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Aggressive surgical management of penetrating cardiac injuries
Aggressive surgical management of penetrating cardiac injuries Paul J. P. Bolanowski, M.D., A. P. Swaminathan, M.D., and William E. Neville, M.D., Newark, N. J.
The efficacy of cardiorrhaphy in the treatment of penetrating wounds of the heart was demonstrated by Rehn ' in 1897, when he sutured an actively bleeding 5 em. wound of the right ventricle and the patient survived. Since then there have been numerous reports firmly establishing this surgical modality. However, because of the appreciable mortality rate inherent in the procedure and the fact that cardiac tamponade was the usual component, a more conservative treatment, pericardiocentesis, was introduced in the 1940's.~' ~ This was adopted by many groups because of its negligible mortality rate, Although controversy still exists regarding the relative merits of needle aspiration of the pericardial sac versus open thoracotomy, recent publicationsv" have clearly enunciated the concept that all patients with penetrating heart wounds should be treated by early thoracotomy. The purpose of this paper is twofold: ( 1) to present our results during the past 4 years in patients with penetrating cardiac trauma who arrived at Martland Hospital Medical Center in Newark in a resuscitative state and (2) to emphasize that more lives will be saved by adopting the policy of early thoracotomy and relegating pericardiocentesis to a diagnostic and occasionally lifesaving therapeutic modality. From The Department of Cardiothoracic Surgery, The New Jersey Medical School at Newark, Newark. N. J. 07107. Received for publication Feb. 7, 1973.
52
Diagnosis A precordial wound, the presence of shock with venous distention, muffled heart sounds and a paradoxic pulse, rapid respiration, and restlessness are diagnostic but not always present. Massive external or intrapleural bleeding from injury to the great vessels, intercostals, or internal mammary arteries compounds the problem of diagnosing a concomitant cardiac wound. Even a pericardiocentesis may not be rewarding, since clotted blood, pericardial adhesions, and a large laceration of the pericardium which prevents entrapment of blood militates against a positive tap. On the other hand, it is an essential component of the treatment and occasionally is lifesaving in acute cardiac tamponade, since aspiration of as little as IO to 20 C.c. of blood may result in dramatic clinical improvement. Depending upon x-ray films of the chest to diagnose cardiac injuries is hazardous. Cardiac tamponade may be present despite a normal cardiac silhouette inasmuch as the production of tamponade does not necessarily depend upon the amount of blood as the rapidity of its formation. The sudden release of as little as 100 C.c. of blood into a relatively intact pericardium can seriously interfere with diastolic filling of the right atrium and ventricle and thereby sharply curtail left ventricular output. The most reliable criterion for the presence of cardiac compression is an increase
Volume 66 Number 1
Penetrating cardiac injuries
53
July, 1973
in the central venous pressure." However, it must be remembered that pericardial tamponade may occur in the absence of increased central venous pressure when hypovolemia coexists. 10 This is extremely important in gunshot injuries with multiple organ involvement.
Treatment After a cursory examination of the disrobed patient and location of the pertinent injuries, an adequate airway is first assured and oxygen is administered. An endotracheal tube is inserted when necessary rather than performing a tracheostomy, and manual ventilation is begun. A catheter is placed into the right atrium via a peripheral vein or through a subclavian venipuncture to measure central venous pressure. Another peripheral vein is exposed and cannulated with a larger section of tubing, such as that used for an intravenous extension or infant tube feeding, to facilitate the rapid administration of Ringer's lactate solution and available blood. Concomitantly, a Foley catheter is placed into the urinary bladder, and blood is drawn for typing and crossmatching. If the blood pressure is low and there is evidence of poor peripheral perfusion, I to 2 ampules of sodium bicarbonate (44.6 mEq.) is empirically infused to ameliorate the predictable metabolic acidosis. A slow drip of Isuprel (3 mg. in 250 c.c. glucose in water) or epinephrine (4 mg. in 250 c.c. glucose in water) may even be warranted at this time to augment myocardial contractions when intravascular volume replacement does not immediately restore hemodynamics. The patient's general condition and physical findings dictate whether further diagnostic procedures are performed. A chest x-ray film may reveal widening of the cardiac shadow and a hemopneumothorax. However, the exigencies of the moment ordinarily demand that pericardiocentesis or thoracocentesis be performed solely on clinical judgment without the benefit of x-ray films. If blood is obtained from the pleural cavity, a large chest tube is immedi-
