Cardiac trauma

6. The Diabetes Control and Complications Trial Research Group. The effect of

intensive diabetes treatment on the development and progression of long-term complications in insulin-resistant diabetes mellitus. N Engl J Med. 1993;329: 977-986. 7. Kelly WD, Lillehei RC, Merkel FK, et al. Allotransplantation of the pancreas and

duodenum along with the kidney in diabetic nephropathy. Surgery. 1967;61: 827-837. 8. Luzzi L, Hering BJ, Socci C, et al. Metabolic effects of successful intraportal islet

transplantation in insulin-dependent diabetics. J Clin Invest. 1996;97:26112618. 9. Kendall DM, Robertson RP. Pancreas and islet transplantation: challenges for

the twenty-first century. Endocrinol Metab Clin North Am. 1997;26:611-630. 10. Zehrer CL, Gross CR. Quality of life of pancreas transplant recipients. Diabeto-

logia. 1991;34(suppl 1):S145-S149. 11. Zehrer CL, Gross CR. Comparison of quality of life between pancreas/kidney

and kidney transplant recipients: one year follow-up. Transplant Proc. 1994;26: 508-509. 12. American Diabetes Association. Position statement on pancreas transplantation

for patients with diabetes mellitus. Diabetes Care. 1992;15:1673. 13. Gruessner AC, Sutherland DER. Analysis of United States and non-U.S. pan-

creas transplants as reported to the International Pancreas Transplant Registry (IPTR) and to the United Network for Organ Sharing (UNOS). In: Cecka JM, Terasaki PI, eds. Clinical Transplants 1998. Los Angeles, Calif: UCLA Tissue Typing Laboratory; 1999:53-71. 14. Sindhi R, Stratta RJ, Lowell JA, et al. Experience with enteric conversion after

pancreatic transplantation with bladder drainage. J Am Coll Surg. 1997;184:281289.

Trauma Cardiac Trauma Guest Reviewers: Richard P. Gonzalez, MD, and Arnold Luterman, MD PENETRATING CARDIAC INJURIES: A POPULATION-BASED STUDY. Rhee

REVIEWER COMMENTS

PM, Foy H, Kaufmann C, et al. J Trauma. 1998;45:366-370.

This retrospective review from Harborview Medical Center is a populationbased study that identifies penetrating cardiac trama patients that were treated at Harborview and patients that expired in the field and were taken to the King County Medical Examiner. Many of the previously published series1-5 (including the reviewed articles by Thourani and associates and Tyburski and associates) are hospital-based studies that do not report

Objective: To report population-based as well as hospital-based survival rates after penetrating cardiac injury. To determine confounding variables and outcome in patients that have suffered penetrating cardiac injuries in a modern, mature, regionalized trauma system. To determine if a preoperative factor uniformly predictive of death or disabling neurologic outcome was available to prevent the massive expenditure of energy and resources. Design: Retrospective cohort analysis of consecutive trauma admissions and medical

examiners’ reports. A meta-analysis was done comparing survival rates with other published population-based reports. CURRENT SURGERY • Volume 58/Number 2 • March/April 2001

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REVIEWER COMMENTS (Con’t)

death rates from the field. Regions with less-developed prehospital systems are more likely to deliver stable and less severely injured patients to their respective trauma centers. Consequently, hospitals from regions with less-developed prehospital systems report better survival rates from penetrating cardiac trauma in their hospital-based studies. In 1966, Sugg and associates published the most recent population-based report from Dallas that demonstrated an overall improved survival in the Harborview patients; however, survival rates were essentially equal when injuries were classified by mechanism (gunshot wound [GSW] vs stab wound [SW]).6 The Sugg report had a greater number of GSWs, which have an inherently higher mortality. Hospital survival was worse in the Harborview report, which may reflect the more recent and improved prehospital care provided in King County. These results are discouraging because they suggest improvements in prehospital care have not impacted survival from penetrating cardiac trauma and overall survival from penetrating cardiac injury has not improved during the last 30 years. Because this was a retrospective review with its inherent limitations, the authors were unable to obtain paramedic and prehospital times and show whether a more rapid response time and improved prehospital care impact survival. The authors did not use a calculated Penetrating Cardiac Trauma Index that would facilitate comparisons with other institutions. Although the authors can report a hospital-based survival for penetrating cardiac injuries, the quality of their management is not tenable because the physiologic status of the patients upon trauma center arrival has not been reported. Therefore, the authors’ conclusions that their hospital-based survivals were worse because their patients were less stable is not valid. The authors final conclusion that emergency room or operating resuscitative thoracotomy remains necessary to assess ultimate survivability is not supported by their results because the authors did not report indications, timing or physiologic status of patients that underwent ERT.

