Penetrating Cardiac Trauma Experience with Thirty-Four Patients in a Hospital without Cardiopulmonary Bypass Capability

P. Maynard Beach, Jr, MD, Bangor, Maine Diego Bcgnolo, MD, New York, New York John E. Hutchlnson, MD, New York, New York

During the past quarter century great strides have been made in salvaging patients sustaining penetrating cardiac trauma. Although controversy continues regarding the relative merits of pericardiocentesis and early thoracotomy, Maynard and associates 11-31 from the Harlem Hospital emphasized as early as 1952 that an extremely high survival rate could be obtained if individuals with penetrating cardiac injuries were submitted to prompt surgical exploration. Material and Methods During a three year period from July 1,1967 through June 30, 1970, thirty-four consecutive patients showing signs of life on arrivaI at the Harlem Hospital emergency room were treated for penetrating cardiac trauma. The subjects ranged in age from eighteen to sixty-five years. In six instances, the assailants had used a gun. The firearms were all hand guns ranging from the “Saturday night special” to Colt .45. The remaining twenty-eight patients sustained single or multiple stab wounds. In one third of the thirty-four patients, the estimated length of time between injury and arrival at the hospital was recorded by the police or ambulance drivers. This period varied from 15 minutes to 2 hours, the average being 34 minutes. Three of the patients were normotensive and communicative on arrival at the hospital. Seventeen patients were in a state of shock but responsive. Ten were comatose and had unobtainable blood pressure, and four were moribund with agonal respirations. The majority of the wounds of entry were over the left anterior and lateral chest. There were eighteen wounds in the right ventricle, eleven in the left ventricle, three in the right atrium, and two in the left atrium. Two gun-

From theHarlem Hospital Medical Center, New York, New York. Reprint requests should be addressed to P. Maynard Beach, Jr, MD, 43 1 State Street. Bangor, Maine 0440 f Presented at the Fifty-Sixth Annual Meeting of the New England Surgical Society, Portsmouth, New Hampshire, September 25-27, 1975.

voluma 131, rprw 1976

shot wounds were through-and-through. All six subjects wounded by gunshot sustained associated major organ injury. Of the twenty-eight subjects who were stabbed, ten had associated injuries. Four patients underwent laparotomy after cardiorrhapy, with repair of very significant injuries in three patients. The diagnosis of cardiac injury was not made immediately in four patients. Thoracotomy was subsequently performed in each case within 2 to 24 hours, as the diagnosis of cardiac penetration was made. The policy at the Harlem Hospital is to move any individual strongly suspected of having penetrating cardiac trauma to the operating room as soon as possible. If the diagnosis is immediately apparent, time is spent in the emergency room only to obtain a blood sample for crossmatching, insert a central venous catheter, begin infusions, and establish an airway. Other studies, such as chest roentgenograms and electrocardiograms, are performed in the operating room if time permits. We reserve pericardiocentesis as a temporizing measure to decompress the pericardium before operation if hemodynamic deterioration is present or develops. The patient is positioned for thoracotomy, the chest prepared, and the surgical team is scrubbed and gowned before any anesthetic agent is administered. This measure is taken, as not uncommonly patients with cardiac tamponade and hypoxia undergo cardiac arrest if peripheral pressure drops further with induction of anesthesia. We have generally used a left submammary incision and entered the chest through the fifth intercostal space. Additional exposure may be gained by dividing costal cartilages or by extending the incision medially and dividing the sternum. The opening in the pericardium is best made longitudinally, anterior and parallel to the phrenic nerve to avoid injuring that structure. If necessary, the pericardial opening may be carried anteriorly as an inverted “T” incision to gain broader exposure of the heart. Traction on the anterior edge of the pericardium delivers the heart, and the wound is gently occluded by the surgeon’s finger as mattress sutures are placed in the myocardium. Before closing the pericardium the surgeon should always carefully palpate the diaphragmatic aspect of the heart to be sure that no cryptic wound of exit exists.