ately inserted and connected to an underwater seal drainage bottle. A positive, reliable, productive pericardiocentesis through the paraxyphoid route demands immediate surgical intervention. It must be remembered, however, that a negative tap does not rule out the presence of a cardiac wound. Except in a few patients in whom a median sternotomy was used, the heart was approached through a left anterolateral thoracotomy in the fourth or fifth intercostal space. In cases in which further exposure was necessary, the sternum was divided transversely and into the opposite intercostal space. If the heart was arrested, efforts were first directed toward restoring cardiac action. Manual massage ordinarily sufficed, but 2 to 3 ml. of 1 to 10,000 solution of epinephrine and/or' 10 C.c. of calcium chloride injected directly into the ventricular chambers was occasionally necessary to stimulate myocardialcontractility. When the hemorrhage is from the ventricle it can be controlled temporarily by placing a finger over the laceration and inserting a loop suture parallel to the opening on either side and then crossing it after removal of the finger. A definitive repair is performed with horizontal mattress sutures buttressed with pledgets of Teflon felt. Bleeding can usually be controlled 'from the auricles by compression between the thumb and index finger. An atraumatic par. tial-occlusion clamp can then be placed beneath the fingers across the rent. Cardiopulmonary bypass has not been utilized in our patients because of time limitations. For ·some inexplicable reason, the vagal response to these injuries can be significant. Two of our patients had severe bradycardia which responded dramatically to an intravenous injection of 1 mg. of atropine. When the ·bradycardia persists despite vagal blockade or when inefficient cardiac contractions exist, an intravenous drip of Isuprel (3 mg. in 250 C.c. of 5 per cent glucose in water) · is infused. Ventricular arrhythmias such as premature ventricular contractions or runs
The Journal of
54
Bolanowski, Swaminathan, Neville
Thoracic and Cardiovascular Surgery
Table I Type of wound
Gunshot Stab
10 34
6 5
60 15
Table II. Associated injuries Type of injury
Thoracic (IO patients) Internal mammary artery Pulmonary artery Aortic arch Pulmonary vein Coronary artery Lung Diaphragm Total Abdominal (5 patients) Liver Spleen Colon Stomach Total
No. of injuries
1 I I I I
8 1
14 4 I
2 2 9
of ventricular tachycardia are managed initially with 50 mg. of lidocaine administered intravenously. If these arrhythmias persist, a continuous infusion of lidocaine is instituted. Clinical material
From July, 1968, when Martland Medical Center became the primary patient care facility for the New Jersey Medical School in Newark, to September, 1972, 44 patients with penetrating wounds of the heart were operated upon. In 34 individuals with stab wounds the mortality was 15 per cent, while in 10 patients with gunshot wounds it was 60 per cent (Table I). There were fourteen associated intrathoracic injuries in 10 patients and multiple concomitant intra-abdominal wounds in 5 individuals (Table II). Since 1970, 37 consecutive patients in whom a cardiac wound was suspected have been taken from the emergency room directly to the operating room for a thoracotomy and definitive control of the bleeding. During this period the survival rate has risen to
86.5 per cent (Table III). Thirty-one of the 44 patients had ventricular wounds, with an even distribution between the two pumping chambers of the heart. Six patients had atrial rents, 6 had lacerations of only the pericardium, and 1 individual had a tear in the inferior vena cava (Table IV). Overall, there were eleven deaths, 9 being caused by uncontrollable hemorrhage from the heart and two caused by brain damage (Table V).
Case reports CASE I. F. C., a 25-year-old Negro man, was admitted on March 7, 1970, with a stab wound in the left seventh intercostal space in the anterior axillary line. His respirations were agonal, and vital signs were absent. He was intubated immediately, and 2 L. of Ringer's lactate solution was rapidly given intravenously. An incision was first made in the left chest preparatory to the insertion of a thoracotomy tube. Palpation of the interior of the chest with a finger through this opening evacuated a considerable amount of blood and disclosed that the heart had arrested. After withdrawal of 50 c.c. of blood, the heart began beating immediately and the blood pressure became perceptible. While the operating room was being prepared, the patient developed bradycardia. The removal of an additional 35 C.c. of blood from the pericardial space restored the heart rate to 90 beats per minute. A thoracotomy was performed in the usual manner, and a laceration of the left ventricle was repaired. The patient's postoperative course was uneventful, and he was discharged on the twelfth postoperative day.
