[Complications after cardiac injuries]

An analysis of 293 victims with cardiac and pericardium injuries was made. Cardiac complications could appear suddenly and be registered on any stage of treatment process. They differentiated by character and duration of wound process. Pericarditis took place in 288 patients. The syndrome of system inflammation reaction was noted in 47.9% of patients, a sepsis (sometimes severe sepsis) was in 14.3%. Complications in postoperative period were determined by posthypoxic and hemic hypoxia, coagulopathy. They were manifested by myocardial ischemia and thromboembolic complications. An acute myocardial infarction took place in 29 (9.8%) cases and rhythm and conductivity abnormalities were in 23 (7.8%) patients. The circulatory failure with clinical picture of pulmonary edema was developed in 12 (4.1%) cases. The lethality consisted of 44 (15%) patients.

Management and outcomes of coronary artery perforation during percutaneous coronary intervention

Coronary perforation is a particularly feared complication of percutaneous coronary intervention. The optimal management and predictors of adverse outcomes for these patients remain to be defined. Advances in management such as the use of polytetrafluoroethylene-covered stents have not been critically examined in terms of efficacy. We analyzed a cohort of patients who sustained coronary perforation during percutaneous coronary intervention at our institution during a 9-year period to examine the trends in incidence, management, and outcomes. The patient medical records were reviewed, and detailed angiographic analysis was undertaken to identify the predictors of adverse outcomes, including the development of tamponade, the requirement for emergency coronary artery bypass grafting, and in-hospital death. One year of follow-up was attempted for all patients. Seventy-two cases of coronary perforation were identified, with an overall incidence of 0.19%. The perforation grade and presence of chronic renal insufficiency were the only predictors of mortality on multivariate regression analysis. The use of polytetrafluoroethylene-covered stents to manage perforations was not associated with any reduction in adverse outcomes, such as the development of tamponade, the need for emergency coronary artery bypass grafting, or in-hospital death. In conclusion, coronary perforation remains a feared complication in the contemporary interventional era with significant in-hospital mortality. Emphasis should be placed on preventing this complication whenever possible, including exercising particular caution in patients with chronic renal insufficiency. The treatment of such patients should be tailored to the severity of the perforation. The optimal treatment of these patients needs to be defined, and the efficacy of covered stents needs to be studied prospectively.

[Treatment of cardiac stab wounds. A thirty-one-year experience]

Penetrating cardiac wounds represent a dramatically pathology of the general surgery because of their clinical presentation and outcome. The cardiorrhaphy with the three successive times, carried out with maximum rapidity is the only safe and efficient surgical technique which leads to hemostasis and healing. The aim of this study was to evaluate our results and experience of penetrating cardiac injuries treated at the Clinic of Surgical Emergencies from Iaşi. 20 patients, 17 men and 3 women, of mean age 34 years (range 18-51), with stab wounds, underwent cardiorrhaphy between 1974 and 2004. The clinical aspects were: "white injured" (hemorrhagic shock) in 3 patients, "blue injured" (cardiac tamponade) in 8 patients, both being implied with some patients, one of the aspects being predominant. 9 patients (45%) had only cardiac injuries and 11 (55%) had other associated injuries. There were 7 intraoperative cardiac arrests and 2 postoperative pulmonary complications. In 16 cases the outcome of patients with cardiac stab wounds was favourable. We recorded 4 deaths. Mortality results from the wounds of the right auricle. The high rate of survival (80%) proves that a penetrating cardiac injury with a heavy prognosis may be turned into a relative traumatism harmless for those patients who will remain alive until they arrive in hospital.

Use of description logic classification to reason about consequences of penetrating injuries

The consequences of penetrating injuries can be complex, including abnormal blood flow through the injury channel and functional impairment of organs if arteries supplying them have been severed. Determining the consequences of such injuries can be posed as a classification problem, requiring a priori symbolic knowledge of anatomy. We hypothesize that such symbolic knowledge can be modeled using ontologies, and that the reasoning task can be accomplished using knowl-edge representation in description logics (DL) and automatic classification. We demonstrate the capabilities of automated classification using the Web Ontology Language (OWL) to reason about the consequences of penetrating injuries. We created in OWL a knowledge model of chest and heart anatomy describing the heart structure and the surrounding anatomic compartments, as well as the perfusion of regions of the heart by branches of the coronary arteries. We then used a domain-independent classifier to infer ischemic regions of the heart as well as anatomic spaces containing ectopic blood secondary to the injuries. Our results highlight the advantages of posing reasoning problems as a classification task, and lever-aging the automatic classification capabilities of DL to create intelligent applications.

