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Penetrating wounds of the heart
PENETRATING WOUNDS OF THE HEART* REPORT OF TWO CASES KENNETH A. MORRIS, M.D., F.A.C.S. JACKSONVILLE,FLORIDA
T
HE number of exceIIent reports in recent years supports EIkin’s statement that “the suture of wounds of the heart is a modern surgica1 attainment.” The year 1936 was outstanding for the numerous series of cases reported, focusing attention on the methods of diagnosis and exceIIent resuIts obtained by suture. In EIkin’s series, rg3o-1936, there were thirteen cases with six deaths. Bigger reported eIeven patients operated upon in the same period, seven of .them successfuIIy. Mayer reported seven cases (October Ig32--October Ig34), five operated upon, three successfuIIy. The percentage of recoveries is a IittIe better than 50 per cent. Cases reported treated conservativeIy in previous years show that onIy IO to 15 per cent recovered. Heart tamponade, or compression of the heart by bIood in the pericardium, was probabIy known and described by Morgagni as earIy as 1761. UntiI recentIy the importance of heart tamponade and its signs and symptoms have been understood onIy by those few surgeons interested in surgery of the heart. UndoubtedIy many cases have been overlooked. The recent reports a11 emphasize the importance of heart tamponade. Recovery of the patient depends upon prompt recognition of this condition and the reIease of the heart from the pressure caused by the tamponade of bIood. Briefly, the diagnosis is made by cIose attention to the foIIowing points: (I) Suspect heart wounds in a11 Iacerations of the chest. The history may heIp by determining the kind of weapon used, the direction in which it entered the chest, and the interva1 between the injury and the colIapse. (2) Profuse bIeeding from the exter* From the section of thoracic
na1 wound may occur for a short period. In very smaI1 wounds of the pericardium, the bIood may be trapped, and IittIe externa1 bIeeding wiI1 occur. (3) During the period of externa1 bIeeding, the patient is usuaIIy free from symptoms. About 150 C.C. of blood flIs the pericardium before an appreciabIe increase in pressure takes pIace. (4) When the pericardium fiIIs with blood, heart tamponade occurs, and the externa1 bIeeding ceases. Signs of Heart Tamponade. I. Marked circuIatory coIIapse which is out of proportion to the amount of bIood Iost. (a) PuIse weak or absent. (b) ArteriaI bIood pressure low or absent. (c) Venous pressure raised. SuperficiaI veins of neck distended. 2. Heart sounds distant or m&led. 3. Ffuoroscopic examination shows diminution or absence of cardiac puIsation (Most vaIuabIe sign, pointed out by Bigger). 4. Marked dyspnea, paIIor and cyanosis. Treatment. I. Immediate operation is necessary to reIease the tamponade as soon as a diagnosis is made. 2. If the patient is in extremis, aspiration of bIood from the pericardium is a Iife saving procedure. It temporariIy decompresses the heart and aIIows su&cient time for operation. 3. AIthough earIy operation is important, suflicient time shouId aIways be alIowed to make a correct diagnosis and especiaIIy to determine whether or not tamponade is present. Penetrating wounds which enter the pericardium and the pIeura1 cavity may aIIow bIeeding into the pIeura1 cavity, and tamponade does not occur. Very Iarge wounds may bIeed prosurgery, Duval County
108
Hospital.
NEW
SERIES VOL. XLI, No.
I
Morris-Wounds
fuseIy externaIIy; tamponade may not occur, and operation may be futiIe. 4. Intravenous fluids are contraindicated
FIG. I. Case I. Distention of external jugular vein from tamponade of heart. Taken immediately before operation.
because they may increase the tamponade. Morphine and externa1 heat are advisabIe. Operation. CarefuI preparation of the operative fieId and strict asepsis are essentia1, as postoperative infection is the main cause of death. Many incisions have been devised for exposing the heart. The simpIest of these is a curved incision concave IateraIIy aIong the Ieft border of the sternum. Sections of the second, third, fourths, or fifth Costa1 cartiIages may be removed according to the Iocation of the wound. An attempt shouId be made to push the pIeura outward away from the pericardium. The pericardium may be opened in the same manner in which the peritoneum is opened. The bIood shouId be evacuated as quickIy
of Heart
American Journal of Surgery
II 09
as possibIe, and the index finger of the Ie:ft hand pIaced over the site of the wound. If the site of the wound in the pericardium is
FIG. 2. Case
I.