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Setting: Harborview Medical Center, University of Washington, Seattle, and King

County, Washington Medical Examiner’s office. Participants: All patients admitted to Harborview Medical Center with penetrating

cardiac injuries during the years 1987 to 1993. All deaths in King County from penetrating cardiac injuries during the same time period were included. Results: During this period, 1109 patients were admitted to Harborview Medical

Center with penetrating chest wounds. During this same time period, 6492 autopsies were performed by the King County medical examiner’s office. The combined databases identified 212 penetrating cardiac injuries. One hundred and sixteen (55%) were dead at the scene, and 96 (45%) were brought to the trauma center because they had at least 1 sign of life at the scene. Of those brought to the trauma center, 41 (42.7%) survived. Of the survivors, 37 (90.2%) had normal neurologic function at the time of discharge from the hospital. Overall survival rate was 19.3% for all cardiac injuries. One cardiac injury occurs for every 210 admissions to Harborview Medical Center’s trauma center. One cardiac injury occurs per 11.5 penetrating chest wounds, and 1 penetrating cardiac death occurs for every 56 autopsies. The average age of patients with cardiac stab wounds was 30.4 years. Males comprised 83% of the penetrating cardiac injury population. Seventy-eight (82%) of the patients were legally intoxicated, with an average blood ethanol (EtOH) level of 218 mg/dL. Forty percent tested positive for illicit drugs. Of the penetrating cardiac injuries that were in extremis, 60.4% underwent emergency room thoracotomy (ERT). Hypotension, cardiopulmonary resuscitation, associated injuries, and ERT were factors associated with death but did not predict death. Survival rate after ERT was higher in stab wound patients (36%) than in gunshot wound patients (14%). Single-chamber injuries (61%) were more common than were multiple chamber injuries (39%). Multiple-chamber injuries had an increased relative risk of death (2.5) compared with single-chamber injuries. Blood pressure greater than 90 mm Hg and tamponade were associated with survival. Conclusions: Penetrating cardiac injury is associated with a high mortality. Despite the institution of elaborate prehospital systems and modern technological advances, survival has improved only minimally over the last 3 decades. Resuscitative thoracotomy for penetrating cardiac injury is an important component of emergency care protocols. Thoracotomy, whether done in the emergency room or in the operating room, remains necessary to completely assess the ultimate survivability of penetrating wounds to the heart.

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PENETRATING CARDIAC TRAUMA AT AN URBAN TRAUMA CENTER: A 22-YEAR PERSPECTIVE. Thourani VH, Feliciano DV, Cooper WA, et al. Am Surg. 1999;65:811-818. Objective: To report on a 22-year experience with penetrating cardiac injuries at a

single level I trauma center. The authors also evaluated clinical and mortality trends between the first and second 11-year periods of the interval studied. Design: A retrospective review of 192 consecutive patients who sustained penetrat-

ing cardiac wounds. Study patients were divided into 2 periods for comparison: Period 1 was from 1975 to 1985, and period 2 was from 1986 to 1996. Setting: Emory University School of Medicine at Grady Memorial Hospital, Atlanta, Georgia. Participants: All patients that presented to the Grady Memorial Hospital level I