Comment. This case clearly demonstrated the value of a pericardiocentesis and the ability to restore cardiac action with the removal of only a limited amount of blood entrapped within the pericardium. CASE 2. J. G., a 40-year-old Negro man, was admitted on June 21, 1970, with a gunshot wound of the left fourth intercostal space in the midclavicular line. The blood pressure and pulse rate were normal. The neck veins were not distended, and the heart sounds were audible. An x-ray film of the chest revealed a left hemothorax. A chest tube was inserted into the hemothorax, and 800 c.c, of blood was evacuated. The patient's abdomen was explored, and a through-and-through perforation of the stomach was repaired. During the laparotomy the patient's blood pressure became imperceptible. Cardiac tamponade was suspected, and the pericardial sac was drained through
Volume 66
Penetrating cardiac injuries
Number 1
55
July, 1973
Table III Year
No. of cases
No. of deaths
1968 (May-Dec." ) 1969 1970 1971 1972 (J arr-Sept.)
3 4 7 17 13
2 3
Survival rate (per cent)
Mortality rate (per cent)
33 25 86 82 85
66 75 14 18 15
I
3 2
'Incomplete.
the diaphragm with improvement in cardiac action. A left anterior thoracotomy was immediately performed, disclosing that the bullet had also transversed the left ventricle. The entry and exit wounds were closed with mattress sutures buttressed with Teflon patches. During the procedure the patient received 13 units of blood and 5,000 C.c. of Ringer's lactate solution. His postoperative course was uncomplicated.
Comment. This case points out the difficulty in diagnosing cardiac injuries in the absence of clear-cut signs of cardiac tamponade. The point of entrance of the missile should have made the surgeons suspicious enough to perform a diagnostic pericardiocentesis. The ability of the human body to maintain normotension temporarily in the face of acute cardiac compression is striking.
Table IV. Location of cardiac injuries No. of injuries
Site
Inferior vena cava Right ventricle Left ventricle Right atrium Pericardium Total
1 15 16 6 6 44
Table V Cause of death
Hemorrhage Stab wounds Gunshot wounds Cerebral
No. of deaths
9
4 5
2
Discussion
In recent years the philosophy in the treatment of cardiac wounds has gradually shifted from one of conservatism toward a more aggressive approach. Sugg and his associates," in analyzing deaths from cardiac wounds during a period when conservatism was in vogue, found that 10 out of 18 patients who arrived alive in their hospital died from recurrent tamponade following pericardiocentesis. Death occurred in 1 to 2 hours, and at autopsy all patients had reparable cardiac wounds. In 1961, Beall and his confreres" reported a mortality rate of 5.5 per cent in 78 patients requiring only pericardial aspiration. In 23 patients who did not respond to pericardiocentesis, the mortality rate was 26.7 per cent when cardiorrhaphy was performed immediately; it increased to 62.5 per cent if cardiac arrest occurred prior to thoracotomy. However, in analyzing their results
from 1966 to 1971, this group" recently reported that their mortality rate for stab wounds was reduced from 22 to 13 per cent and that for gunshot wounds from 40 to 31 per cent after adoption of a policy of performing an early thoracotomy in all patients with suspected cardiac injuries. Despite the controversy regarding the primary treatment of heart wounds, over the years the mortality rate has continually been reduced by each method. In the past, a direct comparison of the results with the two forms of treatment has been misleading, since patients treated with pericardiocentesis were highly selected. Those individuals with large wounds and massive hemorrhage were omitted. The over-all survival rate really depends not only on the form of therapy but also on a multiplicity of factors, such as the wounding instrument and the nature and severity of the injury. For instance, our
The Journal of
56
Bolanowski, Swaminathan, Neville
Thoracic and Cardiovascular Surgery
mortality rate in gunshot wounds was 60 per cent, as compared to a 15 per cent rate for stab wounds. In addition, the efficiency of the system utilized to transport the injured to the hospital is paramount. Prior to 1968, at which time the New Jersey Medical School made Newark City Hospital its primary patient care facility, there were no survivors from penetrating cardiac trauma. At that time an ambulance service operated by the hospital was inaugurated. At present, the average run is 20 minutes from the time the ambulance is dispatched from the emergency room until its return with the patient. Thus more individuals are arriving sooner in the accident ward for definitive therapy. Also, in recent years the use of noncolloid solutions for initial intravascular volume replacement has permitted earlier resuscitation.": 13 Lastly, as a result of their continuing experience in this area, the surgical house staff have been made aware of the lethal consequences in these wounds and have formulated a more aggressive approach. Starting in 1970, pericardiocentesis in our hospital has been used only as a diagnostic or initial therapeutic measure. Since then the survival rate has risen to 86.5 per cent in 37 consecutive patients who, on suspicion of a heart wound, were taken directly from the emergency room to the operating room for a thoracotomy and definitive control of the bleeding. It appears that part of the increased mortality rate previously reported in patients treated by thoracotomy may have been due to a delay in the operation caused by reliance on pericardiocentesis. Aspiration is certainly an important diagnostic procedure and is lifesaving in acute tamponade. However, as stressed by Naclerio," unless surgery is performed one cannot determine whether or not acute hemopericardium and tamponade are secondary to an injury of the ventricle, auricle, intrapericardial portion of a great vessel, or the pericardium. Also, the possibility of secondary hemorrhage, which not infrequently occurs from penetrating wounds, of the heart is an obvious threat to
life. If permitted to occur it is fatal 100 per cent of the time. Although we have not utilized the heartlung machine in these patients because of time limitations, there is no question that our mortality rate could have been reduced if cardiopulmonary bypass had been employed in some of the patients. With the exception of two deaths from brain damage, which might have been prevented had an operating room been available in the emergency area, all of the patients died in surgery during attempts to control bleeding. Retrospectively, in 4 individuals it would have been possible to do a definitive repair of the cardiac lacerations with the heart adequately decompressed and the general circulation maintained by artificial means.
