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Immediate surgery for traumatic heart disease
Volume 50, Number 3
September 1965
The Journal of T H O R A C I C A N
CARDIOVASCULAR SURGERY
Immediate surgery for traumatic heart disease Thomas F. Boyd, M.D.,* and John W. Strieder, M.D.,** Boston, Mass. With the assistance of Robert A. Scarpato, B.S.
.Lwenty-five patients with traumatic hemopericardium due to penetrating wounds of the chest have been seen and treated by the Thoracic Surgical Service at the Boston City Hospital from 1956 through 1964. This group includes every patient who arrived alive at the hospital, even though the only sign of life was a single gasping respiration. Before 1956, penetrating wounds of the heart were extremely infrequent in proper New England cities and indeed in most northern cities of the United States. The favorite means of mayhem or self-protection were the stoutly wielded foot or shillelagh.
From the Thoracic Surgical Service, Boston City Hospital, Boston, Mass. Read at the Forty-fifth Annual Meeting of The American Association for Thoracic Surgery, New Orleans, La., March 29-31, 1965. •Associate Director, Thoracic Surgical Service. Assistant Professor of Surgery, Boston University, School of Medicine. ♦♦Surgeon in Chief, Thoracic Surgical Service. Clinical Professor of Surgery, Boston University, School of Medicine.
Consequently, blunt cerebral trauma was the rule. With changing patterns of immigration and juvenile delinquency, penetrating car diac trauma has become a much more important injury at the Boston City Hos pital. Patient selection In the city of Boston, the majority of ambulances are manned by the police force (Fig. 1). Over the past 15 or 20 years, this system has come under severe criticism by members of agencies that are interested in efficiency of the police force and also by those agencies interested in lowering munic ipal expense. However, this system is unsurpassed in bringing severely injured patients to the hospital quickly, so that, in spite of extremely severe wounds, the pa tient is delivered to the hospital alive. In the years 1960 through 1964, there were 201 homicides in Boston with 52 deaths due to stabbings or shootings.* ♦Courtesy of Homicide Division, Boston Police Depart ment.
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Fig. 1. A police ambulance of the city of Boston is shown. Two policemen whose duty is to bring ill and injured persons to the hospital are unloading a simulated casualty at the accident floor of the Boston City Hospital.
Fourteen of these deaths were due to car diac injury. In the entire 5 year period, 26 people received stab or bullet wounds of the heart in the City of Boston. Only 10 of these people were dead on the scene or dead on arrival at the hospital.* Sixteen of the 26 arrived at the hospital in time for an operative attempt at resuscitation.* Twelve of these patients survived operation and became long-term survivors. The high percentage of patients delivered to this hospital alive is in contradistinction to the statistics from Houston 1 ' 2 and Baltimore 3 ' 4 where a conservative approach to this problem is advocated. In these two cities, 60 to 70 per cent of the patients with cardiac wounds are either dead on the scene or dead on arrival at the hospital. The particular geographic locale of Boston City Hospital favors the delivery of patients with this particular injury to the hospital alive (Fig. 2). The hospital is very centrally located in the city, which is small in area, but, even more important, almost all heart wounds are inflicted in an area within a thirty block radius of the hospital. It is not unusual for a patient to be de*Courtesy of the Medical Examiners, Suffolk County, Mass.
livered to the Accident Floor within 5 to 10 minutes of the wounding. In the past 5 years, 62 per cent of all patients with heart wounds were delivered to the hospital alive and thus were given the chance for restora tive surgery. The final outcome in penetrating cardiac trauma is always determined by the inter play of the three crucial factors which are the myocardial wound, the pericardial wound, and the resultant hemopericardium.5· ° The possibility of the wound involving vital cardiac structures should not enter into the evaluation of a method of therapy, for it appears that the vast majority of patients with injuries to the heart valves and conduction system almost never survive the initial trauma. 5 · 7 Like wise, those patients who sustain injuries to the coronary arteries usually succumb to the injury.8·9>10 However, a single patient in this series had complete transection of the anterior descending coronary artery and survived operation. Therefore, the possi bility of involvement of these structures should not influence the method of therapy. If, on initial wounding, the pericardial wound is large and the myocardial wound
Volume 50 Number 3 September, 1965
is large, there is no chance for hemopericardium and tamponade to form and the patient rapidly becomes exsanguinated. Conversely, if, on initial wounding, the pericardial wound is small and the myo-
Traumatic heart disease 3 0 7
cardial wound is large, hemopericardium will be produced which will serve to pre serve life for additional minutes or hours. Occasionally, when both pericardial and myocardial wounds are small, the amount
TV-
Fig. 2. This is a map of the city of Boston. The small circle in the center indicates the central location of the Boston City Hospital. The larger circle indicates the thirty block radius about the hospital where 90 per cent of the stab and bullet wounds of the heart are inflicted. The most distant portion of the city is only 7.7 miles from the Boston City Hospital.
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of hemopericardium will be small in amount, no signs of blood loss or tamponade will be present, and the patient's condition will stabilize and he will recover without specific therapy. 11 · 12 The method of treatment of these severely injured patients has varied during the course of this study, and the data are best presented in chrono logic sequence. Material and results Evaluation period. In the first 3 years, the over-all approach was to observe the patient with an anterior penetrating chest wound in the operating room. With the development of any stigmata of tamponade, that is, falling arterial pressure, rising venous pressure, dimunition or disappear ance of cardiac sounds, or appearance of
Fig. 3. This is an artist's drawing of the injury received by the first patient in this series. With complete transection of the anterior descending coronary artery, both ends of which were bleed ing actively at operation, it is not surprising that pericardiocentesis did not relieve the tamponade.
a paradoxical pulse, the therapy was to tap the pericardium and again observe the patient. The first several patients in this series were so treated; but the condition of each suddenly deteriorated which led to cardiac arrest and the need for immediate thoracotomy. The first patient had transection of the left anterior descending coronary artery (Fig. 3) which led to the tamponade. This artery was ligated, the underlying ventricu lar myocardium was repaired, and the patient made a satisfactory recovery without a myocardial infarction.9 The second patient in the series (Fig. 4) was taken to the operating room where he had pericardiocentesis, and he also suddenlydeveloped cardiac tamponade and cardiac arrest. Again, emergency thoracotomy was performed with eventual survival. During this first 3 year period, it was occasionally necessary to operate upon patients on the Accident Floor because they were in extremis due to either cardiac arrest or exsanguination. None of those pa tients operated upon in the accident rooms survived. During this evaluation period, 5 of 9 patients operated upon survived. No pa tients were seen that could be handled by pericardiocentesis alone but it was tried first in all patients in whom there was no exsanguination or cardiac arrest. The re-evaluation period. During the suc ceeding 2 year period, operation was begun earlier in the patient's course—that is, before cardiac arrest supervened. Pericar diocentesis was still used, but primarily as a diagnostic method and as preparation for surgery rather than as a definitive method of therapy. There were exceptions to this rule, as one patient had a single pericardio centesis of 410 c.c. of blood, awakened from his comatose state and refused both surgical treatment and any further pericardiocenteses. He went home in 1 week, and, although he had severe pain from the succeeding sterile pericarditis,13 within a year he had returned to his old occupation without difficulty.