Site of stab wound.
noted, it wiI1 aid in Iocating the wound in the heart. A fine siIk suture is pIaced through the muscIes of the heart around the index finger, and this acts as a tractor or stay suture whiIe other sutures are pIaced. A stay suture in the apex of the heart may be used if the wound is in the posterior waI1 of the heart. If the asepsis has been good, the pericardium may be cIosed without drainage. Anesthesia. Novocaine infdtration or bIock anesthesia with the addition of nitrous oxide or ethyIene under pressure is usuaIIy satisfactory. If it is necessary to open the pIeura1 cavity widely, intratrachia1 anesthesia shouId be used. Postoperative Care. Postoperative care does not differ very much from that of
I IO
American Journal of Surgery
Morris-Wounds
other major surgica1 cases. Transfusions may be indicated. Aspiration or drainage of the pericardium or pIeura1 cavity may be
FIG. 3. Case
I. Patient four operation.
weeks
foIIowing
necessary for the remova of the ffuid or pus if infection occurs. The x-ray is vaIuabIe in determining the Iocation and nature of these compIications. CASE
REPORTS
CASE I. A negro man, 25 years of age, was stabbed in the left chest thirty minutes before his admission to the DuvaI County HospitaI, May 25, 1936. There was very IittIe bIeeding from the wound, but he feIt weak and had “a strangling feeling” in the heart. Thirty minutes after admission, his radia1 puIse was absent and his systoIic bIood pressure couId not be heard. The veins of his neck were distended. FIuoroscopic examination showed an absence of cardiac puIsation. Fifty C.C. of blood was aspirated from the pericardium. The radiaI puIse immediateIy became perceptibIe and strong, and the patient became mentaIIy aIert.
of Heart
JULY, 1938
The wound was in the third interspace, 2 cm. to the Ieft of the sternum and had been caused by a Iong pocket knife. Under IocaI anesthesia, a curved incision concave IateraIIy was made along the Ieft border of the sternum. The skin and muscIe fIap were reffected to the Ieft. Sections of the second, third, and fourth Costa1 cartilages were removed. The interna mammary artery was Iigated above and beIow. The pIeura was reflected to the left and torn in a smaI1 area, but not enough to cause compIete coIIapse of the Iung. The opening of the pIeura was pIugged with gauze, and the pericardium was opened. ImmediateIy upon opening the pericardium, severa enormous blood clots were thrown up on the chest waII. The heart began to beat vioIentIy as soon as the pressure was reIeased, and a jet of bIood spurted from a wound 1.5 cm. long in the right ventricIe. The jet of bIood occurred with each systoIic beat of the heart; the wound had defmiteIy entered the right ventricuIar cavity. The contractions of the heart were sIowed up by pressure on the great vesseIs with the fingers, and one siIk suture was pIaced we11 into the heart muscle around the index finger which had been pIaced over the site of the wound. This suture was used for traction, and three more sutures were taken and tied. The first suture was then tied, and the bIeeding stopped. The pericardium was closed without drainage. The patient ate breakfast the next morning and made an uneventfu1 recovery. He returned to work on September 8, 1936, three and one-half months after the operation. Three and four Iead eIectrocardiographic tracings made four to six weeks foIIowing the operation showed nothing abnorma1. CASE II. A negro man, about 50 years of age, was admitted to the DuvaI County Hospital June 18, 1936 foIIowing a stab wound of the Ieft chest which occurred about an hour before admission. Because his radia1 puIse was absent, he was taken immediateIy to the x-ray room where a ffuoroscopic examination showed an absence of puIsations of the heart. The wound, which was made by an ice pick, was in the third interspace, 4 cm. to the Ieft of the sternum. The veins of the neck were distended. After 150 C.C.of bIood was aspirated from the pericardia1 cavity, the radia1 puIse became perceptibIe, and the patient’s condition improved.
