg with an aortic cross-clamp if necessary.

CONCLUSION

The success of RT approximates 35% for the patient arriving in shock with a penetrating cardiac wound and 15% for all patients with penetrating wounds. Conversely, patient outcome is relatively poor when RT is performed for blunt trauma, 2% survival for patients in shock and less than 1% survival for patients with no vital signs. Patients undergoing CPR on arrival to the hospital should be stratified based on injury and transport time to determine the utility of RT. This algorithm represents a rational approach that could be followed at trauma centers with the appropriate resources; it may not be applicable at all hospitals caring for the injured. There will be patient, personnel, institutional, and situational factors that may warrant deviation from the recommended guideline. The annotated algorithm is intended to serve as a quick bedside reference for clinicians.

Penetrating cardiac injury and the significance of chest computed tomography findings

In rare circumstances, hemodynamically stable patients can harbor serious penetrating cardiac injuries. We hypothesized that chest computed tomography (CCT) is potentially useful in evaluation. The records of all patients admitted to our center with wounds to the precordium or who sustained a hemothorax or pneumothorax after penetrating torso injuries over a 48-month period were reviewed. Those having an admission CCT were studied. The potential diagnostic value of hemopericardium (HPC) and pneumopericardium (PPC) on CCT was examined. Most of the 333 patients were male [293 (88.0 %)] with a roughly equal distribution of gunshot [189 (56.8 %)] and stab [144 (43.2 %)] wounds. Mean age was 28.7 ± 12.6 years. Thirteen (3.9 %) patients had cardiac injuries that were operatively managed. Eleven (3.3 %) CCT studies demonstrated HPC and/or PPC. Ten of these patients had an injury with one false positive. Retained hemothorax and proximity findings on the three false negative CCT studies led to video-assisted thoracoscopic surgery or subxiphoid exploration with diagnosis of the injury. HPC and/or PPC on CCT had a sensitivity of 76.9 %, specificity of 99.7 %, positive predictive value of 90.9 %, and negative predictive value (NPV) of 99.1 % for cardiac injuries. However, including all findings that changed management, CCT had a sensitivity and NPV of 100 %. CCT is a potentially useful modality for the evaluation of cardiac injuries in high-risk stable patients. The presence of HPC and/or PPC on CCT after penetrating thoracic trauma is highly indicative of a significant cardiac injury.

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.

Selective non-operative management of a left ventricular pseudoaneurysm after penetrating cardiac wound

Post-traumatic cardiac pseudoaneurysm (PSA) is a rare, potentially life-threatening complication after penetrating cardiac injury. Early surgical intervention has been the treatment of choice for this sequela due to the risk of rupture. Nevertheless, selective non-operative management (SNOM) has been practiced in patients with postinfarct PSA that are small and stable. We report a case of a post-traumatic cardiac PSA subjected to SNOM.

Management of metallic foreign bodies in the heart

Management of the metallic foreign body in the heart remains controversial. Evaluation of possible methods for this issue and its possible treatments are discussed, the results of which may lead to a more effective strategy for management of intracardiac foreign bodies.

Does hemopericardium after chest trauma mandate sternotomy?

BACKGROUND

Recently, three patients with hemopericardium after severe chest trauma were successfully managed nonoperatively at our institution. This prompted the question whether these were rare or common events. Therefore, we reviewed our experience with similar injuries to test the hypothesis that trauma-induced hemopericardium mandates sternotomy.

METHOD

Records were retrospectively reviewed for all patients at a Level I trauma center (December 1996 to November 2011) who sustained chest trauma with pericardial window (PCW, n = 377) and/or median sternotomy (n = 110).

RESULTS

Fifty-five (15%) patients with positive PCW proceeded to sternotomy. Penetrating injury was the dominant mechanism (n = 49, 89%). Nineteen (35%) were hypotensive on arrival or during initial resuscitation. Most received surgeon-performed focused cardiac ultrasound examinations (n = 43, 78%) with positive results (n = 25, 58%). Ventricular injuries were most common, with equivalent numbers occurring on the right (n = 16, 29%) and left (n = 15, 27%). Six (11%) with positive PCW had isolated pericardial lacerations, but 21 (38%) had no repairable cardiac or great vessel injury. Those with therapeutic versus nontherapeutic sternotomies were similar with respect to age, mechanisms of injury, injury severity scores, presenting laboratory values, resuscitation fluids, and vital signs. Multiple logistic regression revealed that penetrating trauma (odds ratio: 13.3) and hemodynamic instability (odds ratio: 7.8) were independent predictors of therapeutic sternotomy.

