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Wounds of the heart and pericardium
WOUNDS
OF THE HEART AND PERICARDIUM*
PHILIP CRASTNOPOL, M.D., EMANUEL GOLDBERGER, M.D., RAYMONDM. MARCUS,M.D. AND LESTEROSTROVE, M.D. New York, New Ipork
T
HE treatment of wounds of the heart and pericardium has changed considerably from the days when cardiac surgery was considered hopeIess and heroic to the present when reports of operative interference are no longer rare. T’he mortaIity rate has been greatIy reduced, due in no smalI part to the more frequent diagnosis of wounds of the heart and pericardium. Perforations of the heart such as the type caused by buIIets and Iacerations of the intrapericardia1 vesseIs will resuIt in rapid exitus before effective therapy can be instituted. Our findings, as we11 as those in the Iiterature, indicate that when the patient arrives at the hospital aIive, no matter how criticaIIy iI1, he may be saved. herein, four cases of We are presenting, stab wounds of the chest with pericardia1 and myocardia1 invoIvement, of which three were treated conservativeIy and one was treated by surgery. The eIectrocardiogram pIayed an important part in the earIy diagnosis of these cases. DIAGNOSIS
Significance of Early ECG’s. Much has been written previousIy about the diagnosis of penetrating wounds of the heart and pericardium. Anyone receiving a Iacerating wound over the precordia1 region must be suspected of having sustained cardiac trauma. This is especiaIIy true when the symptoms of shock are out of a11 proportion to the amount of bIood Iost’ and when a hemopneumothorax has been excIuded. In the presence of hemothorax, the possibiIity of a wound which has pierced both pericardium and pIeura with bIeeding from one cavity into the other must be borne in mind. * From
the Second
Surgica!
and the CardioIogicaI 412
Griswold and Maguire’ mention Beck’s triad of acute cardiac compression: (I ) faIIing arteria1 pressure; (2) rising venous pressure and (3) smaI1, quiet heart. These, together with the physica findings of rapid, paradoxical pulse, low puIse pressure, distention of venous circuIation and distant, m&led heart sounds speak of tamponade. FIuoroscopy in doubtful cases bears out the fact that cardiac activity is reduced, and may further demonstrate intrapericardial fluid. X-ray, on the other hand, is not necessarily of much heIp2 since it will usuaIIy show no abnormality of heart size inasmuch as onIy IOO to 200 cc. of blood wiI1 cause tamponade. These patients are usuaIIy in such deep shock that they appear to be in extremis. It is difficuIt then to move them around for adequate Auoroscopic and roentgenoIogic examination. We have found the electrocardiogram of great heIp in verifying earIy the presence of injury to the heart and pericardium by changes indicative of pericarditis, hemopericardium or myocardia1 injury. In addition to the three standard Ieads, augmented unipolar extremity Ieads and muItipIe unipoIar precordia1 Ieads3xz5 were taken because it has been shown that these are of value in detecting evidence of myocardia1 injury when the standard Ieads are normaI. The augmented unipoIar leads were taken from the Ieft arm (Ieft arm Iead), the right arm (right arm Iead) and the Ieft Ieg (Ieft Ieg Iead). The muItipIe precordia1 leads were taken as foIIows: Iead vl, precordia1 eIectrode on the fourth intercosta1 space just to the right of the sternum; Iead vz precordia1 eIectrode on the fourth interspace just to the Ieft of the sternum; read v3 Services,
Lincoln
Hospital,
New York,
N. Y.
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mid-way between Ieads vz and v4 which is the precordia1 eIectrode on the fifth interCosta1 space at the Ieft of the mid-cIavicuIar Iine; Iead v5, electrode on the left anterior axiIlary line at the IeveI of v4; Iead v6, electrode on the Ieft mid-axillary line at the level of the Iead v4. Many investigators have pointed outi,jz” that pericardial effusion in itself does not cause electrocardiographic changes, and the presence of changes in the RS-T segments and T waves is a sign of injury to the superficia1 Iayer of the myocardium just beneath the pericardium. In cases of penetrating wounds of the heart the presence of RS-T and T changes, however, does not necessariIy indicate that the heart muscIe itseIf has been injured by trauma because a pericardia1 effusion or a hemopericardium can serve to irritate the superfrcia1 Iayers of the heart. The deep wide abnorma1 Q waves that occur after myocardia1 infarction do not appear after penetrating wounds of the heart unIess one of the Iarger coronary arteries is severed as a resuIt of the accident. SoIovay, Rice and SoIovay7 point out that weeks or months after operation T wave changes become more pronounced and then revert to normaI. MANAGEMENT
In the past there has been considerabIe divergence of opinion as to the management of these cases. Bigger predicates the type of treatment on the nature of the injury. In 1932~ he divided his cases into three cIassifications : (I ) PericardiaI injury aIone or pericardia1 and heart injury without penetration into a chamber division or coronary vesseIs. These may be treated penetration into a conservativeIy ; (2) chamber or coronary vesse1 division. Operation is usuaIIy indicated; (3) severe injuries with immediate death. In 1939 Bigger9 divided his cases into four groups and treated them accordingIy: (I) Free communication between the pericardium and pIeura but onIy sIight or moderate hemorrhage. These are treated
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A merican Journal of Surgery
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ConservativeIy. (2) Tamponade present, but folIowing venocIysis, adrenaIin and other supportive measures there is marked improvement. A cannula is pIaced in the pericardia1 cavity and bIood withdrawn. If after fifteen or twenty minutes there is no evidence of further bleeding, conservative therapy is continued. In the interim a11 preparations for operation are made. (3) Greatly increased pericardia1 pressure with no satisfactory response to conservative therapy.. These are expIored. (4) Free communication between pIeura and pericardium with massive intrapleural hemorrhage. Immediate operation is performed and bIood from the pericardia1 cavity is reinfused. He further points out that chance of recovery without expIoration is sIight when the wound has penetrated the heart. SchiebeI’l apparentIy beIieves that a11 heart wounds should be explored since a heaIed wound may cause rupture or aneurysm when no surgica1 repair is performed. NeIson,12 in reporting a series of cases in 1943 from Charity HospitaI, New OrIeans, states that he beIieves patients with stab wounds of the heart shouId be expIored. In certain cases the extent of injury is not immediateIy apparent and death may occur before surgery can be performed. He further states that patients who are brought out of shock and then reIapse under conservative treatment are not apt to recover. Moreover, expIoratory operation has IittIe risk attached. He adds that the possibility of aneurysm formation and Iater pericardia1 adhesions cannot be ignored, and that aspiration of the pericardia1 sac is attended by the risk of puncture of a coronary vessel. From 1906 to 1943 there were twenty-seven cardiorrhapies at Charity, and better resuIts Iater in the series are attributed to more frequent expIoration. BIau13 reports a series of twenty-seven penetrating wounds of the heart at the Detroit Receiving HospitaI; twenty-one were operated on with a mortaIity of 23.8
4 I4
American Journal of Surgery
CrastnopoI
per cent. Of the six remaining
cases,
et aI.-Wounds three
were observed and three were aspirated. In the whole series of twenty-seven cases there were six deaths, five in the operated group and one in the conservatively treated group, with a tota mortality of 22.2 per cent. Blau also refers to a case reported by Vance in which death occurred eight days after the wound due to the wound edges being forced apart, with fatal tamponade resulting. He aIso refers to an article by Long in which Long states that the spontaneous cIosure of the parieta1 pericardium may resuIt with a bIood cIot when the blood pressure is low, changing of reIative openings of the myocardium and the pericardium as the hemopericardium increases, a smaI1 puncture wound of the pericardium over a large heart wound, or non-penetration of either pIeura1 cavity. Bigger9 reported seventeen cases at the MedicaI CoIIege of Virginia Hospital. In tweIve of these there were simpIe penetrating wounds of the heart cavities or Iumina of the intrapericardia1 portions of the great vesseIs, and of these eight recovered and four died. A patient with a heart wound is put in TrendeIenburg position, given morphine sulfate and atropine, and, if in coIlapse, 5 m. of adrenaIin subcutaneousIy and IO to 15 m. by vein. When there is no sign of tamponade, conservatism is practiced. In the past a11 patients with tamponade and signs of heart injury with massive or moderate hemothorax were operated on, but now operation is performed onIy when marked signs of tamponade persist or when the indications are cIear. Otherwise treatment is conservative. He cites the case of a twenty-two year oId patient with a bulIet wound of the chest who, despite the fact that he had bIood and air in the pericardium, had no tamponade. He was given supportive treatment and recovered. He cited another case of a patient who at operation had a cIot attached to the anterior heart waI1 over one of the divided branches of the Ieft descending coronary artery. This patient recovered without Iigature of the artery.