trauma center with penetrating cardiac wounds between January 1975 and December 1996. Results: The number of hypotensive (sBP ⬍ 90 mm Hg) patients that presented to

the trauma center decreased from 62% in period 1 to 54% in period 2. Blood pressure could not be obtained in 31% of patients presenting to the emergency center and was similar for both periods (period 1: 31% and period 2: 30%). Twenty-one out of 29 patients (27%) were normotensive (sBP ⬎ 90 mm Hg) in period 2 versus 8 out of 113 (7%) in period 1. The most common hemodynamic finding on physical examination was increased central venous pressure (CVP) and was present in 48% of all patients. Distant heart sounds was present in 39%, unobtainable pulse in 21%, and pulsus paradoxus in 8% of all patients. The most common initial clinical presentation was cardiac tamponade alone, which was present in 51% of all patients. The most common initial intervention in the emergency center for both periods was tube thoracostomy (45%). The number of emergency center thoracotomies increased in period 2 to 27% from 20% in period 1. In contrast, the number of pericardiocentesis performed declined in period 2 to 3% versus 35% in period 1. Ninety-eight percent of patients were transferred to the operating room. The right ventricle was the most common chamber injured, followed by left ventricle, right atrium, and left atrium. Combination chamber injuries were most common to right and left ventricles. Overall survival for the 22-year period for patients that sustained penetrating cardiac injuries was 75%. Overall survival was similar for both periods, with a 73% survival in period 1 and a 78% survival in period 2. Survival for patients sustaining gunshot wounds to the heart was 61% and 82% survival for patients with cardiac stab wounds. A slight, but not statistically significant, decrease occurred in survival for patients that suffered cardiac gunshot wounds in period 2 (58%) versus period 1 (64%). Survival for cardiac stab wounds increased from period 1 (77%) to period 2 (89%). Survival for patients that arrested in the emergency center was 29% versus 92% for those that did not arrest. Survival was significantly higher for patients that arrested in period 2 (46%) than for patients that arrested in period 1 (8%). Conclusions: Cardiac tamponade is the most common presentation in patients with

penetrating cardiac wounds. The performance of pericardiocentesis in the emergency department for penetrating cardiac injury has essentially disappeared. Surgeon-performed ultrasound of the pericardium should improve survival of patients who are normotensive or mildly hypotensive. Over the last 11 years, a substantial decrease has occurred in mortality in patients with stab wounds and a statistically significant decrease in arrested patients. Overall mortality for penetrating cardiac trauma has not changed during the 22-year interval.

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REVIEWER COMMENTS

This 22-year retrospective review at Grady Memorial Hospital is 1 of the larger series to date published on penetrating cardiac injury. The authors separated the experience into 2 time periods of 11 years each. The most common hemodynamic finding was increased CVP (48%); however the authors did not clearly describe what was considered an increased CVP nor how it was obtained. The authors conclude that the most common initial clinical presentation was cardiac tamponade (51%); yet the authors do not define how cardiac tamponade was defined or determined. No individual sign of cardiac tamponade on physical examination (CVP: 48%, distal heart tones: 39%, unobtainable pulse: 21%, pulsus paradoxus: 8%) was identified more often than cardiac tamponade was diagnosed. Of interest is the significant drop in pericardiocentesis performed in the latter period with a significant increase in the number of ERTs. In the authors’ discussion, they suggest that ultrasound may be an alternative to pericardiocentesis for rapid diagnosis; however, the drop in pericardiocentesis may be caused by more aggressive utilization of ERT in the treatment of hemodynamic instability. The authors also conclude that surgeon-performed pericardial ultrasound should improve survival; yet their data do not support improvement. They have not seen survival improvement between the early and latter periods when ultrasound was instituted. Finally, the authors conclude that a substantial decrease occurred in mortality from stab wounds and had an equal distribution of GSWs and SWs in period 1 and period 2. They also conclude that during the entire 22-year period study period, survival from penetrating cardiac injury did not change. For these conclusions to be consistent, the authors would also have to conclude a substantial increase occurred in mortality from gunshot wounds. The conclusion that survival from penetrating cardiac injury has not improved over recent decades is consistent with series published from other trauma centers (see the reviewed article by Rhee and associates).2