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Fig. 4. Artist's drawing of the injury received by the second patient in this series. Both the external wound of the right ventricle and the external wound of the left ventricle were bleeding actively at operation. The patient endured 50 minutes of cardiac massage and 35 minutes of ventricular fibrillation before repair and conversion of rhythm could be established. He made a complete re covery and returned to hard physical labor.
If this patient whose surgical treatment consisted only of pericardiocentesis is included in this group, 4 of the 7 patients operated upon survived. Analysis of the data from these two groups combined yielded striking conclusions. The most im portant was the relationship of survival to duration of the injury prior to thoracotomy. The time of wounding was quite accu rately known by the Police Department. In many instances, the police saw the wound administered, as for example in a street fight that they were attempting to quell. All patients survived who were operated upon in the operating room within 2 hours after the wounding. It was inconsequential whether the wound involved the right, left, or both ventricles, or whether the coronary artery was severed. Even if cardiac arrest occurred, if the patient was operated upon in this golden period within 2 hours after injury, he survived and left the hospital in good general condition.
Current therapy period. During the last 3 years of study, the over-all strategy was to operate upon all patients with bullet wounds and stab wounds of the heart as soon as the diagnosis was made. The decision for operation was to be made by the senior surgeon in attendance upon the patient, whether he was of the Resident or Attend ing Staff. The only criterion for operation was that the patient be suffering from hemopericardium. This diagnosis could be made on the basis of all facts available to the surgeon. This usually included pericardio centesis, but might include only history and physical examination. The x-ray appearance of the cardiac silhouette and electrocardiographic evidence of pericarditis were occa sionally helpful. The senior surgeon in attendance was never wrong in his diagnosis of hemopericardium. The next 9 patients were all rushed to the operating room and operated upon there within the crucial 2 hour time limit. Eight of these 9 patients survived (Fig. 5). Discussion. Of a total of 25 patients admitted to the Boston City Hospital with penetrating wounds of the chest and hemo pericardium, twenty-one wounds were caused by knives, three by bullets, and one by an intracardiac catheter. All but 1 of the patients were males, and the ages ranged from 19 to 69 years. Of necessity, 3 patients—2 with wounds | ISr
| TOTAL
H
1956I9S9
I9601961
SURVIVORS
19611964
YEARS
Fig. 5. The improvement in survival rate is shown when all patients were rushed to the operating room and operated upon within the first 2 hours after wounding. This is the current ruling and was in force in 1961-1964 when 8 of 9 patients survived.
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caused by knives and 1 who had sustained a bullet wound—were operated upon on the accident floor and did not survive. This should not deter similar attempts, for survival under these operating conditions has been reported.1' " No patients were allowed to go to a ward. All were observed on the operating floor and, after the first few cases, in an operating room, itself. In the early "cases, the patients were observed and treated by pericardiocentesis, as recommended by Blalock and Ravitch,15 plus the intravenous infusion of fluids, blood, and pressor agents. In spite of this therapy, the vast majority still developed cardiac arrest and required surgical intervention. In the last group of patients, as soon as the diagnosis of hemopericardium was made, surgery was undertaken and there were no further cardiac arrests. Of 9 such patients, the only death occurred 3 days postoperatively from a Pseudomonas bacteremia, undoubtedly introduced at the time the patient received the stab wound of the right ventricle. Ten patients received wounds of the right ventricle only. Six received wounds of the left ventricle only. Two received wounds of the atrium only. The others had combined lesions of both ventricles, or a ventricle and a coronary artery; a single patient suffered from extrapericardial bleeding into the pericardial sac with acute tamponade (Table I). The complexity of the wound and its
Table I. Site and type of cardiac injury Num ber
Knif
Right ventricle Left ventricle Both ventricles Right atrium Ventricle and coro nary artery Unknown Extrapericardial bleeding
10 6 2 2
7 5 2 2
3 1
3 1
1
1
Total
25
21
Site
method of causation did not seem to influ ence survival. Four patients were known to have antecedent heart disease. Two of these were operated upon more than 2 hours after the wounding and one of them after cardiac arrest occurred. Both of these patients died. Conversely, 2 other patients with antecedent heart disease, including the oldest patient in the entire series (69 years), were operated upon within 2 hours, and both survived. In the 22 patients that reached the operating room alive, 5 had indications for abdominal exploration in addition to the indication for thoracotomy. There was either a separate abdominal wound, or the wound was at the costal margin and could have penetrated the abdomen, or, at thoracotomy, a wound was seen which penetrated the diaphragm. In our institution, all patients with stab or bullet wounds of the abdomen are ex plored, but very few with stab wounds of the chest are subjected to exploration. Most bullet wounds of the chest are explored, particularly if there is extensive hemorrhage or a question of injury to a vital structure. In the 5 patients in whom abdominal exploration was carried out, there was 1 patient with a lacerated spleen, and she also had multiple bowel perforations. A second patient had perforations of the stomach and pancreas. A third patient had a lacerated liver, and 2 patients had no intra-abdominal injury. One of these was 1 öf the patients with known antecedent heart disease who was operated upon after the crucial time limit of 2 hours, and he succumbed. The patient that sustained a perforating wound from a cardiac catheter, with subsequent development of tamponade, was subjected to thoracotomy. The tampo nade was relieved, the perforation of the heart was closed, and then an inferior vena cava ligation was performed for pre-existing thrombophlebitis and pulmonary emboli under the same anesthesia. He also sur vived. For those patients who were comatose or apneic, trachea! intubation without anes-
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thesia was used, and thoracotomy was started, with the patient respired with 100 per cent oxygen. As soon as tamponade was relieved or the bleeding was controlled and the patient needed anesthesia, cyclopropane was added to the oxygen in the great majority of cases. In more recent years, the same routine has been used but the anes thetic used has been halothane. If the patient is awake prior to thoracotomy, rapid "crash" induction with intravenous thiopental and succinylcholine is now used, with the addition of either halothane or cyclopropane plus oxygen by inhalation. Local infiltration anesthesia is not used. The routine operative approach is with the patient supine, a sandbag beneath the left scapula, and the left arm elevated on an anesthesia screen (Fig. 6). The incision is centered over the fourth intercostal space in the male, and in the infra-mammary fold in the female, and carried well up into the axilla. The left hemithorax is entered through the fourth intercostal space which is opened from the lateral border of the
Fig. 6. Artist's drawing of the position of the patient for an anterior Spangaro incision, which was used in all the cases presented.