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ObviousIy, he adds, aspiration wouId have sufficed. Strieder’” reports the case of a tweIve year oId boy with a stab wound of the heart. Because of evidence of tamponade he was prepared for operation. But when a No. 16 gauge needIe was introduced into the pericardia1 sac and IOO cc. of bIood were obtained and reinfused into his vein, dramatic improvement and eventua1 compIete recovery resuIted without operation. The author adds, however, that the danger of aneurysm of the heart and coronary vesseIs is great so that non-operation in a case of this type is hazardous. GriswoId and Maguire’ report fortyseven cases of diagnosed heart wounds treated at LouisviIIe City HospitaI in an eight-year period. Of these, seven were misdiagnosed and turned out to be pathoIogica1 conditions of organs other than the heart. Thirteen died Iess than twenty minutes after admission to the hospital. Of the twenty-seven patients who Iived Ionger than twenty minutes after admission, twenty-two were operated on with six deaths during or following the operation; five -patients were treated conservativeIy with one death. MortaIity for the twenty-seven cases was 25.9 per cent. EIkin2 reported thirty-eight cases operated upon for heart wounds, of whom twenty-two recovered without sequeIae. He beIieves that operation should be carried out as soon as a heart wound is diagnosed. Three years laterlo he reported a series of twenty-three cases with eighteen recoveries. WhiIe in his first series infection pIayed a Iarge part in causing death, in the Iatter group this compIication was not present due to more meticuIous operative He concurs with Bigger and technic. BIaIock that where there is no immediate urgency for operation and aspiration resuits in continued reIief, conservatism may be practiced. In the MiIitary SurgicaI ManuaI on neurosurgery and thoracic surgery16 it is stated that frequentIy these patients wiI1 respond to conservative treatment, as a
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rapid exsanguination and death occur so that these patients rareIy come to operation. SchiebeI’l states that bIeeding, when it occurs, is into the reIativeIy ineIastic pericardial sac, and the wound is frequentIy plugged by overlying muscle. The intrapericardia1 pressure rises and there is increasing pressure on the chambers of the heart as bIeeding continues. As pressure in the right auricIe rises, there is a decrease in cardiac intake and output, and cerebra1 anemia is rapidIy foIIowed by death. It wouId seem reasonabIe to assume that where there is intrapericardia1 bleeding with increased atria1 and venous pressure and decreased cardiac output, intravenous fluids wouId do IittIe to aIIeviate the state of embarrassed circuIation and periphera1 shock. Though the trauma to the heart is severe, unIess there has been extensive externa hemorrhage or bIeeding into the thorax, the presenting picture is one of coIIapse due to tamponade, diminished cardiac output and cerebra1 anemia. In fact, according to Elkin,‘; “a symptomless intervat . . . during the time the pericardium fiIIs with blood, is the most important point in the history.” TypicaIlS the onset of symptoms dates back to a state of tamponade. Beckl” beIieves that intravenous fIuids cause a rise in arteria1 pressure if there is a fixed state of cardiac compression and some of the bIood can escape from the pericardia1 cavity. Ward and Parker2” beIieve that one must differentiate between symptoms due to shock of hemorrhage or tamponade. However, they concIude that intravenous infusions rareIy do harm and may be Iivesaving. The work of Cooper, Stead and Warren, in 1944, and Iater papers pubIished by them and MerriII and Brannon21Yz1 have shown the beneficial effects of supportive PATHOLOGICAL PHYSIOLOGY intravenous therapy in these patients. The wound is most commonIy caused by They said that as the venous pressure goes a knife or an ice pick, Iess commonIy by a up its effect is to overcome the block ocbuIIet; this is statisticaIIy borne out in a11 casioned by the increasing auricuIar pressure. The amount of bIood entering the Iarge series. In gunshot wounds, because veins is Iimited by the diminishing cardiac of the destructive nature of the injury and because there is perforation of the heart, output, and increasing the bIood voIume smaI1 heart wound may be seaIed off during circuIatory collapse. Pericardiocentesis is recommended when tamponade and hemothorax are not coexistent. When there is a reduction in venous pressure and arteria1 pressure is maintained, it may be assumed that bleeding has ceased and conservati\-e treatment is to be continued. BIaIock and Ravitch17 quote FeIsenreich as saving that the treatment of penetrating vent;icuIar wounds shouId be operative, whiIe auricular wounds may be handIed conservatively because of the IikeIihood of cessation of auricuIar bIeeding. But other writers have stated that because of its Iack of contractihty and eIasticity, wounds of the auricIes are more apt to be foIlowed by fata consequences. They bring up the probIem as to whether the end resuits may not be better if a more conservative poIicy is instituted, and believe that operation may be delayed if symptoms are due to tamponade and not to continued bIeeding. They quaIify this with saying that probabIy not more than two hours should eIapse with continued tamponade and, if blood reaccumuIates, pericardiotomy is indicated. GIasser, Mersheimer and Shiner18 quote Kosmin as saying that isoIated pericardia1 injuries are much more rare than heart injury, occurring in the ratio of I : IO, conceivabIy because of heart activity, nature of the weapon and degree and direction of and penetration. Th ey quote GunzIing Sarkisov as saying that the signs of isoIated pericardia1 injury wiI1 be hemorrhage from the wound, dyspnea and increased cardiac duIIness to percussion, but cIear heart sounds with onIy temporary or insignificant signs of tamponade wiI1 aIso be present.
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wilI increase the venous pressure and help combat tamponade. In their experiments on dogs they found that animaIs couId survive IOO per cent more of increased intrapericardial pressure than before if given intravenous ffuids. There was aIso an associated rise in arteria1 pressure. They concIuded:“l “In patients who survive unti1 they reach the hospita1 the myocardial, and probabIy the pericardia1 rents are at Ieast temporariIy cIosed . . . it is possibIe that, in certain seIected patients, raising the venous pressure by increasing the bIood voIume wiI1 restore the circuIation to an adequate IeveI without aspiration or operation.” In 1946 Brannon, Stead, Warren and MerriI123z2” reported that when bIood voIume in humans was raised with intravenous Auids there was increased cardiac output and arteria1 pressure whiIe the periphera1 resistance dropped. They added, significantIy, that patients who have suffered trauma may react with reffex vasodiIation and present signs of circuIatory coIIapse. These same men24 studied four patients with stab wounds of the heart and found that the situation was different from chest wounds and hemorrhagic shock. They found the atria1 pressure eIevated, the arteria1 puIse paradoxica1, cardiac output decreased and periphera1 resistance up. When two of these were given intravenous aIbumin, there occurred a rise in atria1 pressure, cardiac output and arteria1 pressure, improved oxygenation function of the bIood stream and a diminished degree of paradoxica1 puIse as measured in the femora1 artery. They state that where the circuIation improves promptIy without therapy, the main factor is probabIy one of reffex vasodiIatation and not tamponade; but where faiIure persists unti1 the intrapericardia1 pressure is Iowered, it must be due to tamponade. Raising the venous pressure by intravenous ffuids wiI1 not improve the circuIation unIess the pericardium wiI1 distend in diastoIe and permit the heart to receive more bIood, or unIess bIood is being forced out of the sac.
OcToeER, ,948
of Heart
That some part of the symptomatoIogy compIex of patients who suffer a penetrating wound of the pericardium and heart is due to reffex vasodiIatation is a theory that seems attractive to us. CertainIy, supportive treatment without aspiration has done nothing to remove whatever ffuid is present to cause the tamponade, yet some of these patients wiI1 recover without residual signs of cardiac embarrassment. This has been so in three of our four cases presented. CASE
REPORTS
With the foregoing remarks and especiaIIy with the important experimental studies of the Iast mentioned investigators in mind, the foIIowing cases are presented: CASE I. E. J., a sixteen year oId colored male, was admitted to the hospital May 14, 1946, with a history of having been stabbed in the left chest a short time before admission. Physical examination revealed a well nourished and we11 deveIoped male in deep shock. The skin was cold, cIammy and pallid; the pulse was rapid and weak; the bIood pressure unobtainable and temperature was 95.6”~. There was a puncture wound in the fourth interspace I inch medial to the left nipple line. Heart sounds were distant, weak and rapid. Breath sounds were rapid and shallow, but examination of the Iungs failed to reveal hyperresonance, dullness or flatness. The patient was immediately given 500 cc. of plasma folIowed by 500 cc. of bIood and then 1,000 cc. of 5 per cent glucose in saline. Within one hour he showed definite evidence of coming out of shock, began to talk coherently and the pulse became fulI and regular. He continued to show improvement and on the folIowing day his only compIaint was Iocalized pain over the wound site. The temperature curve remained in the region of IOI OF. for eight days and then returned to normaI. He was discharged eIeven days after admission without complaint. X-rays taken within eight hours of admission and five days Iater are herein reproduced. The x-ray taken on May 14th indicated fluid in the Ieft lower lung freId. This was again noted on May rgth, when the heart shadow was grossly enIarged with C-T ratio of 12/23.5. Five
CrastnopoI I
,I
et aI.-Wounds
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L. Arm
111
Americ:tn
Jo~rn;tl of Surg~y
R. Arm
L. Leg
VS
V,
Fig. IA Vl
V?