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This is a 17-year retrospective review from Detroit Receiving Hospital and is 1 of the largest series reported on penetrating cardiac injury. Many of their conclusions are similar to other large penetrating cardiac injury series. Emergency room thoracotomy had a high death rate (92%), and operating room thoracotomy had a much better survival (74%). Of the operating room deaths, low Revised Trauma Score and emergency room systolic blood pressure were predictive of death in patients that underwent operating room thoracotomy. Similar to other series, GSWs were associated with higher mortality (58%) than were SWs (23%) (see the reviewed articles by Thourani and associates and Rhee and associates).1-6 Gunshot wounds that required ERTs were uniformly fatal (93 patients). This is an important result that should leave readers pondering as to whether ERTs should be performed on patients that suffer penetrating cardiac injuries. The authors found cardiac tamponade to be a favorable prognostic sign; however, this sign was only favorable in patients that suffered SWs. Because the authors did not define how the diagnosis of pericardial tamponade was made, an alternative conclusion could be that SWs cause less intrapericardial bleeding and do not produce the hypotension associated with pericardial tamponade. Thus, it is the mechanism of injury, not the presence of tamponade, that has greatest impact on survival.

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FACTORS AFFECTING PROGNOSIS WITH PENETRATING WOUNDS OF THE HEART. Tyburski JG, Astra L, Wilson RF, Dente C, Steffes C. J Trauma. 2000;48:587-591. Objective: To determine factors affecting the prognosis for patients with penetrating wounds of the heart. Design: A retrospective review of all patients undergoing an emergency thoracotomy for penetrating intrapericardial injury from August 1980 through June 1997. Setting: Wayne State University School of Medicine and Detroit Receiving Hospi-

tal, Detroit, Michigan. Participants: All patients that underwent an emergency thoracotomy for penetrat-

ing intrapericardial injury from August 1980 to July 1997 at Detroit Receiving Hospital. Results: A total of 302 patients were identified for inclusion in this study. Twenty-

seven (9%) of the patients were women, and the average age was 32 ⫾ 11 years. One hundred fifty-four patients with SWs and 148 patients with GSWs were included. A total of 152 ERTs and 150 operating room thoracotomies were performed. Overall survival was 41%. Gunshot wounds and ERTs were associated with lower survival rates (8% for GSWs and 23% for ERTs) than were SWs and operating room thoracotomies (58% for SWs and 74% for operating room thoracotomies). Emergency room thoracotomies were divided into 4r categories according to the patients physiologic status on admission: arrest at the scene, arrest in ambulance, arrest in emergency room, and deterioration in the emergency room. Survival of the patients having ERT progressively improved according to admission physiologic status. Of the 43 patients who arrested at the scene, none survived. Of the 67 patients who arrested in the ambulance, 3 (4%) survived. Of the 27 patients who arrested in the emergency room, 5 (19%) survived. Fifteen patients underwent ERT for rapid deterioration in the emergency room, of which 4 (27%) survived. All 93 patients that suffered GSWs and underwent ERTs expired. The presence of tamponade at thoracotomy was found to be a favorable prognostic factor for survival with 61 out of 118 patients (54%) surviving with tamponade versus 59 out of 184 patients (39%) surviving without tamponade. This favorable outcome was only seen with SWs (56 out of 84 patients [66%] vs 33 out of 70 patients [47%]). The survival rates with GSWs were not affected by the presence of tamponade (24% vs 23% survival rate). A total of 236 patients (78%) had single intrapericardial injuries, and 66 patients (22%) had multiple intrapericardial injuries. Gunshot wounds were responsible for 52 (79%) of the multiple injuries. Multiple intrapericardial injuries were associated with a worse survival rate (8 out of 66 patients [12%]) than were single intrapericardial injuries (115 out of 236 [49%]). The right ventricle was the most commonly injured chamber; however, injury rates for the right and left ventricles were similar with GSWs (61 vs 69 cases). Isolated left ventricular injuries had a lower survival rate (43%) than did isolated right ventricle injuries (60%). Patients with isolated intrapericardial great vessel injury had an 18% survival rate (3 out of 17 patients) and a 10% survival rate (3 out of 29) when cardiac chambers were also involved. Of the 150 patients that had operating room thoracotomies, 11 (74%) patients survived. Twenty-seven of the operating room thoracotomy patients died in the operating room, and 12 of the operating room thoracotomy patients died postoperatively. The number of units of blood transfused was significantly lower in survivors (5 ⫾ 6) versus nonsurvivors (17 ⫾ 15). A low admission Revised Trauma Score and systolic blood pressure were good predictors of operating room deaths. On multivariate analysis, the most significant variables were operating room thoracotomy versus ERT (p ⫽ 0.0002), Revised Trauma Score (p ⫽ 0.0007), the presence of a great vessel injury (p ⫽ 0.0051), the number of blood transfusions in the first 24 hours (p ⫽ 0.0434), and the low systolic blood pressure on admission (p ⫽ 0.0482). CURRENT SURGERY • Volume 58/Number 2 • March/April 2001