NEW S~nres
VOL. XLI, No. I
Morris-Wounds
Under intratrachea1 anesthesia, a curved incision was made aIong the Ieft border of the sternum and sections of the second, third, fourth, and fifth Costa1 cartiIages were removed. The interna mammary was Iigated; the pericardium was opened, and severa Iarge bIood cIots removed. It was noticed that the heart muscle beat feebIy even when the pressure was reIeased. The site of the puncture wound was found in the right ventricIe at the Ieft IateraI border of the heart. The index finger was pIaced over the wound and a fine siIk suture pIaced around the finger we11 into the heart muscIe. An attempt was made to tie this suture and severa other siIk sutures, but the heart muscIe was so friabIe that a11 sutures immediateIy cut through, and hemorrhage was profuse and uncontroIIabIe. The heart stopped beating, and aIthough the wound was finaIIy cIosed, a11 attempts to revive the patient by injections of adrenaIin into the heart and massage of the heart were of no avai1. The heart was examined at autopsy, and a condition of acute myocardial degeneration was found. This undoubtedIy accounted for the fact that the sutures cut through the muscle so easiIy. AIthough this condition couId not be determined before operation, the age of the patient shouId probably have Ied to more copservative measures. It is possible, because the wound itseIf was smaI1, that aspiration aIone might have saved this patient. The heart was removed for examination. The foIIowing gross and microscopic description was made by Dr. C. E. Royce, pathoIogist: “Gross Description. This specimen consists of the heart. Its greatest measurements are 12.5 X 9.5 X 6 cm. Its weight is 308 Gm. The capacity of the right ventricIe is small. Its waI1 is unusuaIIy thick, averaging a IittIe more than a cm. in thickness. The waI1 of the Ieft ventricIe is aIso very thick, reaching a
of Heart
American Journal of Surgery
III
maximum of 3.5 cm. and a minimum of 0.7 cm. near the apex. The root of the aorta is Iarge. The aortic cusps are thin. The edges are somewhat roIIed and thickened. The Iining of the aorta presents IongitudinaI striae with some grayish-yeIIow discoloration beneath one of these just above the vaIves. The waI1 is caIcified. The openings of the puImonary arteries are wide. “Microscopic Description. The muscIe fibers in this heart are more or less shrunken. Cross striation is very poorIy defined. In numerous pIaces apparent destruction of portions of fiber is occupied by pIasma ceIIs and Iymphocytic infdtration. OccasionaIIy poIynucIear neutrophiIes are found in these groups. Next to the bIood vesseIs Iarge groups of Iymphocytes may be seen. “Diagnosis. Acute myocardia1 degeneration.” COMMENT
If the house surgeon or the physician who first sees the patient suspects heart wounds in a11Iacerations of the chest and knows the signs of heart tamponade, the percentage of recoveries wiII undoubtedIy be increased. REFERENCES BIGGER, I. A. The diagnosis of heart wounds. South M. J., 29: 18, 1936. 2. DAVENPORT, G. L., BLUMENTHAL,G., and CANTRIL, S. Electrocardiographic studies of a stab wound of the heart. J. Tborac. Surg., 5: 208, 1935. ELKIN, D. C. Wounds of the heart. J. Tborac. Surg., 5: 590, 1936. GRAHAM, ERNEST A., and BALLON, H. C. SurgicaI diseases of the chest, Phila., 1935. Lea & Febiger. MAYER, J. M. The cIinica1 management of injuries to the heart and pericardium; report of seven cases. Surg., Gynec. @ Obst., 62: 852, 1936. 6. SPALTEHOLZ, WERNER. Hand Atlas of Human Anatomy, Vol. 3. Ed. 5, PhiladeIphia. Lippincott. 1.