Summary Over a 4 year period, 44 patients with penetrating wounds of the heart have been operated upon. The mortality rate was 15 per cent in 34 individuals with stab wounds and 60 per cent in 10 patients with gunshot wounds. Thirty-seven consecutive patients in whom a cardiac wound was suspected were immediately operated upon, with a survival rate of 86.5 per cent. It is concluded that pericardiocentesis should be utilized only as a diagnostic maneuver which occasionally may be lifesaving. The definitive treatment is immediate thoracotomy. REFERENCES
2
3 4
5
Rehn, L.: Uber penetrirende Herziwanden und Herznaht, Arch. Klin. Chir. 55: 315, 1897. Blalock, A, and Ravitch, M. M.: A Consideration of the Nonoperative Treatment of Cardiac Tamponade Resulting From Wounds of the Heart, Surgery 14: 157, 1943. Griswold, R. A, and Maguire, C. H.: Penetrating Wounds of the Heart and Pericardium, Surg. GynecoI. Obstet. 74: 406, 1942. Beall, A C., Jr., Patrick, T. A, Okies, J. E., Bricker, D. L., and De Bakey, M. E.: Penetrating . Wounds of the Heart: Changing Patterns of Surgical Management, J. Trauma 12: 468; 1972. Sugg, W. L., Rea, W. J., Ecker, R. R., Webb, W. R., Rose, E. F., and Shaw, R. R.: Penetrating Wounds of the Heart: An Analysis of
Volume 66 Number 1
Penetrating cardiac injuries
57
July, 1973
6
7
8
9
459 Cases, J. THORAc. CARDIOVASC. SURG. 56: 531, 1968. Naclerio, E. A: Chest Injuries, ill Physiological Principles and Emergency Management, New York and London, 1971, Grune & Stratton, Inc. Steichen, F. M., Dargan, E. L., Efran, G., Pearlman, D. M., and Weil, P. H.: A Graded Approach to the Management of Penetrating Wounds of the Heart, Arch. Surg, 103: 574, 1971. Borja, A. R., Lansing, A. M., and Ransdell, H. I.: Immediate Operative Treatment for Stab Wounds of the Heart, J. THoRAc. CARDIOVASC. SURG. 59: 662, 1970. Yao, S. T., Vanecko, R. M., Printen, K., and Shoemaker, W. c.: Penetrating Wounds of the Heart, Ann. Surg. 168: 67, 1968.
10 Neville, W. E., Lynch, R. D., and Vanecko, R. M.: The Adult Cardiac Patient, ill Neville, W. E., editor: The Care of the Surgical Cardiopulmonary Patient, chap. 2, Chicago, Ill., 1971, Year Book Medical Publishers, Inc. II Beall, A C., Jr., Ochsner, J. L., Morris, G. C., Cooley, D. A, and De Bakey, M. E.: Penetrating Wounds of the Heart, J. Trauma 1: 195, 1961. 12 Neville, W. E., Balis, J. D., Talso, P. J., and Dieter, R.: Postbypass Histochemical Alterations Following Overinfusion of Non-colloids, J. Trauma 8: 827, 1968. 13 Rush, B. J., Richardson, J. D., Bosomworth, P., and Eiseman, B.: Limitations of Blood Replacement With Electrolyte Solutions, Arch. Surg. 98: 49, 196<;.