sternum to the mid-axillary line. A rib spreader is inserted and spread forcibly; the costochondral junctions are allowed to dis locate if necessary. The pericardium is opened widely in a vertical manner anterior to the phrenic nerve. Liquid and clotted blood are removed from the pericardial sac and the bleeding point is immediately ob vious. In almost all instances, the clotted component is much greater than the liquid. This is true for two reasons: (1) in the great majority of cases, pericardiocentesis will have been performed either for diagnosis or therapy (the blood that was removed via the needle would be the unclotted portion); (2) in those patients coming to the operating room with blood rapidly pouring into the pericardium, the relatively large volumes of blood clot before defibrination can take place. The operator's finger is placed over or into the wound in the heart. The blood balance is restored or immediate massage is started to institute normal rhythm, if arrest has occurred. After blood pressure and other vital signs have reached normal limits, the wound is repaired with either simple sutures or mattress sutures, usually of 2-0 or 3-0 silk on atraumatic needles (Fig. 7). Anesthetic agents may be started at this point if they were not previously necessary. If the procedure has been performed without preparation and draping of the operative field and without scrubbing and gowning of the operative team, the team at this point may withdraw to scrub, gown, and glove, and the field may be prepared and draped. New sterile instruments are obtained. At least 6 patients were operated upon without surgical preparation, that is with unsterile instruments, unscrubbed hands, with the surgeons in street clothes, and the patients survived. Interestingly, none of these patients developed a cardiac, pleural, or wound infection. The apical traction suture of Beck10 for exposure of the posterior aspect of the heart is not used. The posterior aspect of
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Fig. 7A. Artist's drawing of a patient's heart that suffered a through-and-through bullet wound per foration of the right ventricle.
dary intention. No infections of either stab or bullet wounds occurred. The pleural space is drained by a catheter attached to a water-sealed drainage bottle. On two occasions, for additional expo sure of the right side of the heart, it was necessary to transect the sternum and enter the opposite pleural cavity. This caused no specific problems but this pleural space was also drained to a water-sealed bottle. All patients in the series were given pro phylactic systemic antibiotics. Usually this was a combination of penicillin and strep tomycin, but, on occasions, chloramphenicol was used in addition and, occasionally, the chest was closed with a mixture of strepto mycin, penicillin, and bacitracin left in the pleural cavity. In recent years, no antibi otics have been placed in the chest. It is believed that the administration of penicillin will prevent clinical tetanus infection and no tetanus toxoid or antitoxin is administered until the patient is several days postopera tive. Then an adequate immunization history is taken and tetanus toxoid is administered if the patient has been pre viously immunized. If he had not, systemic penicillin is continued for 7 to 10 days. Otherwise, antibiotics are discontinued after 5 days. Causes of death (Table II)
Fig. 7B. Drawing of the method of repair used in this particular case. The small inset shows the method of repair of wounds adjacent to the coro nary arteries.
the heart is easily exposed by simple lifting of the apex by the operator's left hand. A large pericardial window is made posterior to the phrenic nerve and the anterior pericardiotomy incision is closed loosely after thorough irrigation of the pericardial and the pleural cavities. If the wound of entrance is in the line of the thoracotomy incision, it is excised. If it is not, it is ignored until the thoracotomy incision is closed. Then it is excised, and packed open with Vaseline gauze and allowed to granulate in and heal by secon-
Deaths on Accident Floor. All 3 patients operated upon on the Accident Floor died. The first was operated upon within 20 minutes of wounding for tamponade and cardiac arrest. The knife entered the right ventricle and transected the right main coronary artery. Resuscitation was impos sible. The second patient was operated upon for exsanguination and cardiac arrest within 15 minutes of the wounding. The knife wounds entered the left ventricle and tran sected the left anterior descending coronary artery. The heart was resuscitated, but blood pressure could not be maintained, even with pressor agents, and the patient died IVi hours postoperatively. The third patient was operated upon
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Table II. Deaths in 25 consecutive patients arriving alive at Boston City Hospital
Site and time of operation
No. oper ated upon
No. of deaths
Cause of death
Accident floor
3
3
1 Arrest 1 Cardiac fail ure 1 Exsanguination
Operating room, more than 2 hr. after wounding
4
4
1 Renal shut down 2 Arrest 1 Pulmonary emboli and cecal volvu lus
Operating room, less than 2 hr. after wounding
18
1
1 Bacteremia
Totals
25
8
within 5 minutes of the wounding, for cardiac arrest and exsanguination with a bullet wound through the right ventricle and aorta. The patient bled to death during the operation. Deaths following operation in operating room later than 2 hours after wounding. The first patient was a 42-year-old man who was watched in the operating room for VA hours with pericardial taps for treat ment. The patient was then operated upon when his condition deteriorated, and tamponade was relieved by surgery. The wound was in the right atrium. Postoperatively the patient developed acute porphyria, cecal volvulus, multiple pulmonary emboli, and died 31-days postoperatively. The second patient was a 60-year-old man with a known history of heart disease who was operated upon after 2 pericardiocenteses and 4 hours after a self-inflicted knife wound. The immediate reason for thoracotomy was cardiac arrest. The wound was in the right ventricle, and was easily repaired, but arrest could not be overcome by vigorous massage, because of the pro longed preceding shock-like state.
