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Ann Thorac Surg 1995;60:117-120
© 1995 The Society of Thoracic Surgeons

Penetrating Intrapericardial Wounds: Clinical Experience With a Surgical Protocol

Department of Cardiothoracic Surgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. From 1972 to 1977, a treatment protocol was developed at our institution for patients with suspected penetrating intrapericardial wounds. It consists of immediate transport to the operating room, pericardial decompression by subxiphoid pericardial window under local or light general anesthesia in patients in stable condition, and median sternotomy and operative repair with limited use of cardiopulmonary bypass.

Methods. The records of 79 consecutive patients with acute penetrating intrapericardial injury who underwent operation from March 1978 to July 1991 were reviewed. There were 59 patients (75%) with stab wounds and 20 (25%) with gunshot wounds. Wound location was as follows: right ventricle, 33 (42%); left ventricle, 28 (35%); multiple sites, 8 (10%); atrium, 5 (6%); and great vessels, 5 (6%).

Results. Subxiphoid pericardial window was performed under local or light general anesthesia in 53 patients (67%). Cardiopulmonary bypass was required in only 4 patients. Overall mortality was 6%.

Conclusion. Approach to a trauma victim must be systematic. We believe one treatment protocol for patients with suspected penetrating intrapericardial wounds is effective.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 120.

Intrapericardial injury can cause cardiac tamponade, shock, and exsanguination and death if not rapidly treated. Over the last several years, a protocol has been developed at our institution to treat trauma patients with suspected penetrating intrapericardial wounds. This protocol comprises the following: (1) stabilization of vital signs; (2) control of exsanguinating hemorrhage; (3) prompt transport to the operating room followed by subxiphoid pericardial window with decompression under local or light general anesthesia; (4) cardiac or great vessel repair or both using simple techniques when possible; and (5) limited use of cardiopulmonary bypass (CPB) [1]. The purpose of this study is to report our experience with this treatment protocol and to determine whether it has resulted in acceptable morbidity and mortality.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patient Population
The charts of patients who underwent operation for penetrating intrapericardial wounds at Medical Center Hospital in San Antonio from March 1978 to August 1991 were reviewed. Data gathered included sex, age, mode of injury, and initial physical findings and hemodynamics. Results of radiologic studies and electrocardiograms were reviewed. Indications, urgency, and type of operation or operations were noted, as was the time from emergency room admission to operative intervention. The need for CPB in relation to the location or locations of intrapericardial injuries was assessed, as were associated injuries and overall morbidity and mortality.

Operative Strategy
A brief history that includes the wounding weapon and the time of injury is obtained, and a physical examination is performed on all patients with suspected penetrating intrapericardial injury on arrival at our emergency department. Oxygen is administered and intubation performed only if needed for assisted ventilation. Large-bore peripheral intravenous lines are placed percutaneously or by cutdown for rapid fluid resuscitation. A central venous pressure line is also placed and a Foley catheter, inserted. If the patient's condition is stable, an electrocardiogram and an upright inspiratory chest roentgenogram are obtained. Indications for immediate tube thoracostomy include hypotension, respiratory distress, and clinical or radiologic evidence or both of major hemothorax or pneumothorax. The patient is immediately taken to the operating room for thoracotomy if he or she has an initial output of more than 1 L of blood or continued blood loss (>200 mL/h) from a chest tube or critical residual hemothorax radiographically despite functioning chest tubes. Emergency department thoracotomy is reserved for patients with signs of life either in the field or on arrival who lose vital signs en route to the hospital or while in the emergency department despite aggressive attempt at cardiopulmonary resuscitation.