Conclusions: The physiologic status of the patient at presentation, the mechanism

of injury, and the presence of a tamponade were significant prognosticators in their series of penetrating cardiac injuries. Multiple-chamber injuries, especially with great vessel involvement, were associated with a high mortality rate. Emergency room thoracotomies for GSWs of the heart were uniformly fatal.

REVIEWER SUMMARY Penetrating cardiac injury continues to have high mortality, despite improvements in prehospital care and diagnostic techniques. As depicted in the population-based study from Harborview and the review from Grady Memorial, the overall mortality has not improved over the last 20 to 30 years. These studies have pointed out that regions with well-developed prehospital emergency medical services often have worse hospitalbased outcomes. This is most likely because of well-developed prehospital systems transporting a greater number of physiologically unstable patients to trauma centers, whereas in less-developed systems, a greater number of unstable patients expire at the scene. The series presented here have also shown that SWs to the heart have a better prognosis than do GSWs. This is most likely because of the greater underlying myocardial damage impacted by GSWs and greater intrapericardial bleeding with associated hypotension. This is consistent with the findings from Detroit Receiving Hospital that tamponade was predictive of survival only in patients that suffered cardiac SWs. The physiologic status of patients at emergency room presentation has consistently been shown to impact survival. Patients that arrive in the emergency room hypotensive or arrest in the emergency room have a significantly worse prognosis. Diagnosis of cardiac injury and pericardial fluid can be diagnosed in the emergency room with diagnostic ultrasound. Several series have shown that ultrasound of the pericardium can be performed by surgeons with excellent results.7,8 Ultrasound has supplanted the use of pericardiocentesis as a diagnostic tool for pericardial fluid. In the series reviewed from Grady Memorial, the number of pericardiocentesis essentially disappeared over the 22-year time period of the study; however, the number of ERTs had increased. This suggests that utilization of pericardiocentesis as temporary therapeutic manuever has been abandoned and emergent thoracotomy (emergency room or operating room) is used as the therapeutic manuever in the face of physiologic deterioration. Patients that require ERT uniformly have a significantly worse prognosis. The anatomic site of cardiac injury and the number of cardiac chambers injured also affects prognosis. Left ventricular wounds carry a worse prognosis than do right ventricular wounds, as do injuries that involve multiple chambers. Injuries that involve intrapericardial great vessels have a much worse prognosis, with intrapericardial aortic injuries almost universally fatal.

RICHARD P. GONZALEZ, MD ARNOLD LUTERMAN, MD Division of Trauma, Critical Care, and Burns Department of Surgery University of South Alabama Mobile, Alabama PII S0149-7944(00)00373-1

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