The third patient was operated upon after Wi hours of observation. This was a 33-year-old man to whom the Anesthesia Service refused to administer anesthesia because he was in shock. He could not be brought out of shock in spite of adequate blood replacement and three pericardial taps. Finally, he was operated upon and a lacerated left ventricle was repaired. The patient developed renal shutdown and died of this complication 8 days postoperatively. The last patient in this group was a 53year-old man who was observed and treated with a single pericardiocentesis for a 2Vi hour period after wounding. This patient had had a documented myocardial infarction 3 years previously. Following pericardiocentesis, tamponade again devel oped and the patient was operated upon for repair of the knife wound of the right atrium. He suffered two episodes of cardiac arrest on the operating table and one post operatively which was the cause of death. Death following operation in the operat ing room less than 2 hours after wounding. The only such death was in a 42-year-old man with a stab wound of the right ventri cle. The indication for operation was tamponade. He was operated upon under the usual sterile operating room conditions, but postoperatively he developed atrial fibrillation and a high spiking temperature in spite of the usual prophylactic antibiotics (penicillin and streptomycin). He also demonstrated delirium tremens. On the third postoperative day, the patient de veloped cardiac arrest and died. Blood cultures drawn before his death grew out Pseudomonas aeruginosa after his death. The surgical wound was not infected at autopsy. The source of the infection must be considered to be the original stab wound, although it was apparently clean at the time of autopsy. Complications in the surviving cases (Table III) Wound infection. There were no thora cotomy wound infections. There were no stab or bullet wound infections. There were
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two abdominal exploratory wound infec tions, one of which was associated with a spontaneously healing small bowel fistula. Pleural effusions requiring thoracentesis. Five patients developed pleural effusion. One thoracentesis sufficed for all but a single patient. He required two taps. Atrial fibrillation. Atrial fibrillation devel oped in 2 patients postoperatively and responded to digitalization in both patients. Bronchopneumonia. One patient devel oped bronchopneumonia which responded to appropriate antibiotics. Atelectasis. One patient required bronchoscopy for lower lobe atelectasis. Period of hospitalization in surviving pa tients. This varied from 7 to 30 days. As might be expected, the shortest periods were for patients who had simple chest wounds and heart injuries. The longer periods of hospitalization were in those patients who required abdominal surgery. The longest periods of hospitalization were in the 2 patients who developed abdominal wound infections. One remained for 28 days. The other remained for 24 days. The patient with thrombophlebitis and pulmo nary emboli prior to cardiac perforation was also kept in the hospital for 28 days following cardiorrhaphy and inferior vena cava ligation. The average stay for all surviving patients was 17 days. Summary A group of 25 patients has been pre sented with traumatic hemopericardium due to penetrating chest trauma or cardiac per foration with an intracardiac catheter. In the early years of the study, attempts at treatment with pericardiocentesis, intra venous infusion of fluids, blood, and pressor agents led frequently to cardiac arrest and/or late operation. When opera tion was conducted in the operating room within 2 hours of the wounding, 17 of 18 patients survived surgery, and left the hospital alive and well. When surgery was performed more than 2 hours after the wounding, no patient survived. (Four of 4 patients succumbed.) The difference be-
Table III. Postoperative complications in surviving patients Complication Atelectasis Wound infections Thoracotomy Abdominal Small bowel fistula Pleural effusion Atrial fibrillation Bronchopneumonia Total No. of patients—17
\
No. 1 0 2 1 5 2 1 Total No. of complications —12
tween the groups is statistically significant (p > 0.01). No patient operated upon in the operating room within 2 hours of the wounding developed a serious postoperative complica tion with the exception of the 1 patient who died of Pseudomonas bacteremia introduced by the initial knife wound. Abdominal exploration was performed upon all patients with specific indications, immediately following relief of tamponade, and cardiorrhaphy. In all instances, this was performed through a separate abdominal incision. Follow-up of these patients is notoriously poor, but the vast majority had returned to pre-injury employment within 3 to 6 months following operation, and were without car diac symptomatology at that time. Conclusions 1. In a large municipal institution, rapid transport of the patient with hemoperi cardium due to penetrating chest trauma to the operating room is mandatory. 2. If the general condition of the patient is deteriorated because of cardiac arrest or exsanguination, operation on the admitting floor is permissible. 3. Many or few diagnostic modalities may be used in the operating room to make the diagnosis of hemopericardium, but, when the diagnosis is made, surgery should be immediately carried out, always within 2 hours of the wounding.
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4. Pre-existing cardiac disease is an indi cation for very urgent surgery. 5. Abdominal exploration should be carried out under the same anesthetic ad ministration, following the thoracotomy, pericardiotomy, cardiorrhaphy, and closure of the thoracotomy wound. A separate ab dominal incision should be used. 6. Prophylactic antibiotics should always be used, particularly if previous tetanus im munization is unknown. REFERENCES 1 Beall, A. C , Jr., Ochsner, J. L., Morris, G. C , Jr., Cooley, D. A., and De Bakey, M. E.: Penetrating Wounds of the Heart, J. Trauma 1: 195, 1961. 2 Cooley, D. A., Dunn, J. R., Brockman, H. L., and De Bakey, M. E.: Treatment of Penetrat ing Wounds of the Heart: Experimental and Clinical Observations, Surgery 37: 882, 1955. 3 Isaacs, J. P.: Sixty Penetrating Wounds of the Heart, Surgery 45: 696, 1959. 4 Blalock, A., and Ravitch, M. M.: A Considera tion of the Non-Operative Treatment of Car diac Tamponade Resulting From Wounds of the Heart, Surgery 52: 330, 1962. 5 Naclerio, E. A.: Penetrating Wounds of the Heart, Dis. Chest 46: 1, 1964. 6 Marjash, A. D., and Maynard, A. deL.: Stab Wounds of the Heart, Am. J. Surg. 101: 385, 1961. 7 Sanger, P., Tavana, M., Taylor, F. H., and Robicsek, F.: The Merit of Emergency Thora
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cotomy in the Management of Stab Wounds of the Heart, North Carolina M. J. 25: 1, 1964. Graham, G. K., and Laforet, E. G.: An Elec trocardiographs and Morphologic Study of Changes Following Ligation of the Left Cor onary Artery in Human Beings, Am. Heart J. 43: 42, 1952. Carleton, R. A., and Boyd, T. F.: Traumatic Laceration of the Anterior Descending Coro nary Artery Treated by Ligation Without Myocardial Infarction, Am. Heart J. 56: 136, 1958. Griswold, R. A., and Maguire, C. H.: Pene trating Wounds of Heart and Pericardium, Surg., Gynec. & Obst. 74: 406, 1942. Fischer, G.: Die Wundendes Herzens und des Herzbeutels, Arch. F. Klin. Chir. 9: 571, 1868. (Cited by Lyons and Perkins.12) Lyons, C , and Perkins, R.: Cardiac Stab Wounds, Am. Surg. 23: 507, 1957. Tabatznik, B., and Isaacs, J. P.: Postpericardiotomy Syndrome Following Traumatic Hemopericardium, Am. J. Cardiol. 7: 83, 1961. Baue, A. E.: Immediate Thoracotomy for a Stab Wound of the Heart, J. A. M. A. 186: 521, 1963. Blalock, A., and Ravitch, M. M.: Considera tion of Nonoperative Treatment Cardiac Tam ponade Resulting From Wounds of the Heart, Surgery 14: 157, 1943. Beck, C. S.: Wounds of the Heart: The Technic of Suture, Arch. Surg. 13: 205, 1926. (For Discussion, see page 334)
September 1965
The Journal of T H O R A C I C A N
CARDIOVASCULAR SURGERY
Immediate surgery for traumatic heart disease Thomas F. Boyd, M.D.,* and John W. Strieder, M.D.,** Boston, Mass. With the assistance of Robert A. Scarpato, B.S.
