Penetrating cardiac injuries: a complex challenge
Introduction
The heart is a unique organ, vital and constant in its tireless function, working 24 h a day during the entire life time of an individual. It has inspired many talented poets, writers and musicians throughout the ages. The first description of a cardiac injury is found is Homer's poetic description of the death of Sarpedon from the classical Greek epic The Iliad [1], [2].
Cardiac injuries remain amongst the most challenging of all injuries seen in the field of trauma surgery. Their management often requires immediate surgical intervention, excellent surgical technique and the ability to provide excellent surgical critical care to these patients postoperatively.
Section snippets
Historical perspective
Cardiac injuries have been well described throughout the times. The earliest descriptions of cardiac injuries appear in the Iliad [1], [2] and the Edwin Smith Papyrus [3] written around 3000 BC. Hippocrates [5], Ovid, Celsus, Pliny, Aristotle, and Galen [6], [7], [8], [9], [10] regarded all cardiac wounds as fatal. Paulus Aegineta [11] described the venting of the pericardial tamponade. Fallopius [12] described the difference between wounds of the right and left ventricles. Ambrose Pare
Clinical presentation of cardiac injuries
The clinical presentations of penetrating cardiac injuries range from complete haemodynamic stability to acute cardiovascular collapse and frank cardiopulmonary arrest. The clinical presentation can also be related to several factors, including the wounding mechanism; the length of time elapsed prior to arrival in a trauma center; the extent of the injury, which if sufficiently large, causes exsanguinating haemorrhage into the left hemithoracic cavity; whether blood loss exceeds 40–50% of the
Subxiphoid pericardial window
The original technique to create a pericardial window was described by Larrey in the 1800's [22]. Remarkably enough, only small variations in the original technique have been added to this procedure. It still remains the gold standard of all procedures for the diagnosis of cardiac injury; however, it requires that the patient be subjected to general anaesthesia, and is an invasive procedure. In trauma centres with availability of ultrasound this technique has been relegated to a second line of
Emergency department thoracotomy
Emergency Department thoracotomy (EDT) remains a formidable tool within the trauma surgeon's armamentarium. Since its introduction during the 1960's, the use of this procedure has ranged from sparing to liberal. In many urban trauma centers, this procedure has found a niche as part of the resuscitative process. Because of great improvements in emergency medical services (EMS) systems, many patients arrive in either impending or full cardiopulmonary arrest. The arrival of these critically
Incisions
Median sternotomy, or the Duval incision [40], [62], is the incision of choice in patients admitted with penetrating precordial wounds that may harbour occult or non-haemodynamically compromising cardiac injuries. Patients admitted with some degree of haemodynamic stability may undergo limited preoperative investigation with chest radiography or echocardiography. Similarly patients that reach the operating room with some degree of stability can undergo a subxiphoid pericardial window if the
Injury scaling
The American Association for the Surgery of Trauma (AAST) and its Organ Injury Scaling Committee (OIS) have developed a cardiac injury scale to uniformly describe cardiac injuries [120] (see Table 1). This scale is quite complex and although it is very comprehensive it is not user friendly in the operating room. Recently Asensio et al. [70] validated and correlated mortality with grade of injury.
Complex and combined injuries
As trauma surgeons develop greater expertise in the management of penetrating cardiac injuries and as patients are subjected to greater degrees of violence many patients arrive harbouring multiple associated injuries, in addition to their penetrating cardiac injuries [62].
We have defined complex and combined cardiac injuries as any penetrating cardiac injury associated with either a neck, thoracic, thoracic-vascular, abdominal, or abdominal vascular injury. In addition, any extremity peripheral
Overview of current philosophies influencing the management of penetrating cardiac injuries
Trinkle et al. [121] has pointed out the difficulty in evaluating different series of penetrating cardiac injuries. The literature over the past 30 years overflows with reports dealing with these injuries, the majority of which have been retrospective reviews. Most have come from institutions treating fewer than 15 such cases annually. Many reports encompass serial and overlapping studies from the same institutions. Similarly, many of these series fail to uniformly report important data that
References (122)
Heart wounds, a report of 17 patients operated upon in the medical college of Virginia hospitals and discussion of the treatment and prognosis
J. Thorac. Surg.
(1939)- et al.