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TABLE I

Associated Injuries Injury

Weapon Gun

Liver, aorta

Gun Gun Gun Gun Gun

Lung Lung Lung Aorta Right pulmonary

Knife Knife Knife Knife Knife Knife Knife Knife Knife Knife

Abdomen, negative exploration Duodenum, jejunum Liver Lung Liver, gallbladder Lung Omentum Lung Lung Diaphragm

vein

Outcome Died Survived Survived Died Died Survived Survived Survived Survived Survived Survived Survived Survived Survived Survived Survived

Results All patients survived surgery, but eight subjects subsequently died while hospitalized, yielding an overall mortality of 23 per cent. Three of the six patients (50 per cent) sustaining gunshot wounds died. Of the twenty-eight individuals receiving stab wounds, five (18 per cent) died. Respiratory complications developed in five survivors and were easily controlled with appropriate tracheobronchial toilet and antibiotics. Although significant coronary artery injuries were controlled by ligation in three patients, only one had electrocardiographic documentation of myocardial infarction. Three surviving patients were subsequently operated on elsewhere for repair of intracardiac defects produced by the injury. Analysis of Deaths

Of the eight patients who did not survive, four were moribund and three were in coma with unobtainable blood pressure on arrival at the hospital. Immediate pericardiocentesis was performed on each of these seven patients. Failing that measure, the four moribund patients were submitted to immediate and futile thoracotomy in the emergency room. Three of these subjects had hemothoraxes of 2,000 to 3,000 cc, and two patients had associated lacerations of the descending aorta. The fourth patient undergoing immediate thoracotomy had a 4 cm rent in the left ventricle with 300 cc of intrapericardial liquid blood and clot severely compressing the heart. Hemodynamic stability was established temporarily in each case, but all four patients were dead within one month of cerebral anoxia and its sequelae.

412

Three of the four remaining subjects who died were comatose with unobtainable blood pressure on arrival and did not respond to initial resuscitation. All underwent thoracotomy within 15 minutes of arrival, and although temporary stability was achieved, cardiac output progressively failed and all died of cardiogenic shock. We consider these seven deaths as unavoidable. We believe that their condition on arrival precluded successful cerebral and myocardial recovery. The one remaining mortality, however, might have been prevented if myocardial decompression had been performed sooner. Comments

Cardiac tamponade as encountered in patients with penetrating trauma may vary greatly. However, once progressive and unrelenting compression develops, a fatality is the rule unless the process is reversed. The pathologic cornerstone is compression of the heart during diastole. Intraventricular pressures increase, thereby increasing the venous pressure required to fill the right heart. As diastolic blood volumes decrease, cardiac output declines despite maximal emptying during systole. In a previously well patient sustaining a penetrating wound of the heart, as little as 150 to 200 ml of blood in the pericardial space readily produces acute tamponade. The characteristic clinical appearance is that of an individual in shock but with distended neck veins, betraying a high venous pressure. Typically the subject is restless and dusky with hypotension and narrowed pulse pressure. Peripheral pulses are absent, urine output is zero, and heart sounds are distant. Chest x-ray film generally shows a transformation of the left cardiac border from the usual concavity to either a “straightening” or convexity. Fluoroscopy demonstrates attenuated pulsations of the cardiac silhouette. The historical setting, when coupled with these clinical and roentgen findings, makes the diagnosis a near certainty. In patients sustaining penetrating wounds of the chest, the surgeon must be aware of the possibility of cardiac involvement, regardless of how remote the wound of entry is from the precordial’region. If the above criteria are met, we proceed with thoracotomy immediately as previously indicated. Among the factors that determine the course of events are the size of the cardiac wound and which chamber is involved. Openings of 1 cm or more are less apt to clot and generally tend to continue bleeding. The right sided cardiac chambers are under low pressure and therefore tend to bleed the

The

American Jwrnal cl Surgery

Penetrating Cardiac Trauma

TABLE II

Arrival Status and Time to Surgery Related to Survival

Time to Surgery Immediate thoracotomy in emergency room 0 to 15 min 15 to 30 min 30 to 60 min 60 to 120 min Greater

than 2 hr

Total

No. of Patients

No. Surviving

4

0

8 8

5 (63%)

6 4 4 34

5 (83%) 4 (100%) 4 (100%) 26

the right ventricle, which has a relatively thick muscular wall that becomes occlusive during systole. The thin walled atria1 chambers have very low occlusive potential, and bleed readily even from small puncture wounds. Large left ventricular defects under high pressure are the most troublesome. Patients succumbing in this series all had large defects ranging from 1.5 to 4.0 cm, half of which were in the left ventricle. The clinical status of a patient at the time of arrival at the hospital has a significant effect on the ultimate outcome. The survival rate in this series of patients was positively related to the viability of the subjects at the time of hospital arrival. All three normotensive patients survived, together with sixteen of seventeen patients (94 per cent) in shock and responsive, and seven of ten patients (70 per cent) in coma with zero blood pressure. None of the four moribund patients survived. Table II relates arrival status and time to corrective surgery with survival. The fact that seven of the eight fatalities occurred in subjects operated on the earliest is a reflection of the dismal clinical status of those patients at the time of arrival. It is noteworthy that approximately half the surviving patients had transport times (time from injury to hospital) averaging 34 minutes, whereas the transport time was not known in any of the patients that died. Concomitant injuries frequently affect overall survival. In this series all patients sustaining gunshot wounds had associated injuries (Table I), and in two thirds of those dying from gunshot wounds, the aortic rents were considered the primary cause of death. All ten patients with associated injuries from stab wounds survived.