T
HE number of exceIIent reports in recent years supports EIkin’s statement that “the suture of wounds of the heart is a modern surgica1 attainment.” The year 1936 was outstanding for the numerous series of cases reported, focusing attention on the methods of diagnosis and exceIIent resuIts obtained by suture. In EIkin’s series, rg3o-1936, there were thirteen cases with six deaths. Bigger reported eIeven patients operated upon in the same period, seven of .them successfuIIy. Mayer reported seven cases (October Ig32--October Ig34), five operated upon, three successfuIIy. The percentage of recoveries is a IittIe better than 50 per cent. Cases reported treated conservativeIy in previous years show that onIy IO to 15 per cent recovered. Heart tamponade, or compression of the heart by bIood in the pericardium, was probabIy known and described by Morgagni as earIy as 1761. UntiI recentIy the importance of heart tamponade and its signs and symptoms have been understood onIy by those few surgeons interested in surgery of the heart. UndoubtedIy many cases have been overlooked. The recent reports a11 emphasize the importance of heart tamponade. Recovery of the patient depends upon prompt recognition of this condition and the reIease of the heart from the pressure caused by the tamponade of bIood. Briefly, the diagnosis is made by cIose attention to the foIIowing points: (I) Suspect heart wounds in a11 Iacerations of the chest. The history may heIp by determining the kind of weapon used, the direction in which it entered the chest, and the interva1 between the injury and the colIapse. (2) Profuse bIeeding from the exter* From the section of thoracic
na1 wound may occur for a short period. In very smaI1 wounds of the pericardium, the bIood may be trapped, and IittIe externa1 bIeeding wiI1 occur. (3) During the period of externa1 bIeeding, the patient is usuaIIy free from symptoms. About 150 C.C. of blood flIs the pericardium before an appreciabIe increase in pressure takes pIace. (4) When the pericardium fiIIs with blood, heart tamponade occurs, and the externa1 bIeeding ceases. Signs of Heart Tamponade. I. Marked circuIatory coIIapse which is out of proportion to the amount of bIood Iost. (a) PuIse weak or absent. (b) ArteriaI bIood pressure low or absent. (c) Venous pressure raised. SuperficiaI veins of neck distended. 2. Heart sounds distant or m&led. 3. Ffuoroscopic examination shows diminution or absence of cardiac puIsation (Most vaIuabIe sign, pointed out by Bigger). 4. Marked dyspnea, paIIor and cyanosis. Treatment. I. Immediate operation is necessary to reIease the tamponade as soon as a diagnosis is made. 2. If the patient is in extremis, aspiration of bIood from the pericardium is a Iife saving procedure. It temporariIy decompresses the heart and aIIows su&cient time for operation. 3. AIthough earIy operation is important, suflicient time shouId aIways be alIowed to make a correct diagnosis and especiaIIy to determine whether or not tamponade is present. Penetrating wounds which enter the pericardium and the pIeura1 cavity may aIIow bIeeding into the pIeura1 cavity, and tamponade does not occur. Very Iarge wounds may bIeed prosurgery, Duval County
108
Hospital.
NEW
SERIES VOL. XLI, No.
I
Morris-Wounds
fuseIy externaIIy; tamponade may not occur, and operation may be futiIe. 4. Intravenous fluids are contraindicated
FIG. I. Case I. Distention of external jugular vein from tamponade of heart. Taken immediately before operation.
because they may increase the tamponade. Morphine and externa1 heat are advisabIe. Operation. CarefuI preparation of the operative fieId and strict asepsis are essentia1, as postoperative infection is the main cause of death. Many incisions have been devised for exposing the heart. The simpIest of these is a curved incision concave IateraIIy aIong the Ieft border of the sternum. Sections of the second, third, fourths, or fifth Costa1 cartiIages may be removed according to the Iocation of the wound. An attempt shouId be made to push the pIeura outward away from the pericardium. The pericardium may be opened in the same manner in which the peritoneum is opened. The bIood shouId be evacuated as quickIy
of Heart
American Journal of Surgery
II 09
as possibIe, and the index finger of the Ie:ft hand pIaced over the site of the wound. If the site of the wound in the pericardium is
FIG. 2. Case
I.