Patients in unstable condition undergo immediate thoracotomy or sternotomy. Stabilized patients with suspected cardiac injury undergo both diagnostic and therapeutic subxiphoid window with pericardial decompression under local or light general anesthesia in the operating room. The patient is placed in the supine position on the operating table, and arterial monitoring is begun. The patient is prepared and draped from the chin to the pubis with the arms tucked. The skin and the subcutaneous tissue in the subxiphoid region are infiltrated with local anesthetic. Light mask anesthesia or intravenous sedation may be necessary, depending on patient tolerance. A relatively short (approximately 8 to 10 cm) subxiphoid skin incision is made. The fascia is identified and additional local anesthetic administered. A grasping clamp is used to carefully lift the xiphoid upward to facilitate the development of a substernal plane. The anterior pericardium is identified and grasped, and traction sutures are placed in the shelving edge where the pericardium meets the diaphragm. A small incision is then made under direct vision. If the window confirms an intrapericardial injury, the pericardial space is decompressed, general endotracheal anesthesia is initiated, and the incision is extended into a median sternotomy.

Techniques of Repair
The pericardium is opened widely. Inflow occlusion may be necessary to control exsanguinating hemorrhage and decompress the heart, although digital pressure is usually all that is required. Injuries are identified, and clot is removed. An assessment of wound location, depth, and extent is made. A search for foreign bodies is done. The need of CPB is assessed, and if necessary, appropriate resources are mobilized.

Simple injuries of the myocardium are repaired with large, Teflon-reinforced mattress sutures. This helps to prevent tearing of the myocardium. Injuries to the atria, venae cavae, and aorta can frequently be controlled with a side-biting vascular clamp and repaired at leisure. It is important to avoid inotropic agents (eg, epinephrine) and to induce controlled hypotension when repairing high-pressure wounds of the left ventricle and aorta. Repair of injured proximal coronary arteries such as the left anterior descending coronary artery proximal to the first septal perforator may require CPB; injured distal coronary vessels can be ligated. Repair of injuries to the great vessels and removal of intracardiac foreign bodies may or may not require CPB depending on their location. The vast majority of injuries are repaired without the use of CPB.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
A total of 79 patients who underwent surgical intervention for intrapericardial injury during the study period were identified. Seventy-six (96%) were male. Age ranged from 4 to 70 years (mean age, 29 years). There were 59 patients with stab wounds and 20 patients with gunshot wounds, 3 of whom sustained shotgun wounds.

Fifteen patients were admitted without obtainable blood pressure. Six of them responded to initial fluid therapy, and 9 were transient responders or nonresponders (systolic blood pressure <80 mm Hg). Transport time from accident scene to emergency department was 18 to 22 minutes for 8 of these 9 patients. The other patient arrived as a transfer from an outside hospital 6 hours after injury and was in stable condition until just prior to arrival. The time interval from admission to the emergency center until skin incision in these 9 patients ranged from 2 to 40 minutes (average time, 13 minutes). Three of the 9 underwent thoracotomy in the emergency department, and 1 underwent thoracotomy en route to the operating room. The remaining hypotensive patients were quickly transported to the operating room where 2 of them sustained arrest on arrival, thereby necessitating incision under semisterile conditions. Both of these patients had undergone an attempt at decompressive pericardiocentesis in the emergency department; one was false-negative and one, false-positive with ``slight'' improvement noted in vital signs. Two additional patients who were initially in stable condition sustained arrest on induction of general anesthesia.

Fifty-three patients underwent placement of preoperative central venous pressure monitoring lines. Forty-one (77%) had a central venous pressure greater than 20 cm H₂O. Only 17 of these 41 patients, however, had documented jugular venous distention on physical examination.

Chest roentgenography was performed on 60 patients: 36 had either hemothorax or pneumothorax; 13 were normal; 6 showed an increase in size of the cardiac silhouette; 3 had projectiles overlying the cardiac shadow; and 2 had mediastinal widening. These last 2 patients underwent angiography, which confirmed ascending aortic injuries. A third angiogram was made for proximity of shotgun pellets and was negative.

Electrocardiograms were generally nonspecific when obtained. One was interpreted as positive for ``inferior ischemia'' and another as positive for third-degree atrioventricular block in 2 of 8 patients with proven cardiac injuries. Two patients, who subsequently died of myocardial failure from proximal coronary artery injuries, had preoperative electrocardiograms interpreted as ``within normal limits—no acute changes.''

