Damage control in penetrating cardiac trauma / El control de daños en el trauma cardíaco penetrante

Abstract Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients.

Resumen El manejo definitivo de los pacientes hemodinámicamente estables con heridas cardíacas penetrantes continúa siendo controversial con abordajes invasivos versus manejos conservadores. Estas posiciones contrarias se extienden hasta aquellos casos de pacientes hemodinámicamente inestables donde se ha descrito y considerado la cirugía de control de daños como un procedimiento útil y efectivo. El objetivo de este artículo es presentar la experiencia en el manejo quirúrgico de heridas cardíacas penetrantes con la creación de un algoritmo práctico que incluye los principios básicos del control de daños. Se recomienda que a todos los pacientes con heridas precordiales penetrantes se les debe realizar un ultrasonido torácico como componente integral de la evaluación inicial. Aquellos que presenten un ultrasonido torácico positivo y se encuentren hemodinámicamente estables se les debe realizar una ventana pericárdica con posterior lavado. Se ha demostrado que el 25% de las ventanas pericárdicas positivas no se benefician ni requieren de posteriores abordajes quirúrgicos invasivos. Antes de este concepto, todos los pacientes con ventana pericárdica positiva terminaban en una exploración abierta del tórax y del pericárdico. Los pacientes hemodinámicamente inestables requieren de una cirugía de control de daños para un adecuado y oportuno control del sangrado. Con este propósito, se propone un algoritmo de manejo quirúrgico que incluye todos estos aspectos esenciales en el abordaje de este grupo de pacientes.

Lesiones precordiales: reporte de dos casos / Precordial injuries: report of two cases

Las heridas precordiales son una entidad poco frecuente y desafiante en cirugía de trauma en los servicios de Emergencia. La incidencia elevada de taponamiento y trauma cardiaco, así como su alta mortalidad obliga a tomar decisiones diagnósticas y terapéuticas rápidas y precisas. Material y Métodos: se presentan los casos de dos pacientes masculinos que ingresaron al servicio de Emergencia del Hospital Roosevelt con lesiones precordiales penetrantes con trauma pericárdico y cardiaco, con diferentes manifestaciones clínicas a los que se les realizó ventana pericárdica subxifoidea diagnóstica y seguido una esternotomía media con exposición pericárdica y cardiaca como abordaje y tratamiento quirúrgico definitivo. Discusión: Es de suma importancia reconocer los amplios escenarios de presentaciones clínicas del paciente con heridas en la región precordial y mantener un alto índice de sospecha de trauma y taponamiento cardiacos en todas las lesiones precordiales penetrantes en pacientes estables e inestables para no retrasar el diagnóstico y tratamiento quirúrgico temprano y adecuado. Las lesiones asociadas y complicaciones trans y postoperatorias aumentan la mortalidad de estos pacientes (AU)

Precordial wounds are rare and challenging lesions in Trauma Services. The high incidence of cardiac trauma and the high mortality requires fast and precise diagnostic and therapeutic decisions. Case report: Two male patients who were admitted to the Roosevelt Hospital Emergency Service with penetrating precordial injuries with pericardial and cardiac trauma are presented, with different clinical manifestations, who underwent a diagnostic subxiphoid pericardial window and a median sternotomy with pericardial and cardiac exposure as a definitive surgical approach and treatment. Discussion: Is important to recognize the broad scenarios of patients with wounds in the precordial region and to maintain a high index of suspicion of cardiac trauma and tamponade in all penetrating precordial injuries inclusive in stable patients to not delay diagnosis and treatment and a proper surgical intervention. Associated injuries and perioperative complications increase the mortality of these patients

Trauma cardiaco en pediatría / Cardiac trauma in pediatrics

El trauma cardiaco constituye una entidad infrecuente en pediatría que requiere de toma de decisiones rápidas y oportunas, además de un manejo óptimo para obtener una mejor sobrevida de los pacientes. En esta revisión en base a un caso clínico, se actualiza el tema de trauma cardiaco, se describen los tipos más frecuentes, las diferentes formas clínicas de presentación y el enfrentamiento terapéutico. Palabras clave: Trauma cardiaco, penetrante cardiaca, cirugía cardiaca.

Cardiac trauma is an uncommon entity in pediatrics that requires quick and timely decision making, as well as optimal management to obtain a better survival of patients. In this review based on a case report, the issue of cardiac trauma is updated, the most frequent types, the different clinical forms of presentation and the therapeutic confrontation are described.

Traumatismo cardíaco penetrante en pediatría: presentación de caso, Hospital Infantil Dr. Robert Reid Cabral (HIRRC), República Dominicana / Penetrating Cardiac Trauma in Children: Case Presentation, Hospital Infantil Dr. Robert Reid Cabral, Dominican Republic.