Vd
V,
_-
.l______l_-_I_Fig.
Fig. IC
___~
____..,_” _._. .
IB
Fig. ID
FIG. I. Case I, A and B, tracings taken seven days after the stab wound and five months Iater. The upper rows (a) reveal the folIowing: The standard Ieads I and II show abnorma1 elevation of the RS-T segments. This can aIso be seen in the precordia1 Ieads Vg and VS. This indicates that the stab wound had caused (directly or indirectly by means of a hemopericardium) myocardia1 injury. The Iower tracings (b) are normaI. c, May 14, 1946, bedside chest fiIm showing diffuse cIouding over the left lower Iung field suggesting fluid. The heart does not appear unusuaI. D, on May 19, 1946, there was diffuse cIouding of the Ieft Iower Iung field with increased pulmonary markings, suggestive of fluid with underIying consolidation. The heart was now grossly enlarged, C/T ratio r3.iz3.5, which suggested pericardia1 effusion.
_&17
3.18 Am&can
Journalof
Surgery
CrastnopoI
et a&Wounds
months later the heart and Iungs were essentiaIIy normal. EIectrocardiographic findings are recorded (Fig. I) and show evidence of hemopericardium or myocardial injury. Tracings Iive months later are normal. Laboratory studies of the blood, urine and serology were all negative. Venous pressure, taken in September, was IOO mm. of water. The circulation time was normal. Note that there was earIy x-ray evidence of fluid in the Ieft lung field, and this was probabIy a communication between pleura and pericardium. Because the patient was comfortabIe, out of shock and without evidence of continued bleeding, expIoration was not undertaken. The Iocation of the wound, clinica findings and the electrocardiogram provide proof of intrapericardia1 injury. CASE II. A. D., a twenty-five year old coIored male, was admitted to the ward on August I I, 1946, with a history of having been stabbed in the chest with a knife. On examination he was comatose, skin coId and cIammy, pulse rapid and weak, respirations rapid and shahow, bIood pressure 50/o. There was a I inch Iacerating wound one inch from the sterna1 margin in the left fourth interspace, stil1 oozing a smaI1 trickle of blood. Heart sounds were reguIar and distant at 140 per minute; examination of the lungs was negative. The patient was given 500 cc. of plasma with 5 cc. of coramine intravenously and placed in an oxygen tent. This was followed with 500 cc. of whoIe bIood and 1,000 cc. of 5 per cent glucose in saline. Within two hours he began to react favorabIy. He became coherent in his speech; his pulse became stronger and blood pressure rose to 74/36. Examination of the heart failed to revea1 evidence of tamponade or cardiac shift. Ten hours foIlowing admission the bIood pressure was 1zo/80 p&e rate 120 per minute; respiration 20 per minute. On the following day he had no compIaint other than miId tenderness over the region of the wound. FIuoroscopy two days Iater showed dIminished intensity of expansion of the right side of the heart, &dings consistent with the presence of a smaI1 amount of fluid in the pericardium. His temperature rose to 102.8”F. twenty-four hours after admission but thereafter he ran an afebrile course. He was discharged asymptomatic fifteen days after admission. On August 14th an upright film showed an enIargement of the heart to the right and to the
of Heart
OCTOBER, 19‘48
left, and on August z2nd a teleroentgenogram was suggestive of pericardial &id. The eIectrocardiogram (Fig. 2) shows evidence of myocardial injury up to five weeks after the stab wound. On August 15th the venous pressure was 120 mm. of water; arm to tongue circulation time was 23 seconds; arm to lung circuIation time was IO seconds. Note that the circulation times are dehniteIy prolonged. Other laboratory findings were negative. Electrocardiograms, IIuoroscopic examination, cIinica1 Iindings and Iocation of the wound support a diagnosis of penetrating heart injury in this patient. CASE III. F. P., a hfty-one year oId, coIored male, was admitted to the ward with a transverse laceration in the fourth interspace on the left, approximately 2 inches from the sterna1 border. There was bIood oozing from the wound. He was comatose; his skin was coId and cIammy, bIood pressure was 60/20, heart sounds were distant and rapid. The rest of the physical examination was essentiaIIy negative. The patient was immediately placed on intravenous fluids which included 1,000 cc. of 5 per cent glucose in saline, 500 cc. of plasma and 500 cc. of whole brood, and he was placed in an oxygen tent. Within an hour he showed considerable improvement; his speech was coherent; his skin was warm and his bIood pressure Eight hours later he was quite rising. comfortable. On three occasions during his period of convaIescence he complained of severe pain in the left chest which responded to miId sedation. Examination of the heart during these periods was negative. The patient was discharged from the hospital asymptomatic fourteen days after admission. Fluoroscopy performed on August 14th showed norma contour of the heart on the Ieft, with moderately diminished pulsation at the right lower border with obIiteration of the normal cardiophrenic angle suggestive of a small amount of pericardial fluid. The electrocardiogram (Fig. 3) was normal five days after the stab wound. However, two weeks later there was evidence of myocardial injury and two months later the tracings were once more normal. On admission a portable chest plate was not remarkabIe. On August 12th there was reported to be a bulge in the waII of the left post-traumatic ventricle consistent with aneurysm and some diminution of ihumination
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A merican Journal of Surgery
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FIG. z. Case II, A and B, the upper rows (a) of tracings were taken two days after the stab wound. The middle rows (b) were taken tweIve days after the stab wound, and the Iower rows (c) were taken five weeks after the stab wound was inflicted. The upper rows show the folIowing: onIy precordia1 Ieads V, and V6 were taken because a dressing Iay over the remainder of the chest. Marked and abnormal etevation of the RS-T segments of these leads were present. This indicated that the stab wound had resulted in myocardia1 injury. This was further confirmed by the eIevated RS-T segments in Ieads I, II, L. Arm and L. Leg. The middIe rows show the foIlowing: with the exception of lead V6, the precordial Ieads are normaI. The standards Ieads aIso appear normal but the L. Leg Iead shows an abnorma1 eIevation of the RS-T segment. The Iower rows show the folIowing: a11the precordia1 Ieads are normaI. The standard Ieads arc also normal but signs of myocardial injury stiI1 are present in the L. Leg lead.
419
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American Journal 01 Surgery
CrastnopoI
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Fig. 3~
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A merican Jo~I~
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in the left lower lung field. Calcification in the walls of the descending aorta wouId indicate that there might we11 be an antecedent history of arterioscIerotic heart disease in this patient. Venous pressure reading on the day after admission was 95 mm. of water, with arm to Iung circuIation time of IO seconds and arm to tongue circulation time of 25 seconds. One month Iater the venous pressure was still norma1; arm to lung time was I I seconds and arm to tongue time was 20 seconds. These are considered retarded. Other than positive Kline and Wassermann tests, bIood chemistries and hematoIogic study were normal. Figure 3D, taken two months Iater, shows the heart to be smaIIer.
more comfortable, with the pulse stronger at 110 per minute; respirations smooth and reguIar at 30 per minute, and the skin warm and its color improved. Twelve hours after admission, however, it was noted that she was bleeding actively from her chest wound, and immediate expIoration was deemed advisable. A laceration of the Ieft auricular appendage of the heart was repaired at this time, 300 cc. of bIood removed from the Ieft pleural cavity and the patient was returned to the ward. PostoperativeIy she deveIoped an empyema of the chest which responded to aspiration and supportive blood transfusions. The patient was discharged from the hospita1 thirty-six days after admission, relatively asymptomatic.
Here again, the cIinicaI findings and aided in making eIectrocardiogram diagnosis of stab wound of the heart.