.Lwenty-five patients with traumatic hemopericardium due to penetrating wounds of the chest have been seen and treated by the Thoracic Surgical Service at the Boston City Hospital from 1956 through 1964. This group includes every patient who arrived alive at the hospital, even though the only sign of life was a single gasping respiration. Before 1956, penetrating wounds of the heart were extremely infrequent in proper New England cities and indeed in most northern cities of the United States. The favorite means of mayhem or self-protection were the stoutly wielded foot or shillelagh.
From the Thoracic Surgical Service, Boston City Hospital, Boston, Mass. Read at the Forty-fifth Annual Meeting of The American Association for Thoracic Surgery, New Orleans, La., March 29-31, 1965. •Associate Director, Thoracic Surgical Service. Assistant Professor of Surgery, Boston University, School of Medicine. ♦♦Surgeon in Chief, Thoracic Surgical Service. Clinical Professor of Surgery, Boston University, School of Medicine.
Consequently, blunt cerebral trauma was the rule. With changing patterns of immigration and juvenile delinquency, penetrating car diac trauma has become a much more important injury at the Boston City Hos pital. Patient selection In the city of Boston, the majority of ambulances are manned by the police force (Fig. 1). Over the past 15 or 20 years, this system has come under severe criticism by members of agencies that are interested in efficiency of the police force and also by those agencies interested in lowering munic ipal expense. However, this system is unsurpassed in bringing severely injured patients to the hospital quickly, so that, in spite of extremely severe wounds, the pa tient is delivered to the hospital alive. In the years 1960 through 1964, there were 201 homicides in Boston with 52 deaths due to stabbings or shootings.* ♦Courtesy of Homicide Division, Boston Police Depart ment.
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Fig. 1. A police ambulance of the city of Boston is shown. Two policemen whose duty is to bring ill and injured persons to the hospital are unloading a simulated casualty at the accident floor of the Boston City Hospital.
Fourteen of these deaths were due to car diac injury. In the entire 5 year period, 26 people received stab or bullet wounds of the heart in the City of Boston. Only 10 of these people were dead on the scene or dead on arrival at the hospital.* Sixteen of the 26 arrived at the hospital in time for an operative attempt at resuscitation.* Twelve of these patients survived operation and became long-term survivors. The high percentage of patients delivered to this hospital alive is in contradistinction to the statistics from Houston 1 ' 2 and Baltimore 3 ' 4 where a conservative approach to this problem is advocated. In these two cities, 60 to 70 per cent of the patients with cardiac wounds are either dead on the scene or dead on arrival at the hospital. The particular geographic locale of Boston City Hospital favors the delivery of patients with this particular injury to the hospital alive (Fig. 2). The hospital is very centrally located in the city, which is small in area, but, even more important, almost all heart wounds are inflicted in an area within a thirty block radius of the hospital. It is not unusual for a patient to be de*Courtesy of the Medical Examiners, Suffolk County, Mass.
livered to the Accident Floor within 5 to 10 minutes of the wounding. In the past 5 years, 62 per cent of all patients with heart wounds were delivered to the hospital alive and thus were given the chance for restora tive surgery. The final outcome in penetrating cardiac trauma is always determined by the inter play of the three crucial factors which are the myocardial wound, the pericardial wound, and the resultant hemopericardium.5· ° The possibility of the wound involving vital cardiac structures should not enter into the evaluation of a method of therapy, for it appears that the vast majority of patients with injuries to the heart valves and conduction system almost never survive the initial trauma. 5 · 7 Like wise, those patients who sustain injuries to the coronary arteries usually succumb to the injury.8·9>10 However, a single patient in this series had complete transection of the anterior descending coronary artery and survived operation. Therefore, the possi bility of involvement of these structures should not influence the method of therapy. If, on initial wounding, the pericardial wound is large and the myocardial wound
Volume 50 Number 3 September, 1965
is large, there is no chance for hemopericardium and tamponade to form and the patient rapidly becomes exsanguinated. Conversely, if, on initial wounding, the pericardial wound is small and the myo-
Traumatic heart disease 3 0 7
cardial wound is large, hemopericardium will be produced which will serve to pre serve life for additional minutes or hours. Occasionally, when both pericardial and myocardial wounds are small, the amount
TV-
Fig. 2. This is a map of the city of Boston. The small circle in the center indicates the central location of the Boston City Hospital. The larger circle indicates the thirty block radius about the hospital where 90 per cent of the stab and bullet wounds of the heart are inflicted. The most distant portion of the city is only 7.7 miles from the Boston City Hospital.
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of hemopericardium will be small in amount, no signs of blood loss or tamponade will be present, and the patient's condition will stabilize and he will recover without specific therapy. 11 · 12 The method of treatment of these severely injured patients has varied during the course of this study, and the data are best presented in chrono logic sequence. Material and results Evaluation period. In the first 3 years, the over-all approach was to observe the patient with an anterior penetrating chest wound in the operating room. With the development of any stigmata of tamponade, that is, falling arterial pressure, rising venous pressure, dimunition or disappear ance of cardiac sounds, or appearance of
Fig. 3. This is an artist's drawing of the injury received by the first patient in this series. With complete transection of the anterior descending coronary artery, both ends of which were bleed ing actively at operation, it is not surprising that pericardiocentesis did not relieve the tamponade.
a paradoxical pulse, the therapy was to tap the pericardium and again observe the patient. The first several patients in this series were so treated; but the condition of each suddenly deteriorated which led to cardiac arrest and the need for immediate thoracotomy. The first patient had transection of the left anterior descending coronary artery (Fig. 3) which led to the tamponade. This artery was ligated, the underlying ventricu lar myocardium was repaired, and the patient made a satisfactory recovery without a myocardial infarction.9 The second patient in the series (Fig. 4) was taken to the operating room where he had pericardiocentesis, and he also suddenlydeveloped cardiac tamponade and cardiac arrest. Again, emergency thoracotomy was performed with eventual survival. During this first 3 year period, it was occasionally necessary to operate upon patients on the Accident Floor because they were in extremis due to either cardiac arrest or exsanguination. None of those pa tients operated upon in the accident rooms survived. During this evaluation period, 5 of 9 patients operated upon survived. No pa tients were seen that could be handled by pericardiocentesis alone but it was tried first in all patients in whom there was no exsanguination or cardiac arrest. The re-evaluation period. During the suc ceeding 2 year period, operation was begun earlier in the patient's course—that is, before cardiac arrest supervened. Pericar diocentesis was still used, but primarily as a diagnostic method and as preparation for surgery rather than as a definitive method of therapy. There were exceptions to this rule, as one patient had a single pericardio centesis of 410 c.c. of blood, awakened from his comatose state and refused both surgical treatment and any further pericardiocenteses. He went home in 1 week, and, although he had severe pain from the succeeding sterile pericarditis,13 within a year he had returned to his old occupation without difficulty.