The efficacy of cardiorrhaphy in the treatment of penetrating wounds of the heart was demonstrated by Rehn ' in 1897, when he sutured an actively bleeding 5 em. wound of the right ventricle and the patient survived. Since then there have been numerous reports firmly establishing this surgical modality. However, because of the appreciable mortality rate inherent in the procedure and the fact that cardiac tamponade was the usual component, a more conservative treatment, pericardiocentesis, was introduced in the 1940's.~' ~ This was adopted by many groups because of its negligible mortality rate, Although controversy still exists regarding the relative merits of needle aspiration of the pericardial sac versus open thoracotomy, recent publicationsv" have clearly enunciated the concept that all patients with penetrating heart wounds should be treated by early thoracotomy. The purpose of this paper is twofold: ( 1) to present our results during the past 4 years in patients with penetrating cardiac trauma who arrived at Martland Hospital Medical Center in Newark in a resuscitative state and (2) to emphasize that more lives will be saved by adopting the policy of early thoracotomy and relegating pericardiocentesis to a diagnostic and occasionally lifesaving therapeutic modality. From The Department of Cardiothoracic Surgery, The New Jersey Medical School at Newark, Newark. N. J. 07107. Received for publication Feb. 7, 1973.
52
Diagnosis A precordial wound, the presence of shock with venous distention, muffled heart sounds and a paradoxic pulse, rapid respiration, and restlessness are diagnostic but not always present. Massive external or intrapleural bleeding from injury to the great vessels, intercostals, or internal mammary arteries compounds the problem of diagnosing a concomitant cardiac wound. Even a pericardiocentesis may not be rewarding, since clotted blood, pericardial adhesions, and a large laceration of the pericardium which prevents entrapment of blood militates against a positive tap. On the other hand, it is an essential component of the treatment and occasionally is lifesaving in acute cardiac tamponade, since aspiration of as little as IO to 20 C.c. of blood may result in dramatic clinical improvement. Depending upon x-ray films of the chest to diagnose cardiac injuries is hazardous. Cardiac tamponade may be present despite a normal cardiac silhouette inasmuch as the production of tamponade does not necessarily depend upon the amount of blood as the rapidity of its formation. The sudden release of as little as 100 C.c. of blood into a relatively intact pericardium can seriously interfere with diastolic filling of the right atrium and ventricle and thereby sharply curtail left ventricular output. The most reliable criterion for the presence of cardiac compression is an increase
Volume 66 Number 1
Penetrating cardiac injuries
53
July, 1973
in the central venous pressure." However, it must be remembered that pericardial tamponade may occur in the absence of increased central venous pressure when hypovolemia coexists. 10 This is extremely important in gunshot injuries with multiple organ involvement.
Treatment After a cursory examination of the disrobed patient and location of the pertinent injuries, an adequate airway is first assured and oxygen is administered. An endotracheal tube is inserted when necessary rather than performing a tracheostomy, and manual ventilation is begun. A catheter is placed into the right atrium via a peripheral vein or through a subclavian venipuncture to measure central venous pressure. Another peripheral vein is exposed and cannulated with a larger section of tubing, such as that used for an intravenous extension or infant tube feeding, to facilitate the rapid administration of Ringer's lactate solution and available blood. Concomitantly, a Foley catheter is placed into the urinary bladder, and blood is drawn for typing and crossmatching. If the blood pressure is low and there is evidence of poor peripheral perfusion, I to 2 ampules of sodium bicarbonate (44.6 mEq.) is empirically infused to ameliorate the predictable metabolic acidosis. A slow drip of Isuprel (3 mg. in 250 c.c. glucose in water) or epinephrine (4 mg. in 250 c.c. glucose in water) may even be warranted at this time to augment myocardial contractions when intravascular volume replacement does not immediately restore hemodynamics. The patient's general condition and physical findings dictate whether further diagnostic procedures are performed. A chest x-ray film may reveal widening of the cardiac shadow and a hemopneumothorax. However, the exigencies of the moment ordinarily demand that pericardiocentesis or thoracocentesis be performed solely on clinical judgment without the benefit of x-ray films. If blood is obtained from the pleural cavity, a large chest tube is immedi-