Site of stab wound.
noted, it wiI1 aid in Iocating the wound in the heart. A fine siIk suture is pIaced through the muscIes of the heart around the index finger, and this acts as a tractor or stay suture whiIe other sutures are pIaced. A stay suture in the apex of the heart may be used if the wound is in the posterior waI1 of the heart. If the asepsis has been good, the pericardium may be cIosed without drainage. Anesthesia. Novocaine infdtration or bIock anesthesia with the addition of nitrous oxide or ethyIene under pressure is usuaIIy satisfactory. If it is necessary to open the pIeura1 cavity widely, intratrachia1 anesthesia shouId be used. Postoperative Care. Postoperative care does not differ very much from that of
I IO
American Journal of Surgery
Morris-Wounds
other major surgica1 cases. Transfusions may be indicated. Aspiration or drainage of the pericardium or pIeura1 cavity may be
FIG. 3. Case
I. Patient four operation.
weeks
foIIowing
necessary for the remova of the ffuid or pus if infection occurs. The x-ray is vaIuabIe in determining the Iocation and nature of these compIications. CASE
REPORTS
CASE I. A negro man, 25 years of age, was stabbed in the left chest thirty minutes before his admission to the DuvaI County HospitaI, May 25, 1936. There was very IittIe bIeeding from the wound, but he feIt weak and had “a strangling feeling” in the heart. Thirty minutes after admission, his radia1 puIse was absent and his systoIic bIood pressure couId not be heard. The veins of his neck were distended. FIuoroscopic examination showed an absence of cardiac puIsation. Fifty C.C. of blood was aspirated from the pericardium. The radiaI puIse immediateIy became perceptibIe and strong, and the patient became mentaIIy aIert.
of Heart
JULY, 1938
The wound was in the third interspace, 2 cm. to the Ieft of the sternum and had been caused by a Iong pocket knife. Under IocaI anesthesia, a curved incision concave IateraIIy was made along the Ieft border of the sternum. The skin and muscIe fIap were reffected to the Ieft. Sections of the second, third, and fourth Costa1 cartilages were removed. The interna mammary artery was Iigated above and beIow. The pIeura was reflected to the left and torn in a smaI1 area, but not enough to cause compIete coIIapse of the Iung. The opening of the pIeura was pIugged with gauze, and the pericardium was opened. ImmediateIy upon opening the pericardium, severa enormous blood clots were thrown up on the chest waII. The heart began to beat vioIentIy as soon as the pressure was reIeased, and a jet of bIood spurted from a wound 1.5 cm. long in the right ventricIe. The jet of bIood occurred with each systoIic beat of the heart; the wound had defmiteIy entered the right ventricuIar cavity. The contractions of the heart were sIowed up by pressure on the great vesseIs with the fingers, and one siIk suture was pIaced we11 into the heart muscle around the index finger which had been pIaced over the site of the wound. This suture was used for traction, and three more sutures were taken and tied. The first suture was then tied, and the bIeeding stopped. The pericardium was closed without drainage. The patient ate breakfast the next morning and made an uneventfu1 recovery. He returned to work on September 8, 1936, three and one-half months after the operation. Three and four Iead eIectrocardiographic tracings made four to six weeks foIIowing the operation showed nothing abnorma1. CASE II. A negro man, about 50 years of age, was admitted to the DuvaI County Hospital June 18, 1936 foIIowing a stab wound of the Ieft chest which occurred about an hour before admission. Because his radia1 puIse was absent, he was taken immediateIy to the x-ray room where a ffuoroscopic examination showed an absence of puIsations of the heart. The wound, which was made by an ice pick, was in the third interspace, 4 cm. to the Ieft of the sternum. The veins of the neck were distended. After 150 C.C.of bIood was aspirated from the pericardia1 cavity, the radia1 puIse became perceptibIe, and the patient’s condition improved.