This patient was observed for a period of tweIve hours before expIoration was decided upon and the Iacerated myocardium sutured. This may be accepted as further evidence that wounds of the auricIes are Iess apt to be foIIowed by the degree of rapid and massive bIeeding characterizing Iacerations of the ventricIes and conservative therapy, whiIe not advocated for this case, is apt to maintain the patient over a Ionger period of time. When there is communication between pIeura and pericardium with evidence of continued bIeeding, conservatism cannot be maintained for Iong and expIoration becomes mandatory. Though the essentiaIs of treatment in the first three cases were supportive onIy, in the giving of oxygen, pIasma, bIood and isotonic ffuids with stimuIants when necessary, this is not presented as an argument for the non-operative handIing of a11 wounds of the heart. When the hazards of operation, the chances of pericarditis with or without empyema, coronary occIusion
the the
CLASS IV. E. C., a twenty-one year oId white femaIe, was admitted to the ward with a history of having stabbed herseIf two hours before admission whiIe drunk. Physical examination revealed a we11 deveIoped and we11 nourished white femaIe, conscious and oriented, with cold, paIlid skin and bIood pressure of 55/32. There was a Iacerating wound in the third Ieft interspace, si; of an inch Iong, located ,$s inch from the midline. Respirations were rapid and shaIIow and examination of the chest reveaIed hyperresonance to percussion note above the region of the fourth interspace with duhness beIow that Ievel, while heart sounds were m&led and distant. There were no breath sounds to be heard over the entire left chest. The patient was immediateIy started on 1,000 cc. of 5 per cent glucose in saline and then switched to pIasma. A chest tap in the fifth interspace Ieft mid-axiIIary Iine was unsuccessful, with onIy 12 cc. of bIood withdrawn. Four hours after admission she appeared much
FIG. 3. Cast III, A and H, the upper rows (a) of tracings were taken five days after the stab wound. The middle rows Cb) were taken two weeks after the stab wound and the Iower rows (c) of tracings were taken two months after the stabbing. The upper rows show the folIowing: no abnormaIities are present. Precordial Ieads vi and V3 were not taken because this area was covered by the dressing over the stab wound. The middle rows show the foIIowinp: standard leads aipear norma but precordial Iead VS and the L. Leg lead show abnormal RS-T segments and T waves indicating that myocardial injury is present. The lower rows are norma again. c, August 12, 1946, portabIe chest film shows some haziness in tower left Iung field. A buIge in the left ventricular waI1, consistent with post-traumatic aneurysm, was present. Calcification of the aortic arch and descending aorta were aIso noted. D, Two months Iater 6 foot fiIm shows slight haziness in both lower lung fieIds.
422
American
Journal
of Surgery
Crastnopol
et al.-Wounds
with myocardia1 infarction, hemothorax and pneumothorax, pneumonia, embolism and ateiectasis are considered, operation is not IightIy undertaken and definite indications for it shouId be present. On the other hand, when it is remembered that non-operation may resuIt in aneurysm of the heart or coronary vesseIs, or that at some time a cIot may give way and sudden death occur, or that recurrent tamponade may cause death of cardiac faiIure and cerebra1 anemia, there shouId be no hesitancy in undertaking operation when the issue remains in doubt. BIau13 quotes DshaneIidze as having proven that few cases have sequelae after operation. He coIIected 535 cases from the Iiterature and in 96.5 per cent of I 13 of these, who were foIIowed for a number of years up to eighteen, there was no impairment of cardiac function. It wouId seem to us that the most satisfactory course, when conservative therapy has been decided upon, wouId be to have the operating room in readiness for immediate use should it become apparent that conservative measures have been to no avail. CONCLUSIONS I. In the presence of a stab wound, or other penetrating injury of the chest in the region of the heart, the eIectrocardiogram is usefu1 in determining whether the pericardial cavity has been entered. Where there has been myocardia1 damage, the tracings wiI1 be of immediate diagnostic significance, and in pericardia1 damage the findings wiII be those of pericarditis and hemopericardium. 2. The use of unipoIar extremity Ieads and muItipoIar precordia1 Ieads wiI1 heIp make the diagnosis of myocardia1 injury even when the standard Ieads are normaI. 3. Signs of myocardia1 injury may remain in the unipoIar extremity Ieads or muItipIe precordia1 Ieads even when the standard Ieads have returned to normaI. 4. There are stab wounds of the heart that wiI1 respond to intravenous fluids, oxygen and stimuIants. Among these are
of Heart
OcroeER,1948
incIuded simple pericardia1 injuries and cases which in some manner the bIeeding point has been occIuded and there is Iittle IikeIihood that bIeeding into the pericardia1 sac wiII recur. 5. Intravenous fIuids and aspiration of the distended, compressing pericardium may quickly reIieve the embarrassed heart and circuIation in injuries where bIeeding is not apt to recur. 6. Preparation for operation, in the event that the patient has not responded favorabIy to such a regimen, shouId proceed concomitantIy. 7. When a wound of the heart is accompanied by intrapIeura1 injury and hemorrhage or evidence of considerabIe externa1 bIeeding, even in the presence of tamponade, the indications for prompt bIood repIacement are present. It is difficult, without aspiration, to distinguish between symptoms caused by bIood Ioss and those of tamponade, and they may be coexistent. 8. Again, when externa1 bIeeding has not been excessive, when there is IittIe or no hemorrhage into the pleura in the absence of signs of cardiac tamponade, the possibiIity remains that much of the symptomatoIogy may be due to reff ex vasodilatation, as pointed out by Warren et a1. It is not unreasonabIe that injury to a vita1 organ may be foIIowed by such a sequence of events, but the degree of shock shouId not be deep and the patient shouId be easiIy aroused. Such was not whoIIy the case in any of our patients. REFERENCES I. GRISWOLD, R. A. and MACLXRE, C. H. Penetrating
2. 3.
4.
5.
6.
wounds of the heart and pericardium. Surg. Gynec. eY Obst., 74: 406-418, 1942. ELKIN, D. C. Diagnosis and treatment of cardiac trauma. Ann. Surg., I rq: 16p185, ,941. GOLDBERGER, EMANUEL. A simpIe eIectrocardiographic electrode of zero potentia1, and a technic of obtaining augmented unipolar extremity Ieads. Am. Heart J., 23: 483, 1942. FOULGER, M. and FOULGER, J. H. The bIood pressure and eIectrocardiogram in experimenta pericardial effusion. An. Heart J., 7: 744, 1932. SCHWAB, E. H. and HERRMAN, G. AIterations of the eIectrocardiogram in disease of the pericardium. Arch. Int. Med., 55: 917, 1935. NOTH, P. H. and BARNES, A. R. EIectrocardio-
graphic changes associated with pericarditis. Arch. Int. Med., 65: 291, 1940. SOLOVAY, J., RICE, G. D. and SOLOVAY, H. U. EIectrocardiographic changes in stab and gunshot wounds of the heart. Ann. Int. Med., IS: 465-477. I 94 1. BIGGER, I. A. Wounds of the heart and pericardium. South. M. J., 25: 785-794, 1932. BIGGER, I. A. Heart wounds. J. Tboracic Surg., 8:
II.
239-253, 1939. ELKIN, D. C. Wounds of the heart. Ann. Surg., 120: 817-821, 1944. SCHIEBEL, H. M. Stab wound of the pulmonary artery with suture and recovery. Arch. Surg., 45:
957-963. 1942. NELSON, HARRY. Penetrating wounds of the heart. Arch. Surg., 47: 571-582, 1943. 13. BLAU, M. H. Wounds of the heart. Am. J. M. SC., 210: 252-262, 1945. 14. STRIEDER, J. S. Stab wounds of the heart. J. *. Tboracic Surg., 8: 576, 1939. ‘5. ELKIN, D. C. Suture in wounds of the heart. Ann. Surg., 95: 573, 1932. Research Council. Military SurgicaI 16 National Manuals, Neurosurgery and Thoracic Surgery. P. 255, PhiladeIphia, 1943. W. B. Saunders and co. 17. BLALOCK, A. and RAVITCII, M. hf. Non-operative treatment of cardiac tamponade resulting from wounds of the heart. Surgery, 14: 157-162, 1943. 12.
18. GLASSER, S. T., MERSHEKMER,W. and SHINER, I. Bullet wound of the left cardiac auricIe with suture and recovery. Am. J. Surg., 53: 131-144, 1941. 19. BECK, C. S. Stab wounds: further observations. Ann. Surg., I 15: 698-704, 1942. 20. WARD, T. P. and PARKER, W. G. Penetrating wounds of the heart. Am. J. &u-g., 50: 712-714, 1940. 21. COOPER, F. W., STEAD, E. A. and WARREN, J. V. Beneficial effects of intravenous infusions in acute pericardial tamponade. Ann. Surg., 120: 822, 1944. 22. MERRILL, A. J., WARREN, J. V., STEAD, E. A. and BRANNON. E. S. The circuIation in oenetratina wounds oi the chest: a study by the&method oyf right heart catheterization. Am. Heart J., 31: 413, 1946. 23. BRANNON, E. S., STEAD, E. A., WARREN, J. V. and MERRILL, A. J. Hemodynamics of acute hemorrhage in man. Am. Heart J., 31: 407, 1946. 24. WARREN, J. V., BRANNON, E. S., STEAD, E. A. and MERRILL, A. J. Pericardial tamponade from stab wound of the heart and pericardia1 effusion or empyema: a study utilizing the method of right heart catheterization. Am. Heart J., 31: 418, 1946. 25. GOLDBERGER, EMANUEL. Unipolar Lead EIectrocardiography. Philadelpia, 1947. Lea and Febiger.