ately inserted and connected to an underwater seal drainage bottle. A positive, reliable, productive pericardiocentesis through the paraxyphoid route demands immediate surgical intervention. It must be remembered, however, that a negative tap does not rule out the presence of a cardiac wound. Except in a few patients in whom a median sternotomy was used, the heart was approached through a left anterolateral thoracotomy in the fourth or fifth intercostal space. In cases in which further exposure was necessary, the sternum was divided transversely and into the opposite intercostal space. If the heart was arrested, efforts were first directed toward restoring cardiac action. Manual massage ordinarily sufficed, but 2 to 3 ml. of 1 to 10,000 solution of epinephrine and/or' 10 C.c. of calcium chloride injected directly into the ventricular chambers was occasionally necessary to stimulate myocardialcontractility. When the hemorrhage is from the ventricle it can be controlled temporarily by placing a finger over the laceration and inserting a loop suture parallel to the opening on either side and then crossing it after removal of the finger. A definitive repair is performed with horizontal mattress sutures buttressed with pledgets of Teflon felt. Bleeding can usually be controlled 'from the auricles by compression between the thumb and index finger. An atraumatic par. tial-occlusion clamp can then be placed beneath the fingers across the rent. Cardiopulmonary bypass has not been utilized in our patients because of time limitations. For ·some inexplicable reason, the vagal response to these injuries can be significant. Two of our patients had severe bradycardia which responded dramatically to an intravenous injection of 1 mg. of atropine. When the ·bradycardia persists despite vagal blockade or when inefficient cardiac contractions exist, an intravenous drip of Isuprel (3 mg. in 250 C.c. of 5 per cent glucose in water) · is infused. Ventricular arrhythmias such as premature ventricular contractions or runs
The Journal of
54
Bolanowski, Swaminathan, Neville
Thoracic and Cardiovascular Surgery
Table I Type of wound
Gunshot Stab
10 34
6 5
60 15
Table II. Associated injuries Type of injury
Thoracic (IO patients) Internal mammary artery Pulmonary artery Aortic arch Pulmonary vein Coronary artery Lung Diaphragm Total Abdominal (5 patients) Liver Spleen Colon Stomach Total
No. of injuries
1 I I I I
8 1
14 4 I
2 2 9
of ventricular tachycardia are managed initially with 50 mg. of lidocaine administered intravenously. If these arrhythmias persist, a continuous infusion of lidocaine is instituted. Clinical material
From July, 1968, when Martland Medical Center became the primary patient care facility for the New Jersey Medical School in Newark, to September, 1972, 44 patients with penetrating wounds of the heart were operated upon. In 34 individuals with stab wounds the mortality was 15 per cent, while in 10 patients with gunshot wounds it was 60 per cent (Table I). There were fourteen associated intrathoracic injuries in 10 patients and multiple concomitant intra-abdominal wounds in 5 individuals (Table II). Since 1970, 37 consecutive patients in whom a cardiac wound was suspected have been taken from the emergency room directly to the operating room for a thoracotomy and definitive control of the bleeding. During this period the survival rate has risen to
86.5 per cent (Table III). Thirty-one of the 44 patients had ventricular wounds, with an even distribution between the two pumping chambers of the heart. Six patients had atrial rents, 6 had lacerations of only the pericardium, and 1 individual had a tear in the inferior vena cava (Table IV). Overall, there were eleven deaths, 9 being caused by uncontrollable hemorrhage from the heart and two caused by brain damage (Table V).
Case reports CASE I. F. C., a 25-year-old Negro man, was admitted on March 7, 1970, with a stab wound in the left seventh intercostal space in the anterior axillary line. His respirations were agonal, and vital signs were absent. He was intubated immediately, and 2 L. of Ringer's lactate solution was rapidly given intravenously. An incision was first made in the left chest preparatory to the insertion of a thoracotomy tube. Palpation of the interior of the chest with a finger through this opening evacuated a considerable amount of blood and disclosed that the heart had arrested. After withdrawal of 50 c.c. of blood, the heart began beating immediately and the blood pressure became perceptible. While the operating room was being prepared, the patient developed bradycardia. The removal of an additional 35 C.c. of blood from the pericardial space restored the heart rate to 90 beats per minute. A thoracotomy was performed in the usual manner, and a laceration of the left ventricle was repaired. The patient's postoperative course was uneventful, and he was discharged on the twelfth postoperative day.
