Surgical management of penetrating cardiac injuries

doi:10.1016/0002-9610(66)90105-X

The American Journal of Surgery

Volume 112, Issue 5, November 1966, Pages 686-692

https://doi.org/10.1016/0002-9610(66)90105-X Get rights and content

Abstract

Among the more spectacular wounds encountered by the surgeon are those involving the heart. Methods of managing these injuries have varied considerably since the first successful clinical cardiorrhaphy seventy years ago. It has been our policy to treat these patients primarily by pericardiocentesis with fluid and blood replacement and pulmonary reexpansion, reserving thoracotomy and cardiorrhaphy for those who fail to respond to such measures or whose condition again deteriorates after pericardial aspiration.

Review of experience gained in the management of 197 consecutive patients in this manner during the period 1951 through 1965 continues to support this plan of treatment. Over-all mortality was 25.4 per cent, but this figure includes eleven patients who died before any form of treatment could be started and thirteen who experienced cardiac arrest prior to the onset of therapy but in whom thoracotomy was performed in an attempt at resuscitation. While thoracotomy and cardiorrhaphy should not be delayed when necessary, primary pericardiocentesis still appears to offer patients with penetrating cardiac injuries their best chance for survival.

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Cited by (83)

Who benefits from resuscitative thoracotomies following penetrating trauma: The patient or the learner?
2023, Injury
Resuscitative thoracotomy (RT) is a salvage procedure following traumatic cardiac arrest. We aim to evaluate RT trends and outcomes in adults with cardiac arrest following penetrating trauma to determine the effect on mortality in this population. Further, we aim to estimate the effect of hospital teaching status on the performance of resuscitative thoracotomies and mortality.
We reviewed the National Trauma Data Bank (2017–2021) for adults (≥16 years old) with penetrating trauma and prehospital cardiac arrest, stratified by the performance of a RT. We performed multivariable logistic regressions to estimate the effect of RT on mortality and the effect of hospital teaching status on the performance of resuscitative thoracotomies and mortality.
13,115 patients met our inclusion criteria. RT occurred in 12.7% (n = 1,664) of patients. Rates of RT trended up over the study period. Crude mortality was similar in RT and Non-RT patients (95.6% vs. 94.5%, p = 0.07). There was no statistically significant difference in the adjusted odds of mortality based on RT status (OR 0.82, 95%CI 0.56–1.21). University-teaching hospitals had an adjusted odds ratio of 1.68 (95% CI 1.31–2.17) for performing a RT than non-teaching hospitals. There was no difference in the adjusted odds of mortality in patients that underwent RT based on hospital teaching status.
Despite up-trending rates, a resuscitative thoracotomy may not improve mortality in adults with penetrating, traumatic cardiac arrest. University teaching hospitals are nearly twice as likely to perform a RT than non-teaching hospitals, with no subsequent improvement in mortality.
Shot through the heart: A 17-year analysis of pre-hospital and hospital deaths from penetrating cardiac injuries
2023, Injury
Penetrating cardiac injuries (PCI) are often fatal despite rapid transport and treatment in the prehospital setting. Although many studies have identified risk factors for mortality, few studies have included non-transported field mortalities. This study analyzes penetrating cardiac injuries including hospital and coroner reports in the current era.
Seventeen years of data were reviewed, including the trauma center (TC) registry, medical records, and coroner reports from 2000-2016. PCI were graded using American Association for the Surgery of Trauma (AAST) cardiac organ injury score (COIS). Subjects were divided into three groups: field deaths, hospital deaths, and survivors to hospital discharge. The primary outcome is survival to hospital discharge overall and among those transported to the hospital.
During the study period, 643 PCI patients were identified, with 52 excluded for inadequate data, leaving 591 for analysis. Mean age was 38.1 ± 17.5 years, and survivors (n=66) were significantly younger than field deaths (n=359) (32.6 ± 14.4 vs 41.1 ± 18.5, p<0.001). Stab wounds had higher survival than gunshot wounds (26.6% vs. 4.3%, p<0.001). COIS grades 4 to 6 (n=602) had lower survival than grades 1 to 3 (n=41) (8.3% vs. 39.0%, p<0.001). Survivors (n=66) had lower median COIS than patients who died in hospital (n=218) (4 vs. 5, p<0.001). Single chamber PCI had higher survival than multiple chamber PCI (13% vs. 5%, p=0.004). The left ventricle is the most injured (n=177), and right ventricle PCI has the highest survival (p<0.001). Of field deaths, left ventricular injuries had the highest single chamber mortality (60%), equaling multi-chamber PCI (60%).
Survival to both TC evaluation and hospital discharge following PCI is influenced by many factors including age, mechanism, anatomic site, and grade. Despite advances in trauma care, survival has not appreciably improved.
Survey of trauma surgeon practice of emergency department thoracotomy
2016, American Journal of Surgery
There continues to be significant debate in the trauma community regarding the indications for emergency department thoracotomy (EDT). Numerous studies have focused on the duration of arrest in EDT, whereas few have examined other factors that influence surgeon decision-making. We hypothesize that there is continued variability among surgeons in the use of EDT.
A 13-question web-based survey was distributed to the membership of a large, national trauma association, examining demographics, trauma fellowship completion, trauma center designation, professional organization membership, and annual EDTs performed. Consideration of patient's age, comorbidities, total injury burden, and the use of technological adjuncts—such as ultrasound—was assessed. Respondents were asked when they would perform the procedure after loss of vital signs for blunt and penetrating trauma. Logistic regression determined factors influencing consideration of EDT.