CONCLUSION

Hemopericardium per se may be overly sensitive for diagnosing cardiac or great vessel injuries after chest trauma. Some stable blunt or penetrating trauma patients without continuing intrapericardial bleeding had nontherapeutic sternotomies, suggesting that this intervention could be avoided in selected cases.

LEVEL OF EVIDENCE

Therapeutic study, level III.

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.

Relationship of echocardiographic and coronary angiographic findings in patients with acute myocardial infarction secondary to penetrating cardiac trauma

BACKGROUND

Patients with cardiac wounds could experience a posttraumatic acute myocardial infarction (PAMI) as a complication. Usually, this complication is explained by occlusion of a coronary artery, but sometimes, it cannot be explained by this pathophysiologic finding. This study aimed to determine the incidence of PAMI, make an approximation of PAMI pathophysiology, and propose management strategies.

METHODS

A prospective observational study was conducted at San Vicente de Paul University Hospital in Medellin, Colombia. During 12 months, we studied 51 patients with a history of a cardiac stab injury. We evaluated variables, such as Revised Trauma Score (RTS), surgical and anesthetic data, and possible risk factors. Diagnosis of PAMI was based on electrocardiogram, echocardiography, and troponin I serum levels. All PAMI patients had an coronary angiography. Risk factors possibly related to the development of PAMI were explored.

RESULTS

Fifty-one patients were evaluated; three died (5.9%). Of the patients, 35 (68.62%) did not develop PAMI, 6 (11.76%) developed PAMI with coronary injury, and 10 (19.6%) experienced PAMI without coronary injury (PAMIWCI). An RTS of 5.3 or lower and a Glasgow Coma Scale score of 9 or lower were risk factors associated with PAMIWCI (relative risk, 11.55; p = 0.03). We did not find a relationship between PAMI and the use of psychoactive substances or other comorbidities.

CONCLUSION

Patients with penetrating cardiac trauma may develop PAMIWCI. Active search for PAMI must be done in all patients with cardiac stab wound trauma, even those without artery coronary injury or symptoms suggestive of coronary ischemia. It is likely that Glasgow Coma Scale score of 9 of lower and RTS of 5.3 of lower for patients with cardiac injury are associated with the development of PAMIWCI.

Predictors of outcome in penetrating cardiac injuries

BACKGROUND

Cardiac injury is one of the most lethal injuries. The objective of this study was to determine the real amount of risk factors for penetrating cardiac injuries.

METHOD

A retrospective review of 64 consecutive penetrating cardiac injuries treated in reference center of the biggest regional hospital from September 2002 to January 2009.

RESULTS

There were 58 men (90.6%) and 6 women (9.4%), with a mean age of 26.19 years ± 11.68 years (range, 13-67 years). The mechanism of injury was stab wound for 57 patients and gunshot wound for the remainder. Mortality was 17.19% (11 of 64 patients). The forward stepwise multivariate logistic regression analysis of the results revealed four risk variables-two were measures of patients, age and pH, and the others were scoring systems, Trauma Injury Severity Scores and Acute Physiology and Chronic Health Evaluation II. The odds ratios and confidence interval of four variables are followed as 6.665 (4.213-10.544), 3.435 (2.171-5.433), 2.715 (1.716-4.295), and 2.201 (1.391-3.481), respectively.

CONCLUSION

Our data have shown the real amount of risk variables for mortality in penetrating cardiac injuries by using binary logistic model.

Emergent cardiopulmonary bypass in canines with penetrating cardiac wounds caused by gunshot

BACKGROUND

Most patients with penetrating cardiac wounds die within minutes of injury from uncontrolled haemorrhage and acute cardiac dysfunction. Thus, sustaining sufficient circulation rapidly is crucial to saving lives. Emergent cardiopulmonary bypass (CPB) is a potential intervention to maintain circulation after penetrating cardiac wounds from a gunshot.