Blunt cardiac injury

In summary, the incidence of BCI following blunt thoracic trauma patients has been reported between 20% and 76%, and no gold standard exists to diagnose BCI. Diagnostic tests should be limited to identify those patients who are at risk of developing cardiac complications as a result of BCI. Therapeutic interventions should be directed to treat the complications of BCI. Finally, the prognosis and outcome of BCI patients is encouraging

Correlation of clinical characteristics and outcomes with injury scoring in blunt cardiac trauma

BACKGROUND

Clinical sequelae from blunt cardiac trauma (BCT) may range from minor electrocardiographic abnormalities to death from free-wall rupture. There are no established clinical characteristics or injury scoring systems that are able to predict survival in these patients.

METHODS

A retrospective review of medical records from a Level I trauma center identified 47 patients with BCT. A grade assigned on the basis of the American Association for the Surgery of Trauma Organ Injury Scale (OIS) was assigned to each case studied. Clinical data, including the Injury Severity Score (ISS), and outcomes were analyzed for association with OIS grade.

RESULTS

The average ISS was 27.9, and the overall mortality rate was 31.9%. The majority of patients were either grade II or IV, with the latter having the highest mortality. Hypotension at admission, cardiac arrest, lack of vital signs at admission, ISS, hours to diagnosis, and death all had significant association with assigned OIS grade. Factors associated with mortality included ISS; OIS grade; shorter time to diagnosis; cardiac tamponade; cardiac rupture; lack of vital signs at admission; and concomitant injury to either the thoracic aorta or to the liver, spleen, or kidneys.

CONCLUSION

The OIS grade, assigned on the basis of anatomic site of injury and electrocardiographic abnormalities, appears to correlate with severity of injury and survival. Although injury scoring should not be used exclusively to guide management in trauma patients, the grading system studied may be useful in predicting outcomes in patients with BCT.

Pericardial tamponade type injury: a 17-year study in an urban trauma center in Japan

We defined injuries to the heart and the pericardium together with hemopericardium as pericardial tamponade type injury regardless of symptoms or signs due to pericardial tamponade. The aim of the study is to examine the important factors related to the diagnosis and treatment of this type of injury. A retrospective chart review was conducted of traumatized patients admitted with hemopericardium to our institution between 1978 and 1995. Ten out of the 19 consecutive patients with pericardial tamponade type injury demonstrated shock and showed a higher Injury Severity Score and mortality (7/11) than the remaining 9 without shock. The majority of our cases received an emergency room thoracotomy or a surgical fenestration and thereafter some of them needed a (re-)thoracotomy in the operating room. We consider a fenestration through the pericardium to be the first choice for the relief of acute hemopericardium due to trauma, while surgeons should not perform pericardiocentesis for the either diagnosis or relief of this type of injury.

The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study

BACKGROUND

Ultrasound is quickly becoming part of the trauma surgeon's practice, but its role in the patient with a penetrating truncal injury is not well defined. The purpose of this study was to evaluate the accuracy of emergency ultrasound as it was introduced into five Level I trauma centers for the diagnosis of acute hemopericardium.

METHODS

Surgeons or cardiologists (four centers) and technicians (one center) performed pericardial ultrasound examinations on patients with penetrating truncal wounds. By protocol, patients with positive examinations underwent immediate operation. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded.

RESULTS

Pericardial ultrasound examinations were performed in 261 patients. There were 225 (86.2%) true-negative, 29 (11.1%) true-positive, 0 false-negative, and 7 (2.7%) false-positive examinations, resulting in sensitivity of 100%, specificity of 96.9%, and accuracy of 97.3%. The mean time from ultrasound to operation was 12.1+/-5 minutes.

CONCLUSION

Ultrasound should be the initial modality for the evaluation of patients with penetrating precordial wounds because it is accurate and rapid.

