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

Focused assessment with sonography for trauma exam for diagnosis of pericardial effusion in penetrating thoracic trauma - A retrospective review from a level 1 trauma center

INTRODUCTION

Point of care ultrasound has long been used in the trauma setting for rapid assessment and diagnosis of critically ill patients. Its utility for diagnosis of pericardial effusion in the setting of penetrating thoracic trauma has more recently been a topic of consideration, given the rapid decompensation that these patients can experience.

OBJECTIVES

This study aims to identify the diagnostic accuracy of point of care ultrasound in the diagnosis of pericardial effusion among patients with penetrating thoracic trauma.

METHODS

Retrospective review of 2099 patients brought to the trauma bay between the years 2016 and 2021 were analyzed for diagnosis of pericardial effusion. Patients who were diagnosed with a pericardial effusion were investigated for point of care ultrasound findings. Descriptive statistics were performed to identify sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

Prevalence was calculated to be 26.7 cases of pericardial effusion per 1000 patients presenting with penetrating thoracic trauma. Incidence was estimated to be 3.8 cases of pericardial effusion per 1000 person-years. Calculation of diagnostic capabilities of ED POCUS revealed a sensitivity of 96.36 ​%, a specificity of 100 ​%, PPV of 100 ​%, and NPV of 99.90 ​%.

CONCLUSIONS

Point of Care cardiac ultrasonography is a reliable tool for the rapid diagnosis of pericardial effusion in penetrating thoracic trauma patients. Patients with ultrasound suggestive of this condition should receive rapid surgical management to prevent decompensation.

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.

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.

Torso damage control for ongoing hemorrhage: Tips and tricks

Thoracic injuries are common and occur in combination with other injuries in various compartments representing a significant pattern of injury in any trauma center. Injured patients presenting with exsanguinating hemorrhage from the thoracic cavity are an acute subset of patients that can be extremely challenging to any trauma surgeon as the immediate need to diagnose and intervene is critical. Diagnosis is based on traumatic history pattern and hemodynamics, assisted with plain films, ultra-sound and properly placed chest tubes. The chest should always be considered as a source of unexplained hemodynamic instability with hemorrhage identification by tube thoracostomy, pericardial window or surgical thoracotomy if the patient is already in the OR or if imaging is not available. Various surgical incisions are possible for thoracic traumatic bleeding with various exposure advantages and disadvantages with care and thought prior to incision. Regardless, delay to intervention or trepidation is lethal particularly in these challenging trauma patients.