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Fig. 4. Artist's drawing of the injury received by the second patient in this series. Both the external wound of the right ventricle and the external wound of the left ventricle were bleeding actively at operation. The patient endured 50 minutes of cardiac massage and 35 minutes of ventricular fibrillation before repair and conversion of rhythm could be established. He made a complete re covery and returned to hard physical labor.
If this patient whose surgical treatment consisted only of pericardiocentesis is included in this group, 4 of the 7 patients operated upon survived. Analysis of the data from these two groups combined yielded striking conclusions. The most im portant was the relationship of survival to duration of the injury prior to thoracotomy. The time of wounding was quite accu rately known by the Police Department. In many instances, the police saw the wound administered, as for example in a street fight that they were attempting to quell. All patients survived who were operated upon in the operating room within 2 hours after the wounding. It was inconsequential whether the wound involved the right, left, or both ventricles, or whether the coronary artery was severed. Even if cardiac arrest occurred, if the patient was operated upon in this golden period within 2 hours after injury, he survived and left the hospital in good general condition.
Current therapy period. During the last 3 years of study, the over-all strategy was to operate upon all patients with bullet wounds and stab wounds of the heart as soon as the diagnosis was made. The decision for operation was to be made by the senior surgeon in attendance upon the patient, whether he was of the Resident or Attend ing Staff. The only criterion for operation was that the patient be suffering from hemopericardium. This diagnosis could be made on the basis of all facts available to the surgeon. This usually included pericardio centesis, but might include only history and physical examination. The x-ray appearance of the cardiac silhouette and electrocardiographic evidence of pericarditis were occa sionally helpful. The senior surgeon in attendance was never wrong in his diagnosis of hemopericardium. The next 9 patients were all rushed to the operating room and operated upon there within the crucial 2 hour time limit. Eight of these 9 patients survived (Fig. 5). Discussion. Of a total of 25 patients admitted to the Boston City Hospital with penetrating wounds of the chest and hemo pericardium, twenty-one wounds were caused by knives, three by bullets, and one by an intracardiac catheter. All but 1 of the patients were males, and the ages ranged from 19 to 69 years. Of necessity, 3 patients—2 with wounds | ISr
| TOTAL
H
1956I9S9
I9601961
SURVIVORS
19611964
YEARS
Fig. 5. The improvement in survival rate is shown when all patients were rushed to the operating room and operated upon within the first 2 hours after wounding. This is the current ruling and was in force in 1961-1964 when 8 of 9 patients survived.
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caused by knives and 1 who had sustained a bullet wound—were operated upon on the accident floor and did not survive. This should not deter similar attempts, for survival under these operating conditions has been reported.1' " No patients were allowed to go to a ward. All were observed on the operating floor and, after the first few cases, in an operating room, itself. In the early "cases, the patients were observed and treated by pericardiocentesis, as recommended by Blalock and Ravitch,15 plus the intravenous infusion of fluids, blood, and pressor agents. In spite of this therapy, the vast majority still developed cardiac arrest and required surgical intervention. In the last group of patients, as soon as the diagnosis of hemopericardium was made, surgery was undertaken and there were no further cardiac arrests. Of 9 such patients, the only death occurred 3 days postoperatively from a Pseudomonas bacteremia, undoubtedly introduced at the time the patient received the stab wound of the right ventricle. Ten patients received wounds of the right ventricle only. Six received wounds of the left ventricle only. Two received wounds of the atrium only. The others had combined lesions of both ventricles, or a ventricle and a coronary artery; a single patient suffered from extrapericardial bleeding into the pericardial sac with acute tamponade (Table I). The complexity of the wound and its
Table I. Site and type of cardiac injury Num ber
Knif
Right ventricle Left ventricle Both ventricles Right atrium Ventricle and coro nary artery Unknown Extrapericardial bleeding
10 6 2 2
7 5 2 2
3 1
3 1
1
1
Total
25
21
Site
method of causation did not seem to influ ence survival. Four patients were known to have antecedent heart disease. Two of these were operated upon more than 2 hours after the wounding and one of them after cardiac arrest occurred. Both of these patients died. Conversely, 2 other patients with antecedent heart disease, including the oldest patient in the entire series (69 years), were operated upon within 2 hours, and both survived. In the 22 patients that reached the operating room alive, 5 had indications for abdominal exploration in addition to the indication for thoracotomy. There was either a separate abdominal wound, or the wound was at the costal margin and could have penetrated the abdomen, or, at thoracotomy, a wound was seen which penetrated the diaphragm. In our institution, all patients with stab or bullet wounds of the abdomen are ex plored, but very few with stab wounds of the chest are subjected to exploration. Most bullet wounds of the chest are explored, particularly if there is extensive hemorrhage or a question of injury to a vital structure. In the 5 patients in whom abdominal exploration was carried out, there was 1 patient with a lacerated spleen, and she also had multiple bowel perforations. A second patient had perforations of the stomach and pancreas. A third patient had a lacerated liver, and 2 patients had no intra-abdominal injury. One of these was 1 öf the patients with known antecedent heart disease who was operated upon after the crucial time limit of 2 hours, and he succumbed. The patient that sustained a perforating wound from a cardiac catheter, with subsequent development of tamponade, was subjected to thoracotomy. The tampo nade was relieved, the perforation of the heart was closed, and then an inferior vena cava ligation was performed for pre-existing thrombophlebitis and pulmonary emboli under the same anesthesia. He also sur vived. For those patients who were comatose or apneic, trachea! intubation without anes-
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thesia was used, and thoracotomy was started, with the patient respired with 100 per cent oxygen. As soon as tamponade was relieved or the bleeding was controlled and the patient needed anesthesia, cyclopropane was added to the oxygen in the great majority of cases. In more recent years, the same routine has been used but the anes thetic used has been halothane. If the patient is awake prior to thoracotomy, rapid "crash" induction with intravenous thiopental and succinylcholine is now used, with the addition of either halothane or cyclopropane plus oxygen by inhalation. Local infiltration anesthesia is not used. The routine operative approach is with the patient supine, a sandbag beneath the left scapula, and the left arm elevated on an anesthesia screen (Fig. 6). The incision is centered over the fourth intercostal space in the male, and in the infra-mammary fold in the female, and carried well up into the axilla. The left hemithorax is entered through the fourth intercostal space which is opened from the lateral border of the
Fig. 6. Artist's drawing of the position of the patient for an anterior Spangaro incision, which was used in all the cases presented.