OF THE HEART AND PERICARDIUM*
PHILIP CRASTNOPOL, M.D., EMANUEL GOLDBERGER, M.D., RAYMONDM. MARCUS,M.D. AND LESTEROSTROVE, M.D. New York, New Ipork
T
HE treatment of wounds of the heart and pericardium has changed considerably from the days when cardiac surgery was considered hopeIess and heroic to the present when reports of operative interference are no longer rare. T’he mortaIity rate has been greatIy reduced, due in no smalI part to the more frequent diagnosis of wounds of the heart and pericardium. Perforations of the heart such as the type caused by buIIets and Iacerations of the intrapericardia1 vesseIs will resuIt in rapid exitus before effective therapy can be instituted. Our findings, as we11 as those in the Iiterature, indicate that when the patient arrives at the hospital aIive, no matter how criticaIIy iI1, he may be saved. herein, four cases of We are presenting, stab wounds of the chest with pericardia1 and myocardia1 invoIvement, of which three were treated conservativeIy and one was treated by surgery. The eIectrocardiogram pIayed an important part in the earIy diagnosis of these cases. DIAGNOSIS
Significance of Early ECG’s. Much has been written previousIy about the diagnosis of penetrating wounds of the heart and pericardium. Anyone receiving a Iacerating wound over the precordia1 region must be suspected of having sustained cardiac trauma. This is especiaIIy true when the symptoms of shock are out of a11 proportion to the amount of bIood Iost’ and when a hemopneumothorax has been excIuded. In the presence of hemothorax, the possibiIity of a wound which has pierced both pericardium and pIeura with bIeeding from one cavity into the other must be borne in mind. * From
the Second
Surgica!
and the CardioIogicaI 412
Griswold and Maguire’ mention Beck’s triad of acute cardiac compression: (I ) faIIing arteria1 pressure; (2) rising venous pressure and (3) smaI1, quiet heart. These, together with the physica findings of rapid, paradoxical pulse, low puIse pressure, distention of venous circuIation and distant, m&led heart sounds speak of tamponade. FIuoroscopy in doubtful cases bears out the fact that cardiac activity is reduced, and may further demonstrate intrapericardial fluid. X-ray, on the other hand, is not necessarily of much heIp2 since it will usuaIIy show no abnormality of heart size inasmuch as onIy IOO to 200 cc. of blood wiI1 cause tamponade. These patients are usuaIIy in such deep shock that they appear to be in extremis. It is difficuIt then to move them around for adequate Auoroscopic and roentgenoIogic examination. We have found the electrocardiogram of great heIp in verifying earIy the presence of injury to the heart and pericardium by changes indicative of pericarditis, hemopericardium or myocardia1 injury. In addition to the three standard Ieads, augmented unipolar extremity Ieads and muItipIe unipoIar precordia1 Ieads3xz5 were taken because it has been shown that these are of value in detecting evidence of myocardia1 injury when the standard Ieads are normaI. The augmented unipoIar leads were taken from the Ieft arm (Ieft arm Iead), the right arm (right arm Iead) and the Ieft Ieg (Ieft Ieg Iead). The muItipIe precordia1 leads were taken as foIIows: Iead vl, precordia1 eIectrode on the fourth intercosta1 space just to the right of the sternum; Iead vz precordia1 eIectrode on the fourth interspace just to the Ieft of the sternum; read v3 Services,
Lincoln
Hospital,
New York,
N. Y.
VOL. LXXVI,
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No. 4
et aI.-Wounds
mid-way between Ieads vz and v4 which is the precordia1 eIectrode on the fifth interCosta1 space at the Ieft of the mid-cIavicuIar Iine; Iead v5, electrode on the left anterior axiIlary line at the IeveI of v4; Iead v6, electrode on the Ieft mid-axillary line at the level of the Iead v4. Many investigators have pointed outi,jz” that pericardial effusion in itself does not cause electrocardiographic changes, and the presence of changes in the RS-T segments and T waves is a sign of injury to the superficia1 Iayer of the myocardium just beneath the pericardium. In cases of penetrating wounds of the heart the presence of RS-T and T changes, however, does not necessariIy indicate that the heart muscIe itseIf has been injured by trauma because a pericardia1 effusion or a hemopericardium can serve to irritate the superfrcia1 Iayers of the heart. The deep wide abnorma1 Q waves that occur after myocardia1 infarction do not appear after penetrating wounds of the heart unIess one of the Iarger coronary arteries is severed as a resuIt of the accident. SoIovay, Rice and SoIovay7 point out that weeks or months after operation T wave changes become more pronounced and then revert to normaI. MANAGEMENT
In the past there has been considerabIe divergence of opinion as to the management of these cases. Bigger predicates the type of treatment on the nature of the injury. In 1932~ he divided his cases into three cIassifications : (I ) PericardiaI injury aIone or pericardia1 and heart injury without penetration into a chamber division or coronary vesseIs. These may be treated penetration into a conservativeIy ; (2) chamber or coronary vesse1 division. Operation is usuaIIy indicated; (3) severe injuries with immediate death. In 1939 Bigger9 divided his cases into four groups and treated them accordingIy: (I) Free communication between the pericardium and pIeura but onIy sIight or moderate hemorrhage. These are treated
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A merican Journal of Surgery
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ConservativeIy. (2) Tamponade present, but folIowing venocIysis, adrenaIin and other supportive measures there is marked improvement. A cannula is pIaced in the pericardia1 cavity and bIood withdrawn. If after fifteen or twenty minutes there is no evidence of further bleeding, conservative therapy is continued. In the interim a11 preparations for operation are made. (3) Greatly increased pericardia1 pressure with no satisfactory response to conservative therapy.. These are expIored. (4) Free communication between pIeura and pericardium with massive intrapleural hemorrhage. Immediate operation is performed and bIood from the pericardia1 cavity is reinfused. He further points out that chance of recovery without expIoration is sIight when the wound has penetrated the heart. SchiebeI’l apparentIy beIieves that a11 heart wounds should be explored since a heaIed wound may cause rupture or aneurysm when no surgica1 repair is performed. NeIson,12 in reporting a series of cases in 1943 from Charity HospitaI, New OrIeans, states that he beIieves patients with stab wounds of the heart shouId be expIored. In certain cases the extent of injury is not immediateIy apparent and death may occur before surgery can be performed. He further states that patients who are brought out of shock and then reIapse under conservative treatment are not apt to recover. Moreover, expIoratory operation has IittIe risk attached. He adds that the possibility of aneurysm formation and Iater pericardia1 adhesions cannot be ignored, and that aspiration of the pericardia1 sac is attended by the risk of puncture of a coronary vessel. From 1906 to 1943 there were twenty-seven cardiorrhapies at Charity, and better resuIts Iater in the series are attributed to more frequent expIoration. BIau13 reports a series of twenty-seven penetrating wounds of the heart at the Detroit Receiving HospitaI; twenty-one were operated on with a mortaIity of 23.8
4 I4
American Journal of Surgery
CrastnopoI
per cent. Of the six remaining
cases,
et aI.-Wounds three
were observed and three were aspirated. In the whole series of twenty-seven cases there were six deaths, five in the operated group and one in the conservatively treated group, with a tota mortality of 22.2 per cent. Blau also refers to a case reported by Vance in which death occurred eight days after the wound due to the wound edges being forced apart, with fatal tamponade resulting. He aIso refers to an article by Long in which Long states that the spontaneous cIosure of the parieta1 pericardium may resuIt with a bIood cIot when the blood pressure is low, changing of reIative openings of the myocardium and the pericardium as the hemopericardium increases, a smaI1 puncture wound of the pericardium over a large heart wound, or non-penetration of either pIeura1 cavity. Bigger9 reported seventeen cases at the MedicaI CoIIege of Virginia Hospital. In tweIve of these there were simpIe penetrating wounds of the heart cavities or Iumina of the intrapericardia1 portions of the great vesseIs, and of these eight recovered and four died. A patient with a heart wound is put in TrendeIenburg position, given morphine sulfate and atropine, and, if in coIlapse, 5 m. of adrenaIin subcutaneousIy and IO to 15 m. by vein. When there is no sign of tamponade, conservatism is practiced. In the past a11 patients with tamponade and signs of heart injury with massive or moderate hemothorax were operated on, but now operation is performed onIy when marked signs of tamponade persist or when the indications are cIear. Otherwise treatment is conservative. He cites the case of a twenty-two year oId patient with a bulIet wound of the chest who, despite the fact that he had bIood and air in the pericardium, had no tamponade. He was given supportive treatment and recovered. He cited another case of a patient who at operation had a cIot attached to the anterior heart waI1 over one of the divided branches of the Ieft descending coronary artery. This patient recovered without Iigature of the artery.