Comment. This case clearly demonstrated the value of a pericardiocentesis and the ability to restore cardiac action with the removal of only a limited amount of blood entrapped within the pericardium. CASE 2. J. G., a 40-year-old Negro man, was admitted on June 21, 1970, with a gunshot wound of the left fourth intercostal space in the midclavicular line. The blood pressure and pulse rate were normal. The neck veins were not distended, and the heart sounds were audible. An x-ray film of the chest revealed a left hemothorax. A chest tube was inserted into the hemothorax, and 800 c.c, of blood was evacuated. The patient's abdomen was explored, and a through-and-through perforation of the stomach was repaired. During the laparotomy the patient's blood pressure became imperceptible. Cardiac tamponade was suspected, and the pericardial sac was drained through
Volume 66
Penetrating cardiac injuries
Number 1
55
July, 1973
Table III Year
No. of cases
No. of deaths
1968 (May-Dec." ) 1969 1970 1971 1972 (J arr-Sept.)
3 4 7 17 13
2 3
Survival rate (per cent)
Mortality rate (per cent)
33 25 86 82 85
66 75 14 18 15
I
3 2
'Incomplete.
the diaphragm with improvement in cardiac action. A left anterior thoracotomy was immediately performed, disclosing that the bullet had also transversed the left ventricle. The entry and exit wounds were closed with mattress sutures buttressed with Teflon patches. During the procedure the patient received 13 units of blood and 5,000 C.c. of Ringer's lactate solution. His postoperative course was uncomplicated.
Comment. This case points out the difficulty in diagnosing cardiac injuries in the absence of clear-cut signs of cardiac tamponade. The point of entrance of the missile should have made the surgeons suspicious enough to perform a diagnostic pericardiocentesis. The ability of the human body to maintain normotension temporarily in the face of acute cardiac compression is striking.
Table IV. Location of cardiac injuries No. of injuries
Site
Inferior vena cava Right ventricle Left ventricle Right atrium Pericardium Total
1 15 16 6 6 44
Table V Cause of death
Hemorrhage Stab wounds Gunshot wounds Cerebral
No. of deaths
9
4 5
2
Discussion
In recent years the philosophy in the treatment of cardiac wounds has gradually shifted from one of conservatism toward a more aggressive approach. Sugg and his associates," in analyzing deaths from cardiac wounds during a period when conservatism was in vogue, found that 10 out of 18 patients who arrived alive in their hospital died from recurrent tamponade following pericardiocentesis. Death occurred in 1 to 2 hours, and at autopsy all patients had reparable cardiac wounds. In 1961, Beall and his confreres" reported a mortality rate of 5.5 per cent in 78 patients requiring only pericardial aspiration. In 23 patients who did not respond to pericardiocentesis, the mortality rate was 26.7 per cent when cardiorrhaphy was performed immediately; it increased to 62.5 per cent if cardiac arrest occurred prior to thoracotomy. However, in analyzing their results
from 1966 to 1971, this group" recently reported that their mortality rate for stab wounds was reduced from 22 to 13 per cent and that for gunshot wounds from 40 to 31 per cent after adoption of a policy of performing an early thoracotomy in all patients with suspected cardiac injuries. Despite the controversy regarding the primary treatment of heart wounds, over the years the mortality rate has continually been reduced by each method. In the past, a direct comparison of the results with the two forms of treatment has been misleading, since patients treated with pericardiocentesis were highly selected. Those individuals with large wounds and massive hemorrhage were omitted. The over-all survival rate really depends not only on the form of therapy but also on a multiplicity of factors, such as the wounding instrument and the nature and severity of the injury. For instance, our
The Journal of
56
Bolanowski, Swaminathan, Neville
Thoracic and Cardiovascular Surgery
mortality rate in gunshot wounds was 60 per cent, as compared to a 15 per cent rate for stab wounds. In addition, the efficiency of the system utilized to transport the injured to the hospital is paramount. Prior to 1968, at which time the New Jersey Medical School made Newark City Hospital its primary patient care facility, there were no survivors from penetrating cardiac trauma. At that time an ambulance service operated by the hospital was inaugurated. At present, the average run is 20 minutes from the time the ambulance is dispatched from the emergency room until its return with the patient. Thus more individuals are arriving sooner in the accident ward for definitive therapy. Also, in recent years the use of noncolloid solutions for initial intravascular volume replacement has permitted earlier resuscitation.": 13 Lastly, as a result of their continuing experience in this area, the surgical house staff have been made aware of the lethal consequences in these wounds and have formulated a more aggressive approach. Starting in 1970, pericardiocentesis in our hospital has been used only as a diagnostic or initial therapeutic measure. Since then the survival rate has risen to 86.5 per cent in 37 consecutive patients who, on suspicion of a heart wound, were taken directly from the emergency room to the operating room for a thoracotomy and definitive control of the bleeding. It appears that part of the increased mortality rate previously reported in patients treated by thoracotomy may have been due to a delay in the operation caused by reliance on pericardiocentesis. Aspiration is certainly an important diagnostic procedure and is lifesaving in acute tamponade. However, as stressed by Naclerio," unless surgery is performed one cannot determine whether or not acute hemopericardium and tamponade are secondary to an injury of the ventricle, auricle, intrapericardial portion of a great vessel, or the pericardium. Also, the possibility of secondary hemorrhage, which not infrequently occurs from penetrating wounds, of the heart is an obvious threat to
life. If permitted to occur it is fatal 100 per cent of the time. Although we have not utilized the heartlung machine in these patients because of time limitations, there is no question that our mortality rate could have been reduced if cardiopulmonary bypass had been employed in some of the patients. With the exception of two deaths from brain damage, which might have been prevented had an operating room been available in the emergency area, all of the patients died in surgery during attempts to control bleeding. Retrospectively, in 4 individuals it would have been possible to do a definitive repair of the cardiac lacerations with the heart adequately decompressed and the general circulation maintained by artificial means.