NEW S~nres
VOL. XLI, No. I
Morris-Wounds
Under intratrachea1 anesthesia, a curved incision was made aIong the Ieft border of the sternum and sections of the second, third, fourth, and fifth Costa1 cartiIages were removed. The interna mammary was Iigated; the pericardium was opened, and severa Iarge bIood cIots removed. It was noticed that the heart muscle beat feebIy even when the pressure was reIeased. The site of the puncture wound was found in the right ventricIe at the Ieft IateraI border of the heart. The index finger was pIaced over the wound and a fine siIk suture pIaced around the finger we11 into the heart muscIe. An attempt was made to tie this suture and severa other siIk sutures, but the heart muscIe was so friabIe that a11 sutures immediateIy cut through, and hemorrhage was profuse and uncontroIIabIe. The heart stopped beating, and aIthough the wound was finaIIy cIosed, a11 attempts to revive the patient by injections of adrenaIin into the heart and massage of the heart were of no avai1. The heart was examined at autopsy, and a condition of acute myocardial degeneration was found. This undoubtedIy accounted for the fact that the sutures cut through the muscle so easiIy. AIthough this condition couId not be determined before operation, the age of the patient shouId probably have Ied to more copservative measures. It is possible, because the wound itseIf was smaI1, that aspiration aIone might have saved this patient. The heart was removed for examination. The foIIowing gross and microscopic description was made by Dr. C. E. Royce, pathoIogist: “Gross Description. This specimen consists of the heart. Its greatest measurements are 12.5 X 9.5 X 6 cm. Its weight is 308 Gm. The capacity of the right ventricIe is small. Its waI1 is unusuaIIy thick, averaging a IittIe more than a cm. in thickness. The waI1 of the Ieft ventricIe is aIso very thick, reaching a
of Heart
American Journal of Surgery
III
maximum of 3.5 cm. and a minimum of 0.7 cm. near the apex. The root of the aorta is Iarge. The aortic cusps are thin. The edges are somewhat roIIed and thickened. The Iining of the aorta presents IongitudinaI striae with some grayish-yeIIow discoloration beneath one of these just above the vaIves. The waI1 is caIcified. The openings of the puImonary arteries are wide. “Microscopic Description. The muscIe fibers in this heart are more or less shrunken. Cross striation is very poorIy defined. In numerous pIaces apparent destruction of portions of fiber is occupied by pIasma ceIIs and Iymphocytic infdtration. OccasionaIIy poIynucIear neutrophiIes are found in these groups. Next to the bIood vesseIs Iarge groups of Iymphocytes may be seen. “Diagnosis. Acute myocardia1 degeneration.” COMMENT
If the house surgeon or the physician who first sees the patient suspects heart wounds in a11Iacerations of the chest and knows the signs of heart tamponade, the percentage of recoveries wiII undoubtedIy be increased. REFERENCES BIGGER, I. A. The diagnosis of heart wounds. South M. J., 29: 18, 1936. 2. DAVENPORT, G. L., BLUMENTHAL,G., and CANTRIL, S. Electrocardiographic studies of a stab wound of the heart. J. Tborac. Surg., 5: 208, 1935. ELKIN, D. C. Wounds of the heart. J. Tborac. Surg., 5: 590, 1936. GRAHAM, ERNEST A., and BALLON, H. C. SurgicaI diseases of the chest, Phila., 1935. Lea & Febiger. MAYER, J. M. The cIinica1 management of injuries to the heart and pericardium; report of seven cases. Surg., Gynec. @ Obst., 62: 852, 1936. 6. SPALTEHOLZ, WERNER. Hand Atlas of Human Anatomy, Vol. 3. Ed. 5, PhiladeIphia. Lippincott. 1.