METHODS

Canines were wounded with a bullet and randomly split into one of three treatment groups. Animals in group 1 (Gp1) were treated with conventional methods. Animals in group 2 (Gp2) received emergent CPB for 180 min and autologous blood transfusion. Animals in group 3 (Gp3) received emergent CPB for 30 min followed by surgical repair. Animal survival, haemodynamics and blood chemistry were measured, and lung water content was evaluated at the end of the experiment.

RESULTS

The right ventricle was the most severely wounded cardiac chamber. In Gp1, mean arterial pressure and central venous pressure were dramatically decreased 8 min after injury, and all animals died within 18 min. In Gp2 and Gp3, mean arterial pressure ranged from 60-90 mm Hg during CPB. 60 min after terminating CPB in Gp2, mean arterial pressure and heart rate were decreased compared to Gp3. In Gp3, most animals maintained haemodynamic stability. 60 min after CPB, free haemoglobin in circulating blood was elevated compared to pre-trauma levels. Pulmonary water content was significantly higher in Gp2 and Gp3 than in Gp1.

CONCLUSIONS

Emergent CPB in the field can maintain haemodynamic stability and supply vital organs with sufficient blood flow, but surgery following CPB is essential to rescue patients with penetrating cardiac wounds.

Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes

In the past three decades there has been a significant clinical shift in the performance of emergency department thoracotomy (EDT), from a nearly obligatory procedure before declaring any trauma patient to select patients undergoing EDT. The value of EDT in resuscitation of the patient in profound shock but not yet dead is unquestionable. Its indiscriminate use, however, renders it a low-yield and high-cost procedure. Overall analysis of the available literature indicates that the success of EDT approximates 35% in the patient arriving in shock with a penetrating cardiac wound, and 15% for all penetrating wounds. Conversely, patient outcome is relatively poor when EDT is done for blunt trauma; 2% survival in patients in shock and less than 1% survival with no vital signs. Patients undergoing CPR upon arrival to the emergency department should be stratified based upon injury and transport time to determine the utility of EDT. The optimal application of EDT requires a thorough understanding of its physiologic objectives, technical maneuvers, and the cardiovascular and metabolic consequences.

Delayed Diagnosis and Management of an “Occult” Stab Wound to the Heart

Stab wounds to the heart can present without clinical evidence of injury. Echocardiography has been advocated as an alternative to subxyphoid exploration in these cases. We present a case in which two serial echocardiography exams missed a diagnosis. Electrocardiographic changes and elevation of serial troponin I levels suggested the diagnosis, which was confirmed by thoracoscopy. Repair was facilitated by use of adenosine cardiac standstill.

Mortality from Isolated Civilian Penetrating Extremity Injury

BACKGROUND

Although studies have ascertained that ten percent of soldiers killed in battle bleed to death from extremity wounds, little data exists on exsanguination and mortality from extremity injuries in civilian trauma. This study examined the treatment course and outcomes of civilian patients who appear to have exsanguinated from isolated penetrating extremity injuries.

METHODS

Five and 1/2 years' data (Aug 1994 to Dec 1999) were reviewed from two Level I trauma centers that receive 95% of trauma patients in metropolitan Houston, TX. Records (hospital trauma registries, emergency medical system (EMS) and medical examiner data) were reviewed on all patients with isolated extremity injuries who arrived dead at the trauma center or underwent cardiopulmonary resuscitation (CPR) or emergency center thoracotomy (ECT).

RESULTS

Fourteen patients meeting inclusion criteria were identified from over 75,000 trauma emergency center (EC) visits. Average age was 31 years and 93% were males. Gunshot wounds accounted for 50% of the injuries. The exsanguinating wound was in the lower extremity in 10/14 (71%) patients and proximal to the elbow or knee in 12/14 (86%). Ten (71%) had both a major artery and vein injured; one had only a venous injury. Prehospital hemorrhage control was primarily by gauze dressings. Twelve (86%) had "signs of life" in the field, but none had a discernable blood pressure or pulse upon arrival at the EC. Prehospital intravenous access was not obtained in 10 patients (71%). Nine patients underwent ECT, and nine were initially resuscitated (eight with ECT and one with CPR). Those undergoing operative repair received an average of 26 +/- 14 units of packed red blood cells. All patients died, 93% succumbing within 12 hours.

