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PENETRATING INJURIES TO THE HEART
|These pages are excerpted from the Trauma
Resident Handbook, Rhode Island Hospital Department of Surgery,
Division of Trauma - updated 2001. The policies herein are intended
to serve as guidelines only. Individual circumstances need to
be considered as there may be times when it is appropriate or
desirable to deviate from these guidelines. These educational
guidelines will be reviewed and updated routinely.
Clinical signs of pericardial tamponade in penetrating
cardiac injuries are the exception, rather than the rule.
Paradoxically, pericardial tamponade itself may act protectively,
as patients with cardiac injuries and tamponade had a higher
survival rate than those presenting without tamponade. Thus,
patients who survive the acute stage after penetrating cardiac
trauma (i.e., those who make it to the ED alive) are more likely
to have tamponade. It is critical to identify patients with cardiac
injury (and tamponade) early on, before the protective
effect is lost.
Pericardiocentesis is unreliable in the acute setting of trauma
with a 20% false (+) and false (-) rate. The most sensitive test
for post-traumatic tamponade is (subxiphoid) pericardial window.
This requires general anesthesia in the operating room.3 In patients
who do not require general anesthesia for surgery following penetrating
trauma, the best non-invasive test for cardiac or pericardial
injury is two-dimensional echocardiography. This test is both
sensitive and specific in the patients without hemothorax (100%/89%),
yet is less accurate in the setting of hemothorax (56%/93%).[4,5]
Penetrating cardiac injuries can occur without entrance or
exit wounds in the box- injuries to the heart can
occur from a transmediastinal gunshot wound. A small retrospective
study on gunshot wounds reveal that 40% of these patients present
in extremis with decreased blood pressure and require emergency
operation, with 1/3 of these patients having cardiac injury.
Approximately 60% of these patients present in stable condition,
but anywhere from 20-50% of these patients have injuries to the
heart, mediastinal vessels, bronchus or esophagus that will present
in a delayed fashion. Evaluation of these injuries requires workup
to include echo/pericardial window, angiogram, bronchoscopy and
esophagoscopy / barium swallow.
The box: definition of proximity to the heart for
penetrating injuries. X = wounds that
produced cardiac injuries (Nagy KK, J Trauma 1995)
1. Asensio JA, Stewart BM, Murray J, et al.
Penetrating cardiac injuries. Surg Clin N Am 1996;76:685.
2. Moreno C, Moore EE, Majune JA, et al. Pericardial tamponade.
A critical determinant for survival following penetrating cardiac
wounds. J Trauma 1994;36:229.
3. Trinkle JK, Toon R, Franz JL, et al. Affairs of the wounded
heart: Penetrating cardiac wounds. J Trauma 1979;19:467.
4. Meyer D, Jessen M, Grayburn P. Use of echocardiography to
detect occult cardiac injury after penetrating thoracic trauma:
A prospective study. J Trauma 1995;39:902.
5. Nagy KK, Lohmann C, Kim DO, et al. Role of echocardiography
in the diagnosis of occult penetrating cardiac injury. J Trauma
6. Richardson JD, Flint LM, Small MJ, Gray LA, Trinkle JK. Management
of transmediastinal gunshot wounds. Surgery 1981;90:671-676.
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