of Heart
OcroseR,1948
ObviousIy, he adds, aspiration wouId have sufficed. Strieder’” reports the case of a tweIve year oId boy with a stab wound of the heart. Because of evidence of tamponade he was prepared for operation. But when a No. 16 gauge needIe was introduced into the pericardia1 sac and IOO cc. of bIood were obtained and reinfused into his vein, dramatic improvement and eventua1 compIete recovery resuIted without operation. The author adds, however, that the danger of aneurysm of the heart and coronary vesseIs is great so that non-operation in a case of this type is hazardous. GriswoId and Maguire’ report fortyseven cases of diagnosed heart wounds treated at LouisviIIe City HospitaI in an eight-year period. Of these, seven were misdiagnosed and turned out to be pathoIogica1 conditions of organs other than the heart. Thirteen died Iess than twenty minutes after admission to the hospital. Of the twenty-seven patients who Iived Ionger than twenty minutes after admission, twenty-two were operated on with six deaths during or following the operation; five -patients were treated conservativeIy with one death. MortaIity for the twenty-seven cases was 25.9 per cent. EIkin2 reported thirty-eight cases operated upon for heart wounds, of whom twenty-two recovered without sequeIae. He beIieves that operation should be carried out as soon as a heart wound is diagnosed. Three years laterlo he reported a series of twenty-three cases with eighteen recoveries. WhiIe in his first series infection pIayed a Iarge part in causing death, in the Iatter group this compIication was not present due to more meticuIous operative He concurs with Bigger and technic. BIaIock that where there is no immediate urgency for operation and aspiration resuits in continued reIief, conservatism may be practiced. In the MiIitary SurgicaI ManuaI on neurosurgery and thoracic surgery16 it is stated that frequentIy these patients wiI1 respond to conservative treatment, as a
VOL. LXXVI.
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et al.---Wounds
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A me&an Journal I,(’Surgery 4
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rapid exsanguination and death occur so that these patients rareIy come to operation. SchiebeI’l states that bIeeding, when it occurs, is into the reIativeIy ineIastic pericardial sac, and the wound is frequentIy plugged by overlying muscle. The intrapericardia1 pressure rises and there is increasing pressure on the chambers of the heart as bIeeding continues. As pressure in the right auricIe rises, there is a decrease in cardiac intake and output, and cerebra1 anemia is rapidIy foIIowed by death. It wouId seem reasonabIe to assume that where there is intrapericardia1 bleeding with increased atria1 and venous pressure and decreased cardiac output, intravenous fluids wouId do IittIe to aIIeviate the state of embarrassed circuIation and periphera1 shock. Though the trauma to the heart is severe, unIess there has been extensive externa hemorrhage or bIeeding into the thorax, the presenting picture is one of coIIapse due to tamponade, diminished cardiac output and cerebra1 anemia. In fact, according to Elkin,‘; “a symptomless intervat . . . during the time the pericardium fiIIs with blood, is the most important point in the history.” TypicaIlS the onset of symptoms dates back to a state of tamponade. Beckl” beIieves that intravenous fIuids cause a rise in arteria1 pressure if there is a fixed state of cardiac compression and some of the bIood can escape from the pericardia1 cavity. Ward and Parker2” beIieve that one must differentiate between symptoms due to shock of hemorrhage or tamponade. However, they concIude that intravenous infusions rareIy do harm and may be Iivesaving. The work of Cooper, Stead and Warren, in 1944, and Iater papers pubIished by them and MerriII and Brannon21Yz1 have shown the beneficial effects of supportive PATHOLOGICAL PHYSIOLOGY intravenous therapy in these patients. The wound is most commonIy caused by They said that as the venous pressure goes a knife or an ice pick, Iess commonIy by a up its effect is to overcome the block ocbuIIet; this is statisticaIIy borne out in a11 casioned by the increasing auricuIar pressure. The amount of bIood entering the Iarge series. In gunshot wounds, because veins is Iimited by the diminishing cardiac of the destructive nature of the injury and because there is perforation of the heart, output, and increasing the bIood voIume smaI1 heart wound may be seaIed off during circuIatory collapse. Pericardiocentesis is recommended when tamponade and hemothorax are not coexistent. When there is a reduction in venous pressure and arteria1 pressure is maintained, it may be assumed that bleeding has ceased and conservati\-e treatment is to be continued. BIaIock and Ravitch17 quote FeIsenreich as saving that the treatment of penetrating vent;icuIar wounds shouId be operative, whiIe auricular wounds may be handIed conservatively because of the IikeIihood of cessation of auricuIar bIeeding. But other writers have stated that because of its Iack of contractihty and eIasticity, wounds of the auricIes are more apt to be foIlowed by fata consequences. They bring up the probIem as to whether the end resuits may not be better if a more conservative poIicy is instituted, and believe that operation may be delayed if symptoms are due to tamponade and not to continued bIeeding. They quaIify this with saying that probabIy not more than two hours should eIapse with continued tamponade and, if blood reaccumuIates, pericardiotomy is indicated. GIasser, Mersheimer and Shiner18 quote Kosmin as saying that isoIated pericardia1 injuries are much more rare than heart injury, occurring in the ratio of I : IO, conceivabIy because of heart activity, nature of the weapon and degree and direction of and penetration. Th ey quote GunzIing Sarkisov as saying that the signs of isoIated pericardia1 injury wiI1 be hemorrhage from the wound, dyspnea and increased cardiac duIIness to percussion, but cIear heart sounds with onIy temporary or insignificant signs of tamponade wiI1 aIso be present.
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A m&can Journal of Surgery
CrastnopoI
et a&Wounds
wilI increase the venous pressure and help combat tamponade. In their experiments on dogs they found that animaIs couId survive IOO per cent more of increased intrapericardial pressure than before if given intravenous ffuids. There was aIso an associated rise in arteria1 pressure. They concIuded:“l “In patients who survive unti1 they reach the hospita1 the myocardial, and probabIy the pericardia1 rents are at Ieast temporariIy cIosed . . . it is possibIe that, in certain seIected patients, raising the venous pressure by increasing the bIood voIume wiI1 restore the circuIation to an adequate IeveI without aspiration or operation.” In 1946 Brannon, Stead, Warren and MerriI123z2” reported that when bIood voIume in humans was raised with intravenous Auids there was increased cardiac output and arteria1 pressure whiIe the periphera1 resistance dropped. They added, significantIy, that patients who have suffered trauma may react with reffex vasodiIation and present signs of circuIatory coIIapse. These same men24 studied four patients with stab wounds of the heart and found that the situation was different from chest wounds and hemorrhagic shock. They found the atria1 pressure eIevated, the arteria1 puIse paradoxica1, cardiac output decreased and periphera1 resistance up. When two of these were given intravenous aIbumin, there occurred a rise in atria1 pressure, cardiac output and arteria1 pressure, improved oxygenation function of the bIood stream and a diminished degree of paradoxica1 puIse as measured in the femora1 artery. They state that where the circuIation improves promptIy without therapy, the main factor is probabIy one of reffex vasodiIatation and not tamponade; but where faiIure persists unti1 the intrapericardia1 pressure is Iowered, it must be due to tamponade. Raising the venous pressure by intravenous ffuids wiI1 not improve the circuIation unIess the pericardium wiI1 distend in diastoIe and permit the heart to receive more bIood, or unIess bIood is being forced out of the sac.
OcToeER, ,948
of Heart
That some part of the symptomatoIogy compIex of patients who suffer a penetrating wound of the pericardium and heart is due to reffex vasodiIatation is a theory that seems attractive to us. CertainIy, supportive treatment without aspiration has done nothing to remove whatever ffuid is present to cause the tamponade, yet some of these patients wiI1 recover without residual signs of cardiac embarrassment. This has been so in three of our four cases presented. CASE
REPORTS
With the foregoing remarks and especiaIIy with the important experimental studies of the Iast mentioned investigators in mind, the foIIowing cases are presented: CASE I. E. J., a sixteen year oId colored male, was admitted to the hospital May 14, 1946, with a history of having been stabbed in the left chest a short time before admission. Physical examination revealed a well nourished and we11 deveIoped male in deep shock. The skin was cold, cIammy and pallid; the pulse was rapid and weak; the bIood pressure unobtainable and temperature was 95.6”~. There was a puncture wound in the fourth interspace I inch medial to the left nipple line. Heart sounds were distant, weak and rapid. Breath sounds were rapid and shallow, but examination of the Iungs failed to reveal hyperresonance, dullness or flatness. The patient was immediately given 500 cc. of plasma folIowed by 500 cc. of bIood and then 1,000 cc. of 5 per cent glucose in saline. Within one hour he showed definite evidence of coming out of shock, began to talk coherently and the pulse became fulI and regular. He continued to show improvement and on the folIowing day his only compIaint was Iocalized pain over the wound site. The temperature curve remained in the region of IOI OF. for eight days and then returned to normaI. He was discharged eIeven days after admission without complaint. X-rays taken within eight hours of admission and five days Iater are herein reproduced. The x-ray taken on May 14th indicated fluid in the Ieft lower lung freId. This was again noted on May rgth, when the heart shadow was grossly enIarged with C-T ratio of 12/23.5. Five
CrastnopoI I
,I
et aI.-Wounds
of Heart
L. Arm
111
Americ:tn
Jo~rn;tl of Surg~y
R. Arm
L. Leg
VS
V,
Fig. IA Vl
V?