CONCLUSION

Although rare, death from isolated extremity injuries does occur in the civilian population. The majority of injuries that lead to immediate death are proximal injuries of the lower extremities. The cause of death in this series appears to have been exsanguination, although definitive etiology cannot be discerned. Intravenous access was not obtainable in the majority of patients. Eight patients (57%) had bleeding from a site that anatomically might have been amenable to tourniquet control. Patients presenting to the EC without any detectable blood pressure and who received either CPR or EC thoracotomy all died.

Large Left Ventricular Pseudoaneurysm Presenting 25 Years After Penetrating Chest Trauma

Penetrating chest wounds leading to damage of thoracic structures are common. A rare sequelae of chest trauma is a contained rupture of the left ventricle of the heart leading to the development of a pseudoaneurysm. This complication needs prompt recognition and repair because of the high likelihood of rupture and death. We report the case of a 47-year-old man who underwent repair of a stab wound to the heart 25 years ago and subsequently developed a large left ventricular pseudoaneurysm and presented with angina.

Trauma cardíaco: estudo de necropsias

RESUMO OBJETIVO: Pacientes vítimas de trauma cardíaco morrem, na maioria das vezes, antes de receberem atendimento médico. Porém, são poucos os estudos epidemiológicos deste tipo de lesão descrevendo a porcentagem de pacientes que chegam a ser tratados. O objetivo do presente trabalho é avaliar as características das vítimas de trauma cardíaco através da interpretação de laudos de necropsia. MÉTODO: Foram revisados 1.976 casos de óbito por causas externas submetidos a necropsia no Instituto Médico Legal de Campinas, num período de dois anos. Os casos foram divididos em dois grupos: I, trauma penetrante; e II, trauma fechado. RESULTADOS: Houve predomínio dos traumas penetrantes (1.294 casos - 65,5%). Trauma cardíaco foi identificado em 359 laudos (18,2%), sendo 296 do grupo I e 63 do grupo II. No grupo I, 73,6% dos óbitos ocorreram no local do trauma e apenas 18 pacientes (6%) foram atendidos em hospital e submetidos a toracotomia. No grupo II o tratamento cirúrgico foi indicado em dois dos 14 traumatizados (3,2% dos traumas fechados) admitidos com presença de sinais vitais. A câmara cardíaca mais acometida no grupo I foi o ventrículo esquerdo (lesão isolada em 24,6% dos casos) e no grupo II o ventrículo direito (25%). CONCLUSÕES: Conclui-se que as lesões cardíacas são eminentemente fatais e apenas 5,6% destes traumatizados que morreram chegaram a receber tratamento efetivo.

Seven hundred fifty-three consecutive deaths in a level I trauma center: the argument for injury prevention

BACKGROUND

The past century has seen improvement in trauma care, with a resulting decrease in therapeutically preventable deaths. We hypothesize that further major reduction in injury mortality will be obtained through injury prevention, rather than improvements in therapy.

METHODS

Seven hundred fifty-three deaths in an American College of Surgeons-verified, Level I trauma center were reviewed as they occurred. Deaths were classified as therapeutically not preventable, possibly preventable, or preventable. These charts were also reviewed for factors that might have prevented or lessened the severity of the injury.