Summary Over a 4 year period, 44 patients with penetrating wounds of the heart have been operated upon. The mortality rate was 15 per cent in 34 individuals with stab wounds and 60 per cent in 10 patients with gunshot wounds. Thirty-seven consecutive patients in whom a cardiac wound was suspected were immediately operated upon, with a survival rate of 86.5 per cent. It is concluded that pericardiocentesis should be utilized only as a diagnostic maneuver which occasionally may be lifesaving. The definitive treatment is immediate thoracotomy. REFERENCES
2
3 4
5
Rehn, L.: Uber penetrirende Herziwanden und Herznaht, Arch. Klin. Chir. 55: 315, 1897. Blalock, A, and Ravitch, M. M.: A Consideration of the Nonoperative Treatment of Cardiac Tamponade Resulting From Wounds of the Heart, Surgery 14: 157, 1943. Griswold, R. A, and Maguire, C. H.: Penetrating Wounds of the Heart and Pericardium, Surg. GynecoI. Obstet. 74: 406, 1942. Beall, A C., Jr., Patrick, T. A, Okies, J. E., Bricker, D. L., and De Bakey, M. E.: Penetrating . Wounds of the Heart: Changing Patterns of Surgical Management, J. Trauma 12: 468; 1972. Sugg, W. L., Rea, W. J., Ecker, R. R., Webb, W. R., Rose, E. F., and Shaw, R. R.: Penetrating Wounds of the Heart: An Analysis of
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459 Cases, J. THORAc. CARDIOVASC. SURG. 56: 531, 1968. Naclerio, E. A: Chest Injuries, ill Physiological Principles and Emergency Management, New York and London, 1971, Grune & Stratton, Inc. Steichen, F. M., Dargan, E. L., Efran, G., Pearlman, D. M., and Weil, P. H.: A Graded Approach to the Management of Penetrating Wounds of the Heart, Arch. Surg, 103: 574, 1971. Borja, A. R., Lansing, A. M., and Ransdell, H. I.: Immediate Operative Treatment for Stab Wounds of the Heart, J. THoRAc. CARDIOVASC. SURG. 59: 662, 1970. Yao, S. T., Vanecko, R. M., Printen, K., and Shoemaker, W. c.: Penetrating Wounds of the Heart, Ann. Surg. 168: 67, 1968.
10 Neville, W. E., Lynch, R. D., and Vanecko, R. M.: The Adult Cardiac Patient, ill Neville, W. E., editor: The Care of the Surgical Cardiopulmonary Patient, chap. 2, Chicago, Ill., 1971, Year Book Medical Publishers, Inc. II Beall, A C., Jr., Ochsner, J. L., Morris, G. C., Cooley, D. A, and De Bakey, M. E.: Penetrating Wounds of the Heart, J. Trauma 1: 195, 1961. 12 Neville, W. E., Balis, J. D., Talso, P. J., and Dieter, R.: Postbypass Histochemical Alterations Following Overinfusion of Non-colloids, J. Trauma 8: 827, 1968. 13 Rush, B. J., Richardson, J. D., Bosomworth, P., and Eiseman, B.: Limitations of Blood Replacement With Electrolyte Solutions, Arch. Surg. 98: 49, 196<;.