Indications for operation included the following: cardiac tamponade, 29 (37%); tamponade with shock, 19 (24%); exsanguinating hemorrhage 3 (4%); and hemorrhage with shock, 17 (22%). Nine patients underwent surgical intervention for wound proximity only; 4 of them were thought to have intracardiac foreign bodies. Two patients underwent median sternotomy for confirmed aortic injuries.

Fifty-three patients underwent diagnostic or therapeutic subxiphoid pericardial window or both under local or light general anesthesia. Three of these patients had an obvious nonbleeding epicardial injury near the site of the window, thus making further cardiac exploration unnecessary. The remaining 50 patients underwent superior extension of their incisions into median sternotomies. Table 1 lists the operations performed.

Locations and frequencies of injuries are shown in Table 2. Five patients had injuries to major branches of the coronary arteries. One patient sustained an injury to the right ventricle and a laceration of the right coronary artery as just described. Four patients sustained injuries to branches of the left coronary artery as well as to the left ventricle. Two of these patients died intraoperatively of myocardial failure, and the other 2 survived simple ligation of the injured coronary vessel and myocardial repair.

Thirty-two clinically significant postoperative complications occurred in 20 patients. Complications included wound infection, pericardial effusion, and pleural effusion (five each); nonfatal cardiac arrest, anoxic brain injury, arrhythmia, sepsis, pneumonia, and pericarditis, (two each); and myocardial infarction, empyema, urinary tract infection, bundle-branch block, and pancreatitis (one each). One patient who underwent emergency department thoracotomy eventually required a second thoracotomy with decortication and tracheostomy. One patient required emergent opening of the median sternotomy wound in the intensive care unit to relieve cardiac tamponade. Another patient, who eventually died of multiorgan system failure related to multiple abdominal stab wounds, subsequently underwent multiple abdominal explorations to debride infected or necrotic tissue. Four ventricular septal defects were diagnosed postoperatively, and one became hemodynamically important, requiring reoperative repair 7 weeks after injury. One mitral valve and one tricuspid valve injury were diagnosed postoperatively in separate patients; the mitral valve injury became hemodynamically important and required reoperative replacement 2 months after injury.

There were a total of five deaths in the series, three due to gunshot wounds and two to multiple stab wounds. Four patients died intraoperatively. Two of them had coronary artery injuries as well as left ventricular injuries. One of these patients, a 70-year-old woman, had been picked up by emergency medical services for ``mental confusion'' and was taken to another hospital prior to being sent to our institution. On arrival, a gunshot wound was found. The bullet had entered the right side of the chest at the posterior axillary line, and the chest roentgenogram showed it near the left diaphragmatic sulcus. Time delay from injury to diagnosis was approximately 6 hours. The other 2 patients arrived in the emergency department with agonal respirations after close-range gunshot wounds. Each was taken to the operating room after having undergone emergency department thoracotomy where large aortic and left ventricular injuries were found. Both patients exsanguinated before repair of these injuries could be performed. The remaining death occurred 2 months postoperatively and was due to overwhelming sepsis from multiple concomitant abdominal injuries as described previously. Mortality by site of injury was as follows: left ventricle with aorta, 2/2 (100%); left ventricle with coronary artery, 2/5 (40%); and right ventricle, 1/33 (3%).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
During the preceding period 1968 to 1977, a total of 100 patients with penetrating intrapericardial injuries were treated at our institution with an overall mortality of 11% (11/100) [1]. This has dropped to 6% for the current study period and compares quite favorably with the mortality rates in other reported series [2, 3]. Contributing factors may include better emergency medical services, education, and transportation; advances in understanding and treatment of hemorrhagic shock and pericardial tamponade; and earlier operation.

Cardiac tamponade can be fatal within minutes. A subxiphoid pericardial window is done to confirm the diagnosis of intrapericardial injury and cardiac tamponade [1, 4, 5]. Echocardiography, pericardiocentesis, and chest roentgenography are all unreliable in the acute trauma setting [1, 6, 7]