Penetrating cardiac injuries: a prospective study of variables predicting outcomes

BACKGROUND

Penetrating cardiac injuries are one of the leading causes of death from urban violence.

STUDY DESIGN

This is a prospective, 1-year study in a Level I Trauma Center with the objective of analyzing: (1) the parameters measuring the physiologic condition of patients sustaining penetrating cardiac injuries in the field during transport and on arrival, (2) the cardiovascular-respiratory score (CVRS) component of the trauma score, (3) the mechanism and anatomic site of injury, (4) the presence or absence of tamponade, and (5) the cardiac rhythm as a predictor of outcomes. We attempted to correlate cardiac injury grade (AAST-OIS) with mortality. Our main intervention was thoracotomy for resuscitation and definitive repair of cardiac injury. Main outcomes measures were all parameters measuring the physiologic condition of patients, CVRS, mechanism and anatomic site of injury, operative findings and maneuvers, mortality, and grade of injury.

RESULTS

The study consisted of 60 patients sustaining penetrating cardiac injuries, 35 gunshot wound (58%) and 25 stab wounds (42%). The injury severity score (ISS) was > 30 in 22 patients; overall survival was 22 of 60 (36.6%); gunshot wound (GSW) survival, 5 of 35 (14%); and stab wound (SW) survival, 17 of 25 (68%). An emergency department thoracotomy was performed in 37 of 60 (61.7%) with 6 of 37 survivors (16%). CVRS: 96% mortality (25 of 26) when CVRS = 0; 67% mortality (6 of 9) when CVRS = 1-3; and 25% mortality (7 of 25) when CVRS > 4 (p < 0.001). Mechanism of injury, and presence of sinus rhythm when pericardium opened predict outcomes (p < 0.001). Anatomic site of injury and tamponade do not predict outcomes (not significant). AAST-OIS injury grade and mortality: grade IV, 31 of 60 (52%); grade V, 20 of 60 (75%), and grade VI, 6 of 60 (100%).

CONCLUSIONS

Parameters measuring physiologic condition, CVRS, and mechanism of injury plus initial rhythm are significant predictors of outcomes in penetrating cardiac injuries. The need for aortic crossclamping and the inability to restore an organized rhythm or blood pressure after thoracotomy were also predictors of outcomes. The presence of pericardial tamponade was not.

Blunt cardiac injuries in children: a postmortem study

We reviewed the records of the Chief Coroner for all pediatric (< 16 years of age) trauma fatalities in Ontario (pediatric population of 2 million) for the period January 1, 1988 through December 31, 1990. Forty-one (14.5%) of 282 patients for which complete autopsy data were available had sustained cardiac injuries. Nineteen patients (46%) died at the scene of the accident, 15 patients (37%) died in an emergency department, and seven patients (17%) died during hospitalization. Rupture of a cardiac chamber occurred in 16 cases; it was the main cause of death in eight cases and a contributing factor in the remainder. Cardiac contusion without chamber rupture was present in 25 cases, but in none of the cases was it the cause of death. Brain injury was the cause of death in 16 (64%) of the cases of cardiac contusion. Cardiac injuries are more common among children who die from blunt trauma than previous reports have suggested. However, because these injuries are often rapidly fatal, many patients die before they reach a hospital. With improvements in emergency medical services and the resulting reduction in transit time, more patients may reach trauma centers alive. A high index of suspicion and rapid diagnosis and treatment of these injuries can save the lives of some of these patients.

Penetrating cardiac injuries: clinical classification and management strategy

The management of penetrating cardiac injury is controversial. To facilitate decision making, a simple clinical classification of patients with such an injury is proposed. Five categories are considered: (1) lifeless, (2) critically unstable, (3) cardiac tamponade, (4) thoracoabdominal injury and (5) benign presentation. Investigation, if indicated, and the timing and setting of surgical intervention are discussed for each category.