Overall 540 of 1,485 surveys were completed (36.4%). Patient age, total injury burden, and comorbidities are considered by 38.5%, 29.1%, and 55.7% of respondents, respectively. Technological adjuncts are used always or most of the time by 64% of respondents. A majority of respondents (51.9%) would perform an EDT for penetrating trauma with loss of vital signs 5 to 10 minutes before arrival. For blunt trauma, the largest group of respondents (47.0%) would perform an EDT only when loss of vital signs occurred in the ED. In addition, 20.6% would never perform EDT for blunt traumatic arrest.
EDT decision-making is more nuanced than previously described. Variation continues in the use of thoracotomy after loss of vital signs, in both blunt and penetrating trauma. For both mechanisms, there remains little consensus on the appropriate duration of arrest before performing EDT after arrest despite published guidelines. A large proportion of surgeons consider other factors such as patient age, total injury burden, and comorbidities in addition to vital signs when deciding to perform an EDT. Technological adjuncts are frequently used by surgeons to determine the need for EDT.
Emergency thoracotomy. Indications, surgical technique and results
2011, Cirugia Espanola
La toracotomía de urgencia es una técnica quirúrgica que se ha extendido considerablemente en los últimos años, y que se incluye en la actualidad dentro de los protocolos de reanimación cardio-pulmonar avanzada. A pesar de su contrastada utilidad en pacientes con heridas cardiacas penetrantes, en ocasiones no se utiliza por desconocimiento de la técnica, o de sus indicaciones. En la actualidad, el aumento de las lesiones torácicas por violencia, accidentes de tráfico, atropellos, o suicidios, y los avances en los sistemas de atención extrahospitalaria, han despertado nuevamente interés sobre esta técnica.
En este artículo se realiza una revisión de la toracotomía de urgencia: indicaciones, técnica quirúrgica, resultados, y su utilidad en ambiente extrahospitalario.
Emergency thoracotomy is a surgical technique that has been extended in the last few years, and is currently included in advanced cardiopulmonary resuscitation protocols. Despite its proven use in patients with penetrating heart wounds, it is often not used due to lack of knowledge of the technique. Currently, the increase in chest wounds due to violence, traffic accidents, crashes or suicides, and advances in extra-hospital medical care systems, has currently awakened new interest in this technique.
A review of emergency thoracotomy is presented in this article: indications, surgical technique, results, and its usefulness in the extra-hospital setting.
Longterm Outcomes after Combat Casualty Emergency Department Thoracotomy
2009, Journal of the American College of Surgeons
Citation Excerpt :
Eleven percent (6 of 53) of US combat casualties survived hospitalization and remained neurologically intact after EDT in this study. The use of EDT in critically injured trauma patients has been debated since its inception in the 1960s, after the use of EDT by Beall and colleagues5,6 in moribund patients with penetrating chest trauma. Since that time, many authors and researchers have attempted to address the indications for EDT and to evaluate the mortality and neurologic outcomes of survivors associated with this procedure.
The incidence, survival, and blood product use after emergency department thoracotomy (EDT) in combat casualties is unknown.
We performed a prospective and retrospective observational study of EDT at a combat support hospital in Iraq, evaluating the impact of injury mechanisms, blood product use, mortality, and longterm neurologic outcomes of survivors.
From November 2003 to December 2007, 12,536 trauma admissions resulted in 101 EDTs (0.01%). In patients undergoing EDT, penetrating trauma from explosions and firearms accounted for the majority of injuries (93%). There were no survivors after EDT for blunt trauma (n = 7). The areas of primary penetrating injury were the abdomen (30%), thorax (40%), and extremities (22%). Twelve percent (12 of 101) of all patients survived until evacuation, with the overall survival rate (8 to 26 months) of US casualties at 11% (6 of 53). There was no difference in survival seen in either injury mechanism or primary injury location. Signs of life were present in all overall survivors. Cardiopulmonary resuscitation (CPR) was performed in 92% (93 of 101) of all patients, and in 75% (9 of 12) of those evacuated. Mean (±SD) transfusion requirements for all patients were 15.0 ± 12.7 U of RBC and 7.3 ± 8.7 U of fresh frozen plasma during the initial resuscitation. Survivors demonstrated higher fresh frozen plasma:RBC ratios. All survivors were neurologically intact.
In the combat casualty with penetrating injury, arriving with signs of life, receiving CPR, and undergoing EDT, longterm survival with normal neurologic outcomes is possible. CPR is not a contraindication to performance of EDT in penetrating injuries if signs of life are present. A large amount of blood products are used in the resuscitation of EDT patients.
Penetrating Cardiac Injuries: A Historic Perspective and Fascinating Trip Through Time
2009, Journal of the American College of Surgeons

View all citing articles on Scopus

^☆: This work was supported in part by the U. S. Public Health Service (HE-03137 and HE-05387) and the Houston Heart Association.

^☆☆: Presented at the Eighteenth Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 18–21, 1966.

¹: From The Cora and Webb Mading Department of Surgery, Baylor University College of Medicine, and the Jefferson Davis and Ben Taub General Hospitals, Houston, Texas.

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Surgical management of penetrating cardiac injuries☆,☆☆

Abstract

Am. J. Surg.

Dis. Chest

J. Thoracic & Cardiovasc. Surg.

Am. J. Surg.

Ueber penetrirende Herzwnden und Herznaht

Arch. klin. Chir.

A consideration of the nonoperative treatment of cardiac tamponade resulting from wounds of the heart

Surgery

Treatment of penetrating wounds of the heart. Experimental and clinical observations

Surgery

Cardiac injuries. An evaluation of the immediate and long range results of treatment

Ann. Surg.

Aspiration treatment of cardiac tamponade

Arch. Surg.

Sixty penetrating wounds of the heart. Clinical and experimental observations

Surgery

Penetrating wounds of the heart

J. Trauma