Vd
V,
_-
.l______l_-_I_Fig.
Fig. IC
___~
____..,_” _._. .
IB
Fig. ID
FIG. I. Case I, A and B, tracings taken seven days after the stab wound and five months Iater. The upper rows (a) reveal the folIowing: The standard Ieads I and II show abnorma1 elevation of the RS-T segments. This can aIso be seen in the precordia1 Ieads Vg and VS. This indicates that the stab wound had caused (directly or indirectly by means of a hemopericardium) myocardia1 injury. The Iower tracings (b) are normaI. c, May 14, 1946, bedside chest fiIm showing diffuse cIouding over the left lower Iung field suggesting fluid. The heart does not appear unusuaI. D, on May 19, 1946, there was diffuse cIouding of the Ieft Iower Iung field with increased pulmonary markings, suggestive of fluid with underIying consolidation. The heart was now grossly enlarged, C/T ratio r3.iz3.5, which suggested pericardia1 effusion.
_&17
3.18 Am&can
Journalof
Surgery
CrastnopoI
et a&Wounds
months later the heart and Iungs were essentiaIIy normal. EIectrocardiographic findings are recorded (Fig. I) and show evidence of hemopericardium or myocardial injury. Tracings Iive months later are normal. Laboratory studies of the blood, urine and serology were all negative. Venous pressure, taken in September, was IOO mm. of water. The circulation time was normal. Note that there was earIy x-ray evidence of fluid in the Ieft lung field, and this was probabIy a communication between pleura and pericardium. Because the patient was comfortabIe, out of shock and without evidence of continued bleeding, expIoration was not undertaken. The Iocation of the wound, clinica findings and the electrocardiogram provide proof of intrapericardia1 injury. CASE II. A. D., a twenty-five year old coIored male, was admitted to the ward on August I I, 1946, with a history of having been stabbed in the chest with a knife. On examination he was comatose, skin coId and cIammy, pulse rapid and weak, respirations rapid and shahow, bIood pressure 50/o. There was a I inch Iacerating wound one inch from the sterna1 margin in the left fourth interspace, stil1 oozing a smaI1 trickle of blood. Heart sounds were reguIar and distant at 140 per minute; examination of the lungs was negative. The patient was given 500 cc. of plasma with 5 cc. of coramine intravenously and placed in an oxygen tent. This was followed with 500 cc. of whoIe bIood and 1,000 cc. of 5 per cent glucose in saline. Within two hours he began to react favorabIy. He became coherent in his speech; his pulse became stronger and blood pressure rose to 74/36. Examination of the heart failed to revea1 evidence of tamponade or cardiac shift. Ten hours foIlowing admission the bIood pressure was 1zo/80 p&e rate 120 per minute; respiration 20 per minute. On the following day he had no compIaint other than miId tenderness over the region of the wound. FIuoroscopy two days Iater showed dIminished intensity of expansion of the right side of the heart, &dings consistent with the presence of a smaI1 amount of fluid in the pericardium. His temperature rose to 102.8”F. twenty-four hours after admission but thereafter he ran an afebrile course. He was discharged asymptomatic fifteen days after admission. On August 14th an upright film showed an enIargement of the heart to the right and to the
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OCTOBER, 19‘48
left, and on August z2nd a teleroentgenogram was suggestive of pericardial &id. The eIectrocardiogram (Fig. 2) shows evidence of myocardial injury up to five weeks after the stab wound. On August 15th the venous pressure was 120 mm. of water; arm to tongue circulation time was 23 seconds; arm to lung circuIation time was IO seconds. Note that the circulation times are dehniteIy prolonged. Other laboratory findings were negative. Electrocardiograms, IIuoroscopic examination, cIinica1 Iindings and Iocation of the wound support a diagnosis of penetrating heart injury in this patient. CASE III. F. P., a hfty-one year oId, coIored male, was admitted to the ward with a transverse laceration in the fourth interspace on the left, approximately 2 inches from the sterna1 border. There was bIood oozing from the wound. He was comatose; his skin was coId and cIammy, bIood pressure was 60/20, heart sounds were distant and rapid. The rest of the physical examination was essentiaIIy negative. The patient was immediately placed on intravenous fluids which included 1,000 cc. of 5 per cent glucose in saline, 500 cc. of plasma and 500 cc. of whole brood, and he was placed in an oxygen tent. Within an hour he showed considerable improvement; his speech was coherent; his skin was warm and his bIood pressure Eight hours later he was quite rising. comfortable. On three occasions during his period of convaIescence he complained of severe pain in the left chest which responded to miId sedation. Examination of the heart during these periods was negative. The patient was discharged from the hospital asymptomatic fourteen days after admission. Fluoroscopy performed on August 14th showed norma contour of the heart on the Ieft, with moderately diminished pulsation at the right lower border with obIiteration of the normal cardiophrenic angle suggestive of a small amount of pericardial fluid. The electrocardiogram (Fig. 3) was normal five days after the stab wound. However, two weeks later there was evidence of myocardial injury and two months later the tracings were once more normal. On admission a portable chest plate was not remarkabIe. On August 12th there was reported to be a bulge in the waII of the left post-traumatic ventricle consistent with aneurysm and some diminution of ihumination
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FIG. z. Case II, A and B, the upper rows (a) of tracings were taken two days after the stab wound. The middle rows (b) were taken tweIve days after the stab wound, and the Iower rows (c) were taken five weeks after the stab wound was inflicted. The upper rows show the folIowing: onIy precordia1 Ieads V, and V6 were taken because a dressing Iay over the remainder of the chest. Marked and abnormal etevation of the RS-T segments of these leads were present. This indicated that the stab wound had resulted in myocardia1 injury. This was further confirmed by the eIevated RS-T segments in Ieads I, II, L. Arm and L. Leg. The middIe rows show the foIlowing: with the exception of lead V6, the precordial Ieads are normaI. The standards Ieads aIso appear normal but the L. Leg Iead shows an abnorma1 eIevation of the RS-T segment. The Iower rows show the folIowing: a11the precordia1 Ieads are normaI. The standard Ieads arc also normal but signs of myocardial injury stiI1 are present in the L. Leg lead.
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in the left lower lung field. Calcification in the walls of the descending aorta wouId indicate that there might we11 be an antecedent history of arterioscIerotic heart disease in this patient. Venous pressure reading on the day after admission was 95 mm. of water, with arm to Iung circuIation time of IO seconds and arm to tongue circulation time of 25 seconds. One month Iater the venous pressure was still norma1; arm to lung time was I I seconds and arm to tongue time was 20 seconds. These are considered retarded. Other than positive Kline and Wassermann tests, bIood chemistries and hematoIogic study were normal. Figure 3D, taken two months Iater, shows the heart to be smaIIer.
more comfortable, with the pulse stronger at 110 per minute; respirations smooth and reguIar at 30 per minute, and the skin warm and its color improved. Twelve hours after admission, however, it was noted that she was bleeding actively from her chest wound, and immediate expIoration was deemed advisable. A laceration of the Ieft auricular appendage of the heart was repaired at this time, 300 cc. of bIood removed from the Ieft pleural cavity and the patient was returned to the ward. PostoperativeIy she deveIoped an empyema of the chest which responded to aspiration and supportive blood transfusions. The patient was discharged from the hospita1 thirty-six days after admission, relatively asymptomatic.
Here again, the cIinicaI findings and aided in making eIectrocardiogram diagnosis of stab wound of the heart.
