Elsevier

Injury

Volume 32, Issue 7, October 2001, Pages 533-543
Injury

Penetrating cardiac injuries: a complex challenge

https://doi.org/10.1016/S0020-1383(01)00068-7Get rights and content

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

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