sternum to the mid-axillary line. A rib spreader is inserted and spread forcibly; the costochondral junctions are allowed to dis locate if necessary. The pericardium is opened widely in a vertical manner anterior to the phrenic nerve. Liquid and clotted blood are removed from the pericardial sac and the bleeding point is immediately ob vious. In almost all instances, the clotted component is much greater than the liquid. This is true for two reasons: (1) in the great majority of cases, pericardiocentesis will have been performed either for diagnosis or therapy (the blood that was removed via the needle would be the unclotted portion); (2) in those patients coming to the operating room with blood rapidly pouring into the pericardium, the relatively large volumes of blood clot before defibrination can take place. The operator's finger is placed over or into the wound in the heart. The blood balance is restored or immediate massage is started to institute normal rhythm, if arrest has occurred. After blood pressure and other vital signs have reached normal limits, the wound is repaired with either simple sutures or mattress sutures, usually of 2-0 or 3-0 silk on atraumatic needles (Fig. 7). Anesthetic agents may be started at this point if they were not previously necessary. If the procedure has been performed without preparation and draping of the operative field and without scrubbing and gowning of the operative team, the team at this point may withdraw to scrub, gown, and glove, and the field may be prepared and draped. New sterile instruments are obtained. At least 6 patients were operated upon without surgical preparation, that is with unsterile instruments, unscrubbed hands, with the surgeons in street clothes, and the patients survived. Interestingly, none of these patients developed a cardiac, pleural, or wound infection. The apical traction suture of Beck10 for exposure of the posterior aspect of the heart is not used. The posterior aspect of
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Fig. 7A. Artist's drawing of a patient's heart that suffered a through-and-through bullet wound per foration of the right ventricle.
dary intention. No infections of either stab or bullet wounds occurred. The pleural space is drained by a catheter attached to a water-sealed drainage bottle. On two occasions, for additional expo sure of the right side of the heart, it was necessary to transect the sternum and enter the opposite pleural cavity. This caused no specific problems but this pleural space was also drained to a water-sealed bottle. All patients in the series were given pro phylactic systemic antibiotics. Usually this was a combination of penicillin and strep tomycin, but, on occasions, chloramphenicol was used in addition and, occasionally, the chest was closed with a mixture of strepto mycin, penicillin, and bacitracin left in the pleural cavity. In recent years, no antibi otics have been placed in the chest. It is believed that the administration of penicillin will prevent clinical tetanus infection and no tetanus toxoid or antitoxin is administered until the patient is several days postopera tive. Then an adequate immunization history is taken and tetanus toxoid is administered if the patient has been pre viously immunized. If he had not, systemic penicillin is continued for 7 to 10 days. Otherwise, antibiotics are discontinued after 5 days. Causes of death (Table II)
Fig. 7B. Drawing of the method of repair used in this particular case. The small inset shows the method of repair of wounds adjacent to the coro nary arteries.
the heart is easily exposed by simple lifting of the apex by the operator's left hand. A large pericardial window is made posterior to the phrenic nerve and the anterior pericardiotomy incision is closed loosely after thorough irrigation of the pericardial and the pleural cavities. If the wound of entrance is in the line of the thoracotomy incision, it is excised. If it is not, it is ignored until the thoracotomy incision is closed. Then it is excised, and packed open with Vaseline gauze and allowed to granulate in and heal by secon-
Deaths on Accident Floor. All 3 patients operated upon on the Accident Floor died. The first was operated upon within 20 minutes of wounding for tamponade and cardiac arrest. The knife entered the right ventricle and transected the right main coronary artery. Resuscitation was impos sible. The second patient was operated upon for exsanguination and cardiac arrest within 15 minutes of the wounding. The knife wounds entered the left ventricle and tran sected the left anterior descending coronary artery. The heart was resuscitated, but blood pressure could not be maintained, even with pressor agents, and the patient died IVi hours postoperatively. The third patient was operated upon
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Table II. Deaths in 25 consecutive patients arriving alive at Boston City Hospital
Site and time of operation
No. oper ated upon
No. of deaths
Cause of death
Accident floor
3
3
1 Arrest 1 Cardiac fail ure 1 Exsanguination
Operating room, more than 2 hr. after wounding
4
4
1 Renal shut down 2 Arrest 1 Pulmonary emboli and cecal volvu lus
Operating room, less than 2 hr. after wounding
18
1
1 Bacteremia
Totals
25
8
within 5 minutes of the wounding, for cardiac arrest and exsanguination with a bullet wound through the right ventricle and aorta. The patient bled to death during the operation. Deaths following operation in operating room later than 2 hours after wounding. The first patient was a 42-year-old man who was watched in the operating room for VA hours with pericardial taps for treat ment. The patient was then operated upon when his condition deteriorated, and tamponade was relieved by surgery. The wound was in the right atrium. Postoperatively the patient developed acute porphyria, cecal volvulus, multiple pulmonary emboli, and died 31-days postoperatively. The second patient was a 60-year-old man with a known history of heart disease who was operated upon after 2 pericardiocenteses and 4 hours after a self-inflicted knife wound. The immediate reason for thoracotomy was cardiac arrest. The wound was in the right ventricle, and was easily repaired, but arrest could not be overcome by vigorous massage, because of the pro longed preceding shock-like state.
