PENETRATING CARDIAC INJURIES

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El corazon es un loco que no sabe de un color: O es su amor de dos colores, O dice que no hay Amor.

The Heart is a madman, That does not recognize a single color: Either his love is of two colors, Or he declares that there is no love.

JOSE MARTI, Cuban Poet and Liberator

The heart is such a unique organ, so vital and constant in its tireless function, yet so fickle once its never-ending musical rhythms are disturbed. It is never the tired worker, the strong beating never ceasing, yet so romantic in its very reason for existing. No other organ has inspired so many talented poets, writers, and musicians to create sweet and endless poems, alluring novels, and beautiful rhythms. Witness Homer's poetic description of the death of Sarpedon from the classical Greek epic The Iliad67:

  • Not so Patroclus' never erring darts;

  • Aim'd at his breast, it peers at the mortal part,

  • Where the strong fibers bind the solid heart.

  • Th'insulting Victor with disdain bestrode

  • The prostrate prince, and on his bosom trod;

  • Then drew the weapon from his panting heart,

  • The reaking fibers clinging to the dart;

  • From the wide wound gush'd out a stream of blood,

  • And the soul issued in a purple flood.

The purpose of this article is to cover in detail all aspects of cardiac injury management, including the controversies generated by the newer diagnostic modalities such as echocardiography versus the gold standard represented by the subxiphoid pericardial window. This article also examines in great detail the topic of emergency department (ED) thoracotomy, along with the technical complexities of the surgical management of these challenging injuries.

Section snippets

HISTORICAL PERSPECTIVE

Cardiac injuries have been well described throughout time. The earliest descriptions of cardiac injuries appear in the Iliad, which contains specific references to exsanguination as a cause of death and foreign bodies located within the heart. The death of Sarpedon67 describes an episode of exsanguinating hemorrhage from a cardiac injury (Fig. 1). The Iliad66 records an observation of the cardiac impulse transmitted through a spear that had transfixed the heart of Alkathoos: “The hero Idomeneus

CLINICAL PRESENTATION OF CARDIAC INJURIES

Beck's triad represents the classic presentation of a patient arriving in an ED with a full-blown pericardial tamponade. Kussmaul's sign, described as jugular venus distention upon inspiration, is another classic sign attributed to pericardial tamponade. In reality, the presence of Beck's triad or Kussmaul's sign represents the exception rather than the rule. In general, penetrating cardiac injuries can be extremely deceptive in their clinical presentations: Patients may present with

Subxiphoid Pericardial Window

The original technique to create a pericardial window was described by Larrey74 in the 1800s. Remarkably enough, only small variations in the original technique have been added to this procedure. Any patient who sustains a penetrating injury in an area inferior to the clavicles, superior to the costal margins, and medial to the midclavicular lines should be suspected of harboring an injury to the heart (Fig. 7). This technique evaluates the presence of blood in the pericardium; it is indicated

EMERGENCY DEPARTMENT THORACOTOMY

ED thoracotomy is a surgical procedure of great value if undertaken following strict indications for its performance. This procedure is routinely performed in urban trauma centers that receive patients “in extremis.” This technically complex and challenging procedure should be performed by surgeons who are familiar with the management of penetrating cardiothoracic injuries. As the emergency medical services of many large cities continue to improve and to apply the concept of “load and go,” many

Incisions

In contrast to abdominal injuries that can easily be accessed via a celiotomy, the management of penetrating cardiothoracic injuries requires exquisite judgment in selecting the best approach to these injuries. Exercising the wrong choice allows the surgeon no opportunity to exercise his second choice, given the critical nature and severe hemodynamic compromise of these patients. It therefore behooves the surgeon to think critically and choose wisely. The surgeon should be aware that injuries

INJURY SCALING

The American Association for the Surgery of Trauma (AAST) and its Organ Injury Scaling (OIS) Committee have developed a cardiac injury scale to uniformly describe cardiac injuries87 (Table 1). This scale is quite complex, and although it comprehensively describes these injuries, it does not provide any prediction of outcome. No figures exist yet in the literature describing the mortality for each grade of injury.

COMPLEX AND COMBINED INJURIES

Surgeons in trauma centers are developing greater expertise in the management of penetrating injuries. As patients are subjected to greater degrees of violence in the arenas of urban warfare, many patients arrive harboring multiple associated injuries in addition to their penetrating cardiac injuries Figure 22, Figure 23, Figure 24, Figure 25.

Complex and combined cardiac injuries can be defined as a cardiac injury plus associated neck, thoracic, thoracic-vascular, abdominal, or

OVERVIEW OF CURRENT PHILOSOPHIES INFLUENCING MANAGEMENT OF CARDIAC INJURIES

The difficulty in evaluating different series on penetrating cardiac injuries, along with analyzing their results, has been pointed out by Trinkle.113 Over the past 30 years, the literature 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 the series fail to

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    Address reprint requests to Juan A. Asensio, MD, FACS, Division of Trauma Surgery/Surgical Critical Care, LAC–USC Medical Center, 1200 North State Street, Suite 10-750, Los Angeles, CA 90033–4525

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