Penetrating injury to the cardiac box

Bleeding management of thoracic trauma

PURPOSE OF REVIEW

Thoracic injuries are directly responsible for 20-30% of deaths in severe trauma patients and represent one of the main regions involved in preventable or potentially preventable deaths. Controlling bleeding in thoracic trauma is a major challenge because intrathoracic hemorrhagic lesions can lead to hemodynamic instability and respiratory failure.

RECENT FINDINGS

The aim of managing intrathoracic hemorrhagic lesions is to control bleeding as quickly as possible and to control any respiratory distress. Extended focus assessment with sonography for trauma enables us to identify intrathoracic bleeding much more quickly and to determine the most appropriate therapeutic strategy.

SUMMARY

Thoracic bleeding can result from the diaphragm, intrathoracic vessels (aorta, but also inferior or superior vena cava, and suprahepatic veins), lung, cardiac, or chest wall injuries. Depending on thoracic lesions (such as hemothorax or hemopericardium), hemodynamic instability, and respiratory failure, a pericardial window approach, sternotomy, thoracotomy, or emergency resuscitation thoracotomy may be considered after discussion with the surgeon. Alongside treatment of injuries, managing oxygenation, ventilation, hemodynamic, and coagulopathy are essential for the patient's outcome.

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.

ACR Appropriateness Criteria® Penetrating Torso Trauma

This document assesses the appropriateness of various imaging studies for acute penetrating trauma to the torso. Penetrating trauma most commonly occurs from gunshots and stabbings, although any object can impale the patient. Anatomic location, type of penetrating trauma, and hemodynamic status are among the many important factors when deciding upon if, what, and when imaging is needed to further evaluate the patient. Imaging plays a critical role in the management of these patients. CT, in particular, aids in identifying and predicting internal injuries based upon trajectory of the object. Clinical variants are distinguished by ballistic versus nonballistic injuries, hemodynamic status, and compartment of the body injured. Ballistic trauma trajectory is less predictable, and imaging recommendations are adjusted for this unpredictability. Excluded from this document are penetrating traumatic injuries to pediatric patients and specific recommendations when the genitourinary system is clinically suspected to be injured, the latter of which is more specifically discussed in other Appropriateness Criteria documents. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are documented annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer documented journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer documented literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

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.

Delayed cardiac tamponade secondary to blast injury from gunshot wound

Penetrating injuries are recognized for the direct tissue damage, which is typically evident on physical examination. Secondary injuries resulting from kinetic energy transfer in the case of gunshot wounds (GSWs), often referred to as "blast injuries", may affect tissues distant to the ballistic trajectory and are often occult. We present a case of delayed cardiac tamponade resulting from secondary blast injury. The patient sustained a thoraco-abdominal GSW with entry adjacent to the cardiac box. An Advanced Trauma Life Support (ATLS)-guided assessment revealed intra-abdominal injuries necessitating operative intervention without evidence of cardiac injury. On post-operative day four, the patient developed chest pain, tachycardia, and shortness of breath. Imaging revealed a large pericardial effusion with cardiac tamponade. Emergent exploration revealed hemopericardium secondary to a bleeding epicardial hematoma without evidence of pericardial violation. Clinicians must maintain a high clinical suspicion for occult, indirect blast injuries which may be life-threatening.

Thoraco-laparotomy approach to salvage a life-threatening cardiac box stab injury to the infecrior vena cava in Malaysia: a case report

Torso stab injuries near the cardiac box may present unique challenges due to difficulties in hemorrhage control. For a stab injury to the heart, the repair is straightforwardly performed via median sternotomy. In contrast, injuries to the inferior vena cava are challenging to repair, especially when they are close to the diaphragm, and the bleeding can be torrential. Herein, we describe a case of a self-inflicted stab wound within the "cardiac box." The trajectory of the stab injuries went below the diaphragm and injured the infradiaphragmatic inferior vena cava. Successful emergent repair via the thoraco-laparotomy approach revived the young man. In this report, we revisit and discuss previous large series of patients with this rare vena cava injury.

Retrospective analysis of 261 autopsies of penetrating cardiac injuries with emphasis on sociodemographic factors

Penetrating cardiac injuries (PCIs) are highly lethal and several factors are related to its incidence and mortality. While most studies focus on characterizing patients who arrived at a medical facility alive and exploring the relationship between the degree of heart compromise and mortality, our study delved deeper into the topic. This study analyzed 261 autopsy reports from 2017 in Bogotá, Colombia, and characterized the factors surrounding PCI incidence and mortality while emphasizing the role of sociodemographic variables. Of these cases, 247 (94.6%) were males with a mean age of 29.19 ± 9.7 years. Weekends, holidays, and late hours had the highest incidence of PCIs. The victims' deaths occurred at the scene in 66 (25.3%) cases, and 65.1% of the victims died before receiving medical care. Upon admission, patients with vital signs were more likely to have been transported by taxi or a private vehicle. Two or more compromised cardiac chambers, increased time of transportation, trauma occurred in the city outskirts, and gunshot wounds were related to increased mortality. Our data is valuable for surgeons, health system managers, and policy analysts as we conducted a holistic assessment of the anatomical and sociodemographic factors that are closely associated with mortality following a PCI. Surgeons must recognize that PCIs can occur even when the entrance wound is outside the cardiac box. Reinforcing hospital infrastructure in the outskirts and improving the availability, accuracy, and response time of first responders may lead to improved patient mortality rates.