This patient was observed for a period of tweIve hours before expIoration was decided upon and the Iacerated myocardium sutured. This may be accepted as further evidence that wounds of the auricIes are Iess apt to be foIIowed by the degree of rapid and massive bIeeding characterizing Iacerations of the ventricIes and conservative therapy, whiIe not advocated for this case, is apt to maintain the patient over a Ionger period of time. When there is communication between pIeura and pericardium with evidence of continued bIeeding, conservatism cannot be maintained for Iong and expIoration becomes mandatory. Though the essentiaIs of treatment in the first three cases were supportive onIy, in the giving of oxygen, pIasma, bIood and isotonic ffuids with stimuIants when necessary, this is not presented as an argument for the non-operative handIing of a11 wounds of the heart. When the hazards of operation, the chances of pericarditis with or without empyema, coronary occIusion
the the
CLASS IV. E. C., a twenty-one year oId white femaIe, was admitted to the ward with a history of having stabbed herseIf two hours before admission whiIe drunk. Physical examination revealed a we11 deveIoped and we11 nourished white femaIe, conscious and oriented, with cold, paIlid skin and bIood pressure of 55/32. There was a Iacerating wound in the third Ieft interspace, si; of an inch Iong, located ,$s inch from the midline. Respirations were rapid and shaIIow and examination of the chest reveaIed hyperresonance to percussion note above the region of the fourth interspace with duhness beIow that Ievel, while heart sounds were m&led and distant. There were no breath sounds to be heard over the entire left chest. The patient was immediateIy started on 1,000 cc. of 5 per cent glucose in saline and then switched to pIasma. A chest tap in the fifth interspace Ieft mid-axiIIary Iine was unsuccessful, with onIy 12 cc. of bIood withdrawn. Four hours after admission she appeared much
FIG. 3. Cast III, A and H, the upper rows (a) of tracings were taken five days after the stab wound. The middle rows Cb) were taken two weeks after the stab wound and the Iower rows (c) of tracings were taken two months after the stabbing. The upper rows show the folIowing: no abnormaIities are present. Precordial Ieads vi and V3 were not taken because this area was covered by the dressing over the stab wound. The middle rows show the foIIowinp: standard leads aipear norma but precordial Iead VS and the L. Leg lead show abnormal RS-T segments and T waves indicating that myocardial injury is present. The lower rows are norma again. c, August 12, 1946, portabIe chest film shows some haziness in tower left Iung field. A buIge in the left ventricular waI1, consistent with post-traumatic aneurysm, was present. Calcification of the aortic arch and descending aorta were aIso noted. D, Two months Iater 6 foot fiIm shows slight haziness in both lower lung fieIds.
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with myocardia1 infarction, hemothorax and pneumothorax, pneumonia, embolism and ateiectasis are considered, operation is not IightIy undertaken and definite indications for it shouId be present. On the other hand, when it is remembered that non-operation may resuIt in aneurysm of the heart or coronary vesseIs, or that at some time a cIot may give way and sudden death occur, or that recurrent tamponade may cause death of cardiac faiIure and cerebra1 anemia, there shouId be no hesitancy in undertaking operation when the issue remains in doubt. BIau13 quotes DshaneIidze as having proven that few cases have sequelae after operation. He coIIected 535 cases from the Iiterature and in 96.5 per cent of I 13 of these, who were foIIowed for a number of years up to eighteen, there was no impairment of cardiac function. It wouId seem to us that the most satisfactory course, when conservative therapy has been decided upon, wouId be to have the operating room in readiness for immediate use should it become apparent that conservative measures have been to no avail. CONCLUSIONS I. In the presence of a stab wound, or other penetrating injury of the chest in the region of the heart, the eIectrocardiogram is usefu1 in determining whether the pericardial cavity has been entered. Where there has been myocardia1 damage, the tracings wiI1 be of immediate diagnostic significance, and in pericardia1 damage the findings wiII be those of pericarditis and hemopericardium. 2. The use of unipoIar extremity Ieads and muItipoIar precordia1 Ieads wiI1 heIp make the diagnosis of myocardia1 injury even when the standard Ieads are normaI. 3. Signs of myocardia1 injury may remain in the unipoIar extremity Ieads or muItipIe precordia1 Ieads even when the standard Ieads have returned to normaI. 4. There are stab wounds of the heart that wiI1 respond to intravenous fluids, oxygen and stimuIants. Among these are
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incIuded simple pericardia1 injuries and cases which in some manner the bIeeding point has been occIuded and there is Iittle IikeIihood that bIeeding into the pericardia1 sac wiII recur. 5. Intravenous fIuids and aspiration of the distended, compressing pericardium may quickly reIieve the embarrassed heart and circuIation in injuries where bIeeding is not apt to recur. 6. Preparation for operation, in the event that the patient has not responded favorabIy to such a regimen, shouId proceed concomitantIy. 7. When a wound of the heart is accompanied by intrapIeura1 injury and hemorrhage or evidence of considerabIe externa1 bIeeding, even in the presence of tamponade, the indications for prompt bIood repIacement are present. It is difficult, without aspiration, to distinguish between symptoms caused by bIood Ioss and those of tamponade, and they may be coexistent. 8. Again, when externa1 bIeeding has not been excessive, when there is IittIe or no hemorrhage into the pleura in the absence of signs of cardiac tamponade, the possibiIity remains that much of the symptomatoIogy may be due to reff ex vasodilatation, as pointed out by Warren et a1. It is not unreasonabIe that injury to a vita1 organ may be foIIowed by such a sequence of events, but the degree of shock shouId not be deep and the patient shouId be easiIy aroused. Such was not whoIIy the case in any of our patients. REFERENCES I. GRISWOLD, R. A. and MACLXRE, C. H. Penetrating
2. 3.
4.
5.
6.
wounds of the heart and pericardium. Surg. Gynec. eY Obst., 74: 406-418, 1942. ELKIN, D. C. Diagnosis and treatment of cardiac trauma. Ann. Surg., I rq: 16p185, ,941. GOLDBERGER, EMANUEL. A simpIe eIectrocardiographic electrode of zero potentia1, and a technic of obtaining augmented unipolar extremity Ieads. Am. Heart J., 23: 483, 1942. FOULGER, M. and FOULGER, J. H. The bIood pressure and eIectrocardiogram in experimenta pericardial effusion. An. Heart J., 7: 744, 1932. SCHWAB, E. H. and HERRMAN, G. AIterations of the eIectrocardiogram in disease of the pericardium. Arch. Int. Med., 55: 917, 1935. NOTH, P. H. and BARNES, A. R. EIectrocardio-
graphic changes associated with pericarditis. Arch. Int. Med., 65: 291, 1940. SOLOVAY, J., RICE, G. D. and SOLOVAY, H. U. EIectrocardiographic changes in stab and gunshot wounds of the heart. Ann. Int. Med., IS: 465-477. I 94 1. BIGGER, I. A. Wounds of the heart and pericardium. South. M. J., 25: 785-794, 1932. BIGGER, I. A. Heart wounds. J. Tboracic Surg., 8:
II.
239-253, 1939. ELKIN, D. C. Wounds of the heart. Ann. Surg., 120: 817-821, 1944. SCHIEBEL, H. M. Stab wound of the pulmonary artery with suture and recovery. Arch. Surg., 45:
957-963. 1942. NELSON, HARRY. Penetrating wounds of the heart. Arch. Surg., 47: 571-582, 1943. 13. BLAU, M. H. Wounds of the heart. Am. J. M. SC., 210: 252-262, 1945. 14. STRIEDER, J. S. Stab wounds of the heart. J. *. Tboracic Surg., 8: 576, 1939. ‘5. ELKIN, D. C. Suture in wounds of the heart. Ann. Surg., 95: 573, 1932. Research Council. Military SurgicaI 16 National Manuals, Neurosurgery and Thoracic Surgery. P. 255, PhiladeIphia, 1943. W. B. Saunders and co. 17. BLALOCK, A. and RAVITCII, M. hf. Non-operative treatment of cardiac tamponade resulting from wounds of the heart. Surgery, 14: 157-162, 1943. 12.
18. GLASSER, S. T., MERSHEKMER,W. and SHINER, I. Bullet wound of the left cardiac auricIe with suture and recovery. Am. J. Surg., 53: 131-144, 1941. 19. BECK, C. S. Stab wounds: further observations. Ann. Surg., I 15: 698-704, 1942. 20. WARD, T. P. and PARKER, W. G. Penetrating wounds of the heart. Am. J. &u-g., 50: 712-714, 1940. 21. COOPER, F. W., STEAD, E. A. and WARREN, J. V. Beneficial effects of intravenous infusions in acute pericardial tamponade. Ann. Surg., 120: 822, 1944. 22. MERRILL, A. J., WARREN, J. V., STEAD, E. A. and BRANNON. E. S. The circuIation in oenetratina wounds oi the chest: a study by the&method oyf right heart catheterization. Am. Heart J., 31: 413, 1946. 23. BRANNON, E. S., STEAD, E. A., WARREN, J. V. and MERRILL, A. J. Hemodynamics of acute hemorrhage in man. Am. Heart J., 31: 407, 1946. 24. WARREN, J. V., BRANNON, E. S., STEAD, E. A. and MERRILL, A. J. Pericardial tamponade from stab wound of the heart and pericardia1 effusion or empyema: a study utilizing the method of right heart catheterization. Am. Heart J., 31: 418, 1946. 25. GOLDBERGER, EMANUEL. Unipolar Lead EIectrocardiography. Philadelpia, 1947. Lea and Febiger.