RESULTS

Mean age was 43, mean Glasgow Coma Scale score was 5, mean Revised Trauma Score was 4, mean Injury Severity Score was 41, and mean probability of survival was 0.25 (according to TRISS). Forty-six percent underwent cardiopulmonary resuscitation in the field, 52% died within 12 hours, 74% died within 48 hours, and 86% died within 7 days. Primary causes of death included central nervous system injury in 51%, irreversible shock in 21%, multiple injuries (shock plus central nervous system injury) in 9%, multiple organ failure/sepsis and other causes in 3%, and pulmonary embolus in 0.1%. Seven hundred one (93%) were classified as not preventable with a change in therapy, 32 (4.2%) were classified as potentially preventable with a change in therapy, and 20 were classified as preventable with a change in therapy (2.6%). Forty-six percent had cardiopulmonary resuscitation performed before or immediately on arrival to the hospital. Another 23% had vital signs present on arrival, but had a Glasgow Coma Scale score of <or= 4. Of the 546 unintentionally injured patients, 58% had an identifiable factor that contributed to the presence and/or severity of the injury (intoxication, restraint and helmet use), with 28% of patients having a positive blood alcohol level. Of the 206 patients with intentional injuries, 44% were intoxicated at the time of their death. Commensurate with driving-while-intoxicated prevention program(s), the percentage of intoxicated patients significantly ( p= 0.03) decreased from 45% to 34% over the same 7-year period.

CONCLUSION

Dramatically improving therapy (no errors, cure for multiple organ failure, sepsis, and pulmonary embolus) in a modern trauma system would decrease trauma mortality by 13%. In contrast, more than half of all deaths are potentially preventable with preinjury behavioral changes. Injury prevention is critical to reducing deaths in the modern trauma system.

Outcome of major cardiac injuries at a Canadian trauma center

BACKGROUND

Canadian trauma units have relatively little experience with major cardiac trauma (disruption of a cardiac chamber) so injury outcome may not be comparable to that reported from other countries. We compared our outcomes to those of other centers.

METHODS

Records of patients suffering major cardiac trauma over a nine-year period were reviewed. Factors predictive of outcome were analyzed.

RESULTS

Twenty-seven patients (11 blunt and 16 penetrating) with major cardiac trauma were evaluated. Injury severity scores (ISS) were similar for blunt (49.6 +/- 16.6) and penetrating (39.5 +/- 21.6, p = 0.20) injuries. Five of 11 blunt trauma patients, and 9 of 16 penetrating trauma patients, had detectable vital signs on hospital arrival (p = 0.43). Ten patients underwent emergency department thoracotomy and 11 patients had cardiac repair in the operating theatre. Eleven patients survived and 16 died. Survivors had a lower ISS (33.7 +/-15.4) than non-survivors (50.4 +/- 20.4; p = 0.03). Two of 11 blunt trauma patients and 9 of 16 penetrating trauma patients survived (p = 0.06). Eleven of 14 patients with detectable vital signs survived; all 13 without detectable vital signs died (p = 0.00003). Ten of eleven patients treated in the operating theatre survived, while only one of the other 16 patients survived (p = 0.00002).

CONCLUSIONS

Patients with major cardiac injuries and detectable vital signs on hospital arrival can be salvaged by prompt surgical intervention in the operating theatre. Major cardiac injuries are infrequently encountered at our center but patient survival is comparable to that reported from trauma units in other countries.

Late presentation of retained intracardiac ice pick with papillary muscle injury

An unusual case of a penetrating intracardiac injury is described in a 16-year-old boy who presented with a retained 14-cm segment of an ice pick that went unnoticed by the patient for 4 days. The ice pick had lacerated the anterior papillary muscle of the left ventricle causing avulsion of its tip and prolapse of the anterior leaflet of the mitral valve resulting in severe mitral regurgitation. The urgency for surgical correction of the traumatic mitral valve injury at the time of extraction of the intracardiac foreign body through a single-stage approach versus a two-stage approach is discussed.

[Evaluation and treatment of cardiac injuries]

Cardiac injuries caused by a heart traumatism are not frequent but, of great importance given their high morbidity. Two different groups in terms of etiology, clinical picture, application of diagnostic techniques, treatment and prognosis can be considered. On one hand, there are cardiac injuries caused by a thoracal contusion, which provokes a contused lesion can affect the free wall, the interventricular septum, the valves, the subvalvular apparatus, the conduction system and the coronary vessels and, on the other hand, cardiac injuries caused by penetrating objects. Cardiac injury can lead to a life-threatening hemodynamic instability which mandates prompt and clear diagnostic and therapeutic approaches.

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

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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