Penetrating Cardiac Injuries: Outcome of Treatment from a Level 1 Trauma Centre in South Africa

Background: Penetrating cardiac injuries are rare in South African and international literature. Penetrating cardiac injuries are regarded as one of the most lethal injuries in trauma patients. The mechanism of injury varies across the world. In developing countries, stab wounds cause the majority of penetrating cardiac injuries. These injuries remain clinically challenging and are associated with high mortalities. Aim: To describe our experience with penetrating cardiac injuries and the outcome of their management at a level 1 trauma unit in Johannesburg, South Africa. Materials and methods: We retrospectively reviewed all patients who presented with penetrating cardiac injuries over a period of four years (1 January 2016 to 31 December 2019). The patients were identified using the hospital database. The patient’s demographics, mechanism of injury, injury severity score, vital signs, investigation findings, final diagnosis, type of operation, length of hospital stay, morbidities, and mortalities were recorded. Results: There was a total of 167 patients with penetrating cardiac injuries identified. There were 151 (90.4%) males, with an overall median age of 29 years (IQR 24–34). Stab wounds accounted for 77.8% of the injuries, while gunshot wounds (GSW) accounted for 22.2%. The median injury severity score (ISS) and revised trauma score (RTS) were 25 and 7.1, respectively. The right ventricle was the most injured chamber (34.7%), followed by the left ventricle (29.3%), right auricle (13.2%), right atrium (10.2%), and combined injuries accounted for 7% of injuries. A commonly used incision was a sternotomy (51.5%), left anterior-lateral thoracotomy (26.9%), emergency room thoracotomy (19.2%), and clamshell thoracotomy (2.4%). The overall mortality rate was 40.7%, with a 29.2% mortality in the stab wounds. Twenty-four (14.4%) patients died in the emergency department, sixteen (9.6%) patients died on the table in theatre, and the remaining twenty-eight (16.7%) died in the intensive care unit or wards. Gunshot wounds, other associated injuries, right ventricle injuries, a high ISS, low RTS, and low Glasgow coma scale were all significantly more likely to result in death (p < 0.001). Conclusions: Penetrating cardiac injuries are often fatal, but the mortality can be improved with appropriate resuscitation and a work-up. The injuries to the heart can be safely managed by trauma/general surgeons in our setting. The physiology in presentation and other associated injuries determines outcomes in patients with penetrating cardiac injury.

Surgical exploration for stable patients with penetrating cardiac box injuries: when and how? A cohort of 155 patients from Marseille area

BACKGROUND

The management of penetrating thoracic injuries in moribund or unstable patients is clearly described in contrast to that of stable patients, particularly for those with a cardiac box injury. This anatomic location suggests a potentially lethal cardiac injury and requires urgent therapeutic decision making. The present study aims at determining when surgical exploration is beneficial for stable patients presenting with penetrating cardiac box injuries (PCBI).

METHODS

This was a retrospective study of stable civilian patients with PCBI referred to level I trauma centers in the Marseille area between January 2009 and December 2019. Using post-hoc analysis of the management outcomes, patients whose surgery was considered therapeutic (group A) were compared with those surgery was considered non-therapeutic and with non-operated patients (group B).

RESULTS

A total of 155 patients with PCBI were included, with 88% (n = 137) of stab wound injuries (SW). Overall, surgical exploration was performed in 54% (n = 83), considered therapeutic in 71% (n = 59), and performed by video-assisted thoracoscopy (VATS) in 42% (n = 35) with a conversion rates of 14% (n = 5). Initial extended Fast Assessment with Sonography for Trauma (eFAST) revealed the presence of hemopericardium in 29% (n = 29) in group A vs 9.5% (n = 7) in group B, p = 0.010, and was associated with a negative predictive value of 93% regarding the presence of a cardiac injury. Chest tube flow was significantly higher in patients who required surgery, with a median (IQR) of 600.00 (350.00, 1200.00) mL vs. 300.0 (150.00, 400.00) mL (p = 0.001).

CONCLUSION

eFAST and chest tube flow are the cornerstones of the management of stable PCBI. Video-assisted thoracoscopy represents an interesting approach to check intra thoracic wounds while minimizing surgical morbidity.

LEVEL OF EVIDENCE

Level IV, prognostic study.

A meta-analysis of the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma

BACKGROUND

We performed a systematic review (SR) and meta-analysis (MA) to determine the diagnostic accuracy of chest ultrasound (US) compared with a pericardial window (PW) for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma.

METHODS

A literature search in five databases identified relevant articles for inclusion in this SR and MA. Studies were eligible if they evaluated the diagnostic accuracy of chest US, compared with a PW, for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients presenting with penetrating thoracic trauma. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for final analysis. Methodological quality was evaluated using Quality Assessment of Diagnostic Accuracy Studies-2. We performed a MA of binary diagnostic test accuracy within the bivariate mixed-effects logistic regression modeling framework.

RESULTS

We included five studies in our SR and MA. These studies included a total of 556 trauma patients. The MA found that, compared with PW, the US was 79% sensitive and 92% specific for detecting occult penetrating cardiac injuries in hemodynamically stable patients. The presence of a concomitant left hemothorax was frequent in patients with false-negative results.

CONCLUSION

This SR and MA found that, compared with PW, US was 79% sensitive and 92% specific for detecting occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma. Caution interpretation of pericardial US results is suggested in the presence of left hemothorax. In these cases, a second diagnostic test should be performed.

LEVEL OF EVIDENCE

Systematic Review and Meta-analysis, level II.