Penetrating cardiac injuries and the evolving management algorithm in the current era

Abstract

Background

Penetrating cardiac injuries carry a significant mortality, especially if operative intervention is delayed because of diagnostic difficulties.

Methods and materials

We reviewed our experience of 134 consecutive cases over a 6 year period. For the initial 5 years, the diagnosis was based on clinical grounds only. During the final year of study, focused ultrasound focused abdominal sonar for trauma (FAST) and subxiphoid pericardial window were introduced.

Results

Ninety-six per cent (128/134) were males and the overall mean age was 27 y. Eighty-four per cent (112/134) sustained isolated cardiac injury and the remaining sixteen per cent (22/134) had concurrent injuries elsewhere. A total of 10 FAST's were performed and the sensitivity was 20%. Fifteen subxiphoid pericardial window were performed (8 had diagnostic uncertainty, 2 with double jeopardy, and 5 with delayed tamponade) and had a sensitivity of 100%. The survival rate for the 109 patients from the pre-adjunct period was 83% and 88% for the 25 patients in the post-adjunct period, which was not statistically significant (P value = 0.765). There was no significant difference in the complication rate, mean intensive care unit stay, or mean total hospital stay.

Conclusions

Penetrating cardiac injuries are highly lethal. A high index of suspicion, coupled with early operative intervention remains the key in securing the survival of these patients.

Introduction

Penetrating cardiac injuries are highly lethal, and less than 10% of victims will reach hospital alive [1], [2]. Once in hospital, rapid diagnosis and operative intervention is the key to patient survival [3], [4]. In the past, the diagnostic workup of patients with a suspected penetrating cardiac injury was predominantly clinical [5]. Over the last decade, however, a number of new diagnostic and therapeutic modalities have been introduced [6]. The two that have impacted most on the management of these patients have been focused ultrasound scanning Focused abdominal sonar for trauma (FAST) and the subxiphoid pericardial window (SPW). FAST has become widely available and has been applied to the investigation of patients with potential cardiac injuries [7]. Recent work by Nicol et al. [8], [9], [10] from Cape Town has rekindled interest in the use of the SPW to confirm or exclude the presence of a hemopericardium. SPW may be both diagnostic and therapeutic in a defined cohort of patients [9].

As is often the case in surgical practice, new techniques and investigations are adopted in an ad hoc pattern in response to local conditions. This phenomenon of “organic evolution” often leads to management algorithms subtly changing and morphing without there being a formal directive. The adoption in South Africa of the philosophy of selective conservatism in trauma was in direct response to chronic resource constraints in face of a huge burden of trauma and is perhaps the best-known example of this so-called “organic evolution” [11]. There can be little doubt that the approach to penetrating cardiac injury in our service has “organically evolved” in tandem with these developments over the last half decade. In light of this, we reviewed our management of these patients over a six year period and describe the incorporation of new adjuncts (both FAST and SPW) into our management algorithm. The objective of this study was to describe the spectrum of penetrating cardiac injury and provide a better understanding of the difference in clinical outcome after the introduction of FAST and SPW. We that the survival rate may be higher with the introduction of new adjuncts as it will reduce delay to operative intervention previously attributed to diagnostic uncertainty.