Summary A review of thirty-four consecutive penetrating wounds of the heart is presented. Thirty-one patients were in shock at the time of admission, and

131. Aprll 1978

Zero Blood Shock Pressureand Responsive Come

Moribund 4

8 (100%)

least, particularly

vm

Normal Blood Pressure

1

2 3

4

4

5 4 4

2 2 2

17

ld

4

fourteen had no obtainable blood pressure and were comatose or moribund. The weapon used, clinical status of the patient on arrival, size of the cardiac wound, and presence of associated injuries affected the mortality rate. Seven of the eight deaths were considered unpreventable due to clinical deterioration by the time of arrival. Clinical recognition of cardiac tamponade is stressed. Early open thoracotomy and closure of the cardiac wound is advocated as the preferred method of treating this injury. No patient was lost due to lack of cardiopulmonary bypass capability. References 1. Maynard A deL, Cordice JWV. Naclerio EA: Penetrating wounds of the heart: a report of 81 cases. Surg Gynecol Obstet 94: 605, 1952. 2. Maynard A deL, Avecilla MJ, Naclerio EA: The management of wounds of the heart: a recent series of 43 cases with comment on pericardiocentesis in hamcpericardium. Ann Surg 144: 1018,1956. 3. Maynard A deL, Brooks HA, Froix CJ: Penetrating wounds of the heart. Arch Surg 90: 680, 1965.

Discussion

William W. L. Glenn (New Haven, CT): I enjoyed very much this discussion of. these very difficult cases as they were handled in a hospital without facilities for cardiopulmonary bypass, and I think the authors’ results are commendable. I was interested, however, in the fact that a number of these cases that were moribund on arrival at the hospital did not survive a thoracotomy, even in the emergency room, and I wondered, in view of the increasing trauma that is being seen now throughout the country, whether it would be advisable to make available in the emergency rooms-particularly of the larger hospitals-facilities for thoracotomy under the most ideal circumstances. Certainly, some of the hospitals are already developing these facilities and I wonder if the authors have any idea whether their cases might have fared better had the facilities been adequate for thoracotomy in the emergency room. Also, did the authors consider or use autogenous blood that was shed in the chest?

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Gerald 0. Strauch (Stamford, CT): One of the prices that we apparently have to pay for improved survival and successful resuscitation of patients with cardiac injuries is some rather bizarre postinjury complications. Our last patient with a right ventriuclar wound had classic diabetes insipidus after cardiorraphy. This has been reported previously and seems to be a function of the profound central hypoperfusion associated with the cardiac injury and the resuscitative effort. I wonder whether the authors have encountered this and, if so, what the outcome was. P. Maynard Beach, Jr (closing): In reply to Doctor Glenn, we did not use autogenous blood in these patients. Use of such material might have benefited the two patients with concomitant aortic injuries. As noted in the presentation, we had information on transit time from injury to hospital arrival in at least

half the subjects who survived but in none of those who died. I am not sure these data are significant. The four patients who were moribund on arrival were resuscitated in the standard fashion. All had pericardiocentesis immediately without improvement. Whether or not availability of an operating room adjacent to the emergency room would have improved our mortality is problematic. I doubt that it would. That is not to fault the idea, however. We did have such a facility at the Presbyterian Hospital of New York, which was used in just such instances. These patients were operated on at the Harlem Hospital, and there was no pump oxygenator capability. Regarding Doctor Strauch’s comments, we did not encounter the metabolic and biochemical derangements to which he alluded. Indeed, among surviving patients, the hospital courses were remarkably benign with all subjects leaving the hospital within ten days.

lhe American Journal

of Surgery

Penetrating cardiac trauma. Experience with thirty-four patients in a hospital without cardiopulmonary bypass capability.

A review of thirty-four consecutive penetrating wounds of the heart is presented. Thirty-one patients were in shock at the time of admission, and four...
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