Introducción: el traumatismo cardíaco es una condición poco frecuente en edad pediátrica, ocurriendo en menos del 5 % de traumatismos torácicos. Afecta más frecuentemente los ventrículos que las aurículas. Según el mecanismo de injuria puede ser: cerrado (como las contusiones torácicas) o penetrante (como las heridas por arma blanca o armas de fuego). El siguiente documento tiene la intención de describir la presentación clínica y el manejo de un paciente pediátrico con traumatismo cardíaco penetrante; se pretendió realizar una revisión de literatura sobre otros casos de traumatismo cardíaco penetrante. Presentación del caso: se expone el caso clínico de un paciente masculino de 14 años de edad, quien es referido al centro por historia de herida de arma blanca en región precordial izquierda. Se recibe con inestabilidad hemodinámica y hemitórax izquierdo hipodinámico; luego de realizar estudios de imagen y laboratorio se decide realizar toracocentesis. Ante evidente deterioro clínico, se decide realizar exploración quirúrgica, donde se halla laceración del ventrículo izquierdo y hematoma pericárdico, y se procede a drenar hematoma y cardiorrafia de ventrículo izquierdo. Conclusión: luego de describir la presentación y manejo de nuestro paciente, llegamos a la conclusión de que la sospecha clínica y el diagnóstico y manejo precoz son imprescindibles para mejorar el pronóstico de estos traumatismos. Asimismo, entendemos pertinente la exploración quirúrgica temprana ante los casos de inestabilidad hemodinámica, evitando el retraso de un tratamiento oportuno

Introduction: Cardiac trauma is a rare condition in pediatrics, occurring in less than 5 % of thoracic trauma. It affects the ventricles more often than the atria. Depending on the mechanism of injury, it may be classified as closed (such as blunt chest traumas) or penetrating (such as wounds with a knife or guns). The following document has the intention to describe the clinical presentation and management of a pediatric patient with a penetrating cardiac trauma, and it was intended to conduct a literature review on other cases of penetrating cardiac trauma. Case presentation: We present the clinical case of a 14-year-old male, who is referred to the center with history of a knife wound in the left precordial region. He is received with hemodynamic instability and hypodynamic left hemithorax, and, after performing imaging and laboratory studies, it was decided to perform thoracentesis. In the presence of evident clinical deterioration, it was decided to perform surgical exploration, where laceration of the left ventricle and pericardial hematoma is evidenced, for which drainage of hematoma and left ventricle cardiorrhaphy were performed. Conclusion: After describing the presentation and management of our patient, we conclude that clinical suspicion and early diagnosis and management are essential to improve the prognosis of these injuries. Likewise, we recognize the pertinence of early surgical exploration in cases of hemodynamic instability, avoiding the delay of a timely treatment.

Alteraciones electrofisiológicas y/o bioquímicas del trauma cardíaco / Electrophysiological and/or biochemical alterations of cardiac trauma

Resumen El trauma cardíaco constituye una de las primeras causas de mortalidad en la población general. La gran mayoría son causados por accidentes automovilísticos. Su diagnóstico es difícil y requiere alto índice de sospecha en trauma cerrado. Posee un índice de mortalidad muy elevado, cercano al 76%. Existen varios métodos diagnósticos disponibles para facilitar su detección pero ninguno logra alcanzar una sensibilidad cercana al 100%. El trauma cardíaco contuso puede variar desde lesión cardíaca asintomática hasta ruptura cardíaca y muerte. Actualmente se utilizan marcadores bioquímicos como enzimas cardíacas, siendo la Troponina I la más específica; y electrofisiológicos como hallazgos en el electrocardiograma sugestivos de bloqueo de rama y taquicardia sinusal, siendo estos los más frecuentemente encontrados.

Abstract Heart trauma is one of the leading causes of mortality in the general population. The vast majority are caused by automobile accidents. Its diagnosis is difficult and requires a high index of suspicion in closed trauma. It has a very high mortality rate, close to 76%. There are several diagnostic methods available to facilitate its detection, but none can reach a sensitivity close to 100%. Contusive heart trauma can range from asymptomatic cardiac injury to cardiac rupture and death. Currently, biochemical markers are used as cardiac enzymes, with Troponin I being the most specific; and electrophysiological findings in the electrocardiogram suggestive of branch block and sinus tachycardia, these being the most frequently found.