Cardiac injuries: analysis of an unselected series of 251 cases

Retrospective analysis was performed on the medical records of 251 patients treated for cardiac injuries at Highland General Hospital trauma facility in Alameda County, California, to identify factors that contribute to patient survival and predict death. Thirty-six patients (14%) had blunt injuries, 153 patients (61%) had gunshot wounds (GSW), and 62 patients (25%) had stab wounds. The overall survival rate was 18.7%, GSW survival was 6.5%, stab wound survival was 37.1%, and blunt injury survival was 40%. Patients who arrived with some vital signs had 62.2% survival and patients who arrived with absent vital signs had < 1% survival. Stepwise multiple logistic regression analysis revealed that for patients with absent vital signs the only significant predictor of outcome was GSW as the mechanism of injury and for patients with vital signs the ISS and the presence of combined right and left heart injuries were significant independent predictors of outcome. We conclude that the routine and aggressive use of emergency room thoracotomy for patients with penetrating cardiac injury must be re-examined.

[A pathogenetic classification of closed thoracic trauma]

Based on experimental and clinical data the authors propose a classification of closed thoracic traumas which allow to form relatively similar groups among patients with closed thoracic traumas having orientation of the leading pathogenetic factor. The proposed classification allows to form rational curative programs as early as at the prehospital and early hospital stages.

Emergency department echocardiography improves outcome in penetrating cardiac injury

STUDY OBJECTIVES

To determine the effect of immediate two-dimensional echocardiography on the time to diagnosis, survival rate, and neurologic outcome of patients with penetrating cardiac injury.

DESIGN

A ten-year retrospective review.

SETTING

Regional trauma center serving a population base of 1.25 million with 85,000 visits yearly.

TYPE OF PARTICIPANTS

All patients presenting to the emergency department with penetrating cardiac injury.

MEASUREMENTS AND MAIN RESULTS

The records of 49 patients with penetrating cardiac injury were reviewed. Of these, 28 received immediate two-dimensional echocardiography in the ED (echo group) and 21 did not (nonecho group). The probability of survival was derived using TRISS methodology. Differences between groups were determined using either the two sample t-test for parametric data or the Mann-Whitney test for nonparametric data. The overall probability of survival was 33.2%, and the actual survival rate was 81.6%. The probability of survival was 34.2% and 31.8% for the echo group and nonecho group, respectively. The actual survival was 100% in the echo group and 57.1% in the nonecho group. The average time to diagnosis and disposition for surgical intervention was 15.5 +/- 11.4 minutes for the echo group and 42.4 +/- 21.7 minutes for the nonecho group (P less than .001). The Glasgow Outcome Score was 5.0 for the echo group and 4.2 for the nonecho group (P = .007).

CONCLUSION

Since the introduction of immediate ED two-dimensional echocardiography, the time to diagnosis of penetrating cardiac injury has decreased and both the survival rate and neurologic outcome of survivors has improved.

The internist's role in the management of the patient with traumatic heart disease

In a world that is faster-paced, the frequency with which the physician sees cardiac trauma has increased. This article discusses the mechanisms of injury and classification, immediate evaluation and treatment, diagnosis and therapy for specific injuries, great vessel trauma, and other types of injury.

[Multiple thoracic trauma]

The authors observed and helped 157 patients with multiple trauma of the chest. Trauma shock was observed in 97 of them. A clinical classification of such injuries is proposed. Main combinations of injuries of internal organs have been found. Surgical tactics is considered.

Penetrating cardiac injuries: selective conservatism--favorable or foolish?

In a current review of the literature regarding the management of patients with suspected penetrating cardiac injuries there appears to be no place for conservative management. Nine patients with penetrating cardiac injuries were successfully treated conservatively and are reported. This series aims to emphasize the point that there is a place for conservative management of selected cases.

Emergency room thoracotomy for penetrating cardiac injuries

The results of emergency room thoracotomy (ERT) and cardiorrhaphy for 91 patients with penetrating cardiac injuries admitted in extremis to Lincoln Medical and Mental Health Center from 1963 to 1981 are reviewed to determine criteria for selection of patients for this procedure. Four groups were defined based on the severity of the effects of their injuries. The survival rates were 32.1 and 33.3%, respectively, for Group I ('fatal') and Group II ('agonal') patients. There were no survivors in Group IV ('D.O.A.') patients for whom ERT is a fruitless procedure. Survival in Group III ('profound shock') patients was only 40%, which might have been improved if ERT had been performed without delay. We conclude that ERT is essential for patients with 'fatal' and 'agonal' wounds and advise prompt ERT for patients in 'profound shock' who do not respond immediately to rapid volume infusion.