The third patient was operated upon after Wi hours of observation. This was a 33-year-old man to whom the Anesthesia Service refused to administer anesthesia because he was in shock. He could not be brought out of shock in spite of adequate blood replacement and three pericardial taps. Finally, he was operated upon and a lacerated left ventricle was repaired. The patient developed renal shutdown and died of this complication 8 days postoperatively. The last patient in this group was a 53year-old man who was observed and treated with a single pericardiocentesis for a 2Vi hour period after wounding. This patient had had a documented myocardial infarction 3 years previously. Following pericardiocentesis, tamponade again devel oped and the patient was operated upon for repair of the knife wound of the right atrium. He suffered two episodes of cardiac arrest on the operating table and one post operatively which was the cause of death. Death following operation in the operat ing room less than 2 hours after wounding. The only such death was in a 42-year-old man with a stab wound of the right ventri cle. The indication for operation was tamponade. He was operated upon under the usual sterile operating room conditions, but postoperatively he developed atrial fibrillation and a high spiking temperature in spite of the usual prophylactic antibiotics (penicillin and streptomycin). He also demonstrated delirium tremens. On the third postoperative day, the patient de veloped cardiac arrest and died. Blood cultures drawn before his death grew out Pseudomonas aeruginosa after his death. The surgical wound was not infected at autopsy. The source of the infection must be considered to be the original stab wound, although it was apparently clean at the time of autopsy. Complications in the surviving cases (Table III) Wound infection. There were no thora cotomy wound infections. There were no stab or bullet wound infections. There were
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two abdominal exploratory wound infec tions, one of which was associated with a spontaneously healing small bowel fistula. Pleural effusions requiring thoracentesis. Five patients developed pleural effusion. One thoracentesis sufficed for all but a single patient. He required two taps. Atrial fibrillation. Atrial fibrillation devel oped in 2 patients postoperatively and responded to digitalization in both patients. Bronchopneumonia. One patient devel oped bronchopneumonia which responded to appropriate antibiotics. Atelectasis. One patient required bronchoscopy for lower lobe atelectasis. Period of hospitalization in surviving pa tients. This varied from 7 to 30 days. As might be expected, the shortest periods were for patients who had simple chest wounds and heart injuries. The longer periods of hospitalization were in those patients who required abdominal surgery. The longest periods of hospitalization were in the 2 patients who developed abdominal wound infections. One remained for 28 days. The other remained for 24 days. The patient with thrombophlebitis and pulmo nary emboli prior to cardiac perforation was also kept in the hospital for 28 days following cardiorrhaphy and inferior vena cava ligation. The average stay for all surviving patients was 17 days. Summary A group of 25 patients has been pre sented with traumatic hemopericardium due to penetrating chest trauma or cardiac per foration with an intracardiac catheter. In the early years of the study, attempts at treatment with pericardiocentesis, intra venous infusion of fluids, blood, and pressor agents led frequently to cardiac arrest and/or late operation. When opera tion was conducted in the operating room within 2 hours of the wounding, 17 of 18 patients survived surgery, and left the hospital alive and well. When surgery was performed more than 2 hours after the wounding, no patient survived. (Four of 4 patients succumbed.) The difference be-
Table III. Postoperative complications in surviving patients Complication Atelectasis Wound infections Thoracotomy Abdominal Small bowel fistula Pleural effusion Atrial fibrillation Bronchopneumonia Total No. of patients—17
\
No. 1 0 2 1 5 2 1 Total No. of complications —12
tween the groups is statistically significant (p > 0.01). No patient operated upon in the operating room within 2 hours of the wounding developed a serious postoperative complica tion with the exception of the 1 patient who died of Pseudomonas bacteremia introduced by the initial knife wound. Abdominal exploration was performed upon all patients with specific indications, immediately following relief of tamponade, and cardiorrhaphy. In all instances, this was performed through a separate abdominal incision. Follow-up of these patients is notoriously poor, but the vast majority had returned to pre-injury employment within 3 to 6 months following operation, and were without car diac symptomatology at that time. Conclusions 1. In a large municipal institution, rapid transport of the patient with hemoperi cardium due to penetrating chest trauma to the operating room is mandatory. 2. If the general condition of the patient is deteriorated because of cardiac arrest or exsanguination, operation on the admitting floor is permissible. 3. Many or few diagnostic modalities may be used in the operating room to make the diagnosis of hemopericardium, but, when the diagnosis is made, surgery should be immediately carried out, always within 2 hours of the wounding.
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4. Pre-existing cardiac disease is an indi cation for very urgent surgery. 5. Abdominal exploration should be carried out under the same anesthetic ad ministration, following the thoracotomy, pericardiotomy, cardiorrhaphy, and closure of the thoracotomy wound. A separate ab dominal incision should be used. 6. Prophylactic antibiotics should always be used, particularly if previous tetanus im munization is unknown. REFERENCES 1 Beall, A. C , Jr., Ochsner, J. L., Morris, G. C , Jr., Cooley, D. A., and De Bakey, M. E.: Penetrating Wounds of the Heart, J. Trauma 1: 195, 1961. 2 Cooley, D. A., Dunn, J. R., Brockman, H. L., and De Bakey, M. E.: Treatment of Penetrat ing Wounds of the Heart: Experimental and Clinical Observations, Surgery 37: 882, 1955. 3 Isaacs, J. P.: Sixty Penetrating Wounds of the Heart, Surgery 45: 696, 1959. 4 Blalock, A., and Ravitch, M. M.: A Considera tion of the Non-Operative Treatment of Car diac Tamponade Resulting From Wounds of the Heart, Surgery 52: 330, 1962. 5 Naclerio, E. A.: Penetrating Wounds of the Heart, Dis. Chest 46: 1, 1964. 6 Marjash, A. D., and Maynard, A. deL.: Stab Wounds of the Heart, Am. J. Surg. 101: 385, 1961. 7 Sanger, P., Tavana, M., Taylor, F. H., and Robicsek, F.: The Merit of Emergency Thora
8
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10 11 12 13 14 15
16
cotomy in the Management of Stab Wounds of the Heart, North Carolina M. J. 25: 1, 1964. Graham, G. K., and Laforet, E. G.: An Elec trocardiographs and Morphologic Study of Changes Following Ligation of the Left Cor onary Artery in Human Beings, Am. Heart J. 43: 42, 1952. Carleton, R. A., and Boyd, T. F.: Traumatic Laceration of the Anterior Descending Coro nary Artery Treated by Ligation Without Myocardial Infarction, Am. Heart J. 56: 136, 1958. Griswold, R. A., and Maguire, C. H.: Pene trating Wounds of Heart and Pericardium, Surg., Gynec. & Obst. 74: 406, 1942. Fischer, G.: Die Wundendes Herzens und des Herzbeutels, Arch. F. Klin. Chir. 9: 571, 1868. (Cited by Lyons and Perkins.12) Lyons, C , and Perkins, R.: Cardiac Stab Wounds, Am. Surg. 23: 507, 1957. Tabatznik, B., and Isaacs, J. P.: Postpericardiotomy Syndrome Following Traumatic Hemopericardium, Am. J. Cardiol. 7: 83, 1961. Baue, A. E.: Immediate Thoracotomy for a Stab Wound of the Heart, J. A. M. A. 186: 521, 1963. Blalock, A., and Ravitch, M. M.: Considera tion of Nonoperative Treatment Cardiac Tam ponade Resulting From Wounds of the Heart, Surgery 14: 157, 1943. Beck, C. S.: Wounds of the Heart: The Technic of Suture, Arch. Surg. 13: 205, 1926. (For Discussion, see page 334)