Clamshell Thoracotomy for Two Cases of Blunt Traumatic Cardiac Rupture / 日本心臓血管外科学会雑誌

When a sufficient field of view in unilateral thoracotomy cannot be obtained during hemostasis surgery for severe thoracic trauma, clamshell thoracotomy is often necessary to perform aortic cross-clamping in order to avoid cardiac arrest or to treat intrathoracic injury across the chest. Here we describe two successful cases of clamshell thoracotomy for blunt traumatic cardiac rupture. Case 1 was a 41-year-old male motorcyclist, injured in a collision with a truck, who was in a state of shock when transported to our emergency department (ED). Due to the finding of fluid accumulation around the spleen on FAST (focused assessment with sonography for trauma), he underwent emergency laparotomy with gauze packing after splenectomy as damage control surgery. Because of a prolonged state of shock due to extensive right hemothorax, right anterolateral thoracotomy was performed to locate the site of active bleeding in the right mediastinal pleura. However, imminent cardiac arrest necessitated clamshell thoracotomy, which revealed a 4-cm laceration on the right atrium and two lacerations on the upper lobe of the right lung, for which suture repair was performed. His postoperative course was uneventful and he was discharged on postinjury day 57 for rehabilitation. Case 2 was a 75-year-old female motorcyclist who was injured after hitting a curb and falling. She was in a state of shock due to severe right hemothorax when admitted to our ED and underwent anterolateral thoracotomy to treat active bleeding in the right mediastinal pleura. Clamshell thoracotomy was performed because cardiac arrest was imminent, and this was followed by suture repair of a 2-cm laceration identified on the left atrium. Her postoperative course was uneventful and she was transferred to another hospital on postinjury day 37 for rehabilitation. In both cases, Clamshell thoracotomy was performed successfully for blunt traumatic cardiac rupture and the postoperative course was good with no serious complications. Clamshell thoracotomy is an effective approach for trauma resuscitation, so surgeons should be familiar with its indications, surgical techniques, and timing.

Trauma penetrante cardíaco en la Unidad de Emergencia del Hospital Carlos Van Buren / Penetrating cardiac trauma: review of 36 operated patients

Background: The most common cause of cardiac penetrating trauma is wounds caused by knives or firearms. Aim: To review the operated cases of penetrating cardiac trauma in a public hospital emergency room. Material and Methods: Review of medical records of patients operated for penetrating cardiac trauma between 1986 and 2009. Results: We retrieved the records of 36 patients (33 males) with a median age of 30 years. Ninety four percent of lesions were cause by knife wounds. In 24 patients, the right ventncle was injured. Immediate surgical mortality was 17 percent and 22 percent of patients had complications. Conclusions: Surgical mortality in penetrating cardiac trauma is related to the delay of surgical correction, injury by firearms or the presence of complex lesions.

El trauma penetrante cardíaco representa una de las mayores causas de muerte por motivo de violencia urbana y se clasifica en penetrante o contuso. La causa más común de trauma cardíaco penetrante es la herida por arma blanca o de fuego. La principal causa de trauma penetrante cardíaco en nuestra serie fue la lesión por arma blanca, siendo el ventrículo derecho la principal cámara cardíaca afectada. Los resultados quirúrgicos son comparables con otras series, con una mortalidad del 16,6 por ciento y una morbilidad de 22 por ciento. La mortalidad quirúrgica está relacionada con el retraso de la cirugía, o la lesión por arma de fuego, o la presencia de lesiones complejas. Aún sigue siendo fundamental el diagnóstico clínico y el manejo precoz.

Nursing cooperation of prehospital first-aid for patients with cardiac trauma / 中国实用护理杂志

Objective To summarize the nursing experience in prehospital first-aid of patients with cardiac traumas in order to improve the cooperation capability of prehospital first-aid. Methods The nursing cooperation of prehospital first-aid of 33 patients with cardiac trauma was analyzed retrospec-tively. Results 24 cases of them were rescued successfully, and were completely recovered without se-quelas. 4 cases complicated with severe multiple trauma, died after arriving at hospital, and 3 cases com-plicated with multiple trauma died of complications, while 2 cases with injury of thoracic aorta died during the surgery. Conclusions Early emergency treatment and judgment of traumatic condition could pro-vide valuable chance for inhospital first-aid.

A postmortem study of blunt cardiac injuries.

35 cases of blunt cardiac trauma following vehicular accidents brought for autopsy to the morgue of Regional Institute of Medical Sciences, Imphal have been studied to find out types of cardiac injuries, their association with sternal and rib fractures, mechanism of causation, risk factors, etc. It was observed that 48.57% of the cases with blunt cardiac trauma had associated sternal and rib fractures. Maximum number (60%) of the cardiac rupture was seen in run-over cases. 40% of the cases had injury to the right ventricle. All the injuries were located on the anterior surface of the heart. In one (2.86%) case, laceration of the right atrium without any external injury of the chest region was observed. In assessing blunt cardiac trauma victims in vehicular accidents, knowledge about the commonest sites, types and degrees of injuries as has been highlighted in the present study will be of great help in a timely intervention.

Ferimento puntiforme em tórax produzindo lesão cardíaca / Punctiform thoracic wound producing cardiac lesion

We report a case of a 17-year-old man with punctiforms thoracic and abdominal wounds. Clinical examination showed signs of cardiac tamponade. Roentgenogram demonstrated widened mediastinum and thoracotomy confirmed cardiac wound. We analyse the unusual trauma agent and prognostic factors in cardiac trauma. Wounds with "innocent" aspect can cause fatal lesions.