ABSTRACT
Background: Penetrating wounds to the heart and great vessels are fatal unless treated surgically on an emergency basis. The survival after surgery depends on many factors
Aim: The aim of this study is to analyze the clinical spectrum of 58 cases of penetrating wounds to the heart and grea. vessels operated upon in Mansoura Emergency Hospital in the last 8 years, and to determine the factors affecting the results of surgery
Patients and methods: Fifty eight patients with penetrating wounds to the heart and great vessels presented to the emergency room [ER] in Mansoura Emergency Hospital [MEH] from January 1996 to December 2003. The file data of them were analyzed retrospectively. The age, gender, site and mechanism of injury was reviewed. The patients were classified on arrival to the Emergency Room [ER] into 4 categories according to their clinical and functional status. These were [1] Stable patients: 17 patients [29.3%] [2] Shocked and unstablez18 patients [31%]. [3] Agonal: 13 patients [22.4%]. [4] Fatal: 10 patients [17.2%]
Results: There were 56 males [96.55%] and 2 females [3.45%]. The mean age was 27.64 +/- 8.33 years [range 7-47 years]. The causes of injury were stabs in 50 patients [86.2%], gunshots in 7 [12.06 %] and iatrogenic in one patient [1,72%]. There were 50 injuries to the heart [86.2%] and 6 to the aorta [10.34], and 2 to the main pulmonary artery [3.44%]. 12 patients had associated penetrating injuries [20.6%]. All the patients were operated upon, 13 [22.4%] had ER thoracotomy and 45 [77.6%] patients had formal theater thoracotomy. Approach was through left anterior thoracotomy in 47 [81%] , median sternotomy in 10 [17.24%] and left posterior thoracotomy in 1 patient [1.7%]. The site of injury was right ventricle in 26 cases [44.8%], left ventricle in 22 [37.9%] , aorta in 4 [6.85%], right atrium in 4 [6.85%], pulmonary artery 4 [6.85%], left atrium 2 [3.45%], and multiple injuries in 6 [10.43%]. Associated penetrating injuries were found in 16 patients [27.5%]. There were 5 injuries to the lungs, 4 had additional penetrating iniuries to the chest wall structures, 5 to the diaphragm, and 2 to the liver. There were 14 deaths in this series [24.1%] , 8 of them in the fatal group that reached the ER in arrest and managed by ER thoracotomy, only 2 out of 10 could be salvaged [20%] and 80% mortality was faced in this group of patients. The Agonal [tamponading] group suffered 2 intraoperative mortalities due to extensive tear in one victim and pump failure in the other. The other 4 cases were in the shocked group, one due to massive liver tear, one due to circulatory collapse, one had intractable postoperative arrhythmia, and one died of septicemia end DIC. There were 11 complications occurring in 8 patients out of the surviving 44 patients [18.2%]. Wound infection in 3 cases including one case of median Sternotomy, 2 cases of pneumonia, 2 postoperative empyema, 2 cases of residual cerebral deficit due to arrest just before reaching ER, one case of myocardial infarction, due to injury to the distal left anterior descending coronary artery, and one case of arrhythmia following repair of a relatively long right ventricular tear. The mean ICU stay was 2.67 +/- 0.74 days, and the mean hospitalization time was 10.65 +/- 3.73 days. Predictors of mortality of statistical significance were found to be: gunshot type, arrival in near arrest, and multiple associated injuries
Conclusions: penetrating injuries to the heart and great vessels increased significantly in our society due to increased attitude toward violence in young adults. Stabs being the most common type. Rapid ambulance transportation, high index of suspicion of cardiac tamponade, first aid for shocked victims, are need to improve the results of this type of emergency. Utmost care must be given to patients with gunshot wounds, arriving in near arrest and with multiple associated injurie