Penetrating cardiac injuries
Surg. Clin. N. Am.
(1996) - et al.
Penetrating cardiac injuries: a prospective study of variables predicting outcomes
J. Am. Chem. Soc.
(1998) - et al.
Subxiphoid pericardial window in patients with suspected traumatic pericardial tamponade
Ann. Thorac. Surg.
(1977) - et al.
Subxiphoid pericardial window in the diagnosis of penetrating cardiac trauma
Ann. Thorac. Surg.
(1994) - et al.
Two-dimensional echocardiographic findings in cardiac trauma
Am. J. Cardiol.
(1982) - et al.
Penetrating cardiac injury evaluated by two-dimensional echocardiography
Am. Heart J.
(1984) - et al.
Emergency department echocardiography improves outcome in penetrating cardiac injury
Ann. Emer. Med.
(1992) - et al.
Performing thoracotomy in the emergency center
J. Am. Coll. Emer. Physicians
(1974) - et al.
Surgical management of penetrating cardiac injuries
Am. J. Surg.
(1966)
Wounds of the heart. The technic of suture
Arch Surg.
Bull. Sci. Med.
Chir. Chir.
Clinical lecture on Surgery, delivered during Sessions of at the Hotel Dieu, Paris, Lecons Orales de Clinique Chirurgicale on wounds of the heart: Their varieties, causes, symptoms and treatment
Lancet
Reflexions sur les places penetrantes du coeur
Arch. Gen. Med.
Statistical observations on wounds of the heart and on their relations to forensic medicine with a table of 42 recorded cases
NY Med.
Die wunden des herzens und des hertzbeutels
Arch Klin. Chir.
Offenes schreiben an herr der wittelshofer uver die erste mil gustingen susgange ausgefuhrte pylorectomie
Wiener Med. Wochensch.
The surgery of the pericardium
Ann. Anat. Surg.
Cited by (47)
Cardiac Auscultation of Intracardiac Air
2021, Annals of Emergency MedicineCardiac injury following penetrating chest trauma: Delayed diagnosis and successful repair
2018, Journal of Pediatric Surgery Case ReportsCitation Excerpt :Especially in the setting of a left hemothorax, other diagnostic maneuvers including pericardial window should be considered to rule out cardiac injury with penetrating trauma to the cardiac box. Treatment for cardiac injury in an unstable patient is managed by left anterolateral thoracotomy in the emergency department [14,15]. The most common heart chamber to be injured is the right ventricle (43%) followed by the left ventricle (33%) and right atrium (14%) [16].
Penetrating injury to the heart
2017, Cor et VasaComplex gunshot injury to the heart as a consequence of suicide attempt in a schizophrenic patient
2016, International Journal of Surgery Case ReportsCitation Excerpt :One year after the surgery she is well, compliant to antipsychotic medications and on periodic follow-up by psychiatrists. Chest or upper abdomen gunshot wounds need to be suspected along with the cardiac injury in these instances [1,4,5]. There is a considerable risk of concomitant chest or abdominal cavity injuries due to high kinetic energy of the projectile or secondary injuries due to high velocity bone fragments [6].
Penetrating cardiac injuries and the evolving management algorithm in the current era
2015, Journal of Surgical ResearchCitation Excerpt :In the past, the diagnostic workup of patients with a suspected penetrating cardiac injury was predominantly clinical [5]. Over the last decade, however, a number of new diagnostic and therapeutic modalities have been introduced [6]. The two that have impacted most on the management of these patients have been focused ultrasound scanning Focused abdominal sonar for trauma (FAST) and the subxiphoid pericardial window (SPW).
Thoracic gunshot wound: A pediatric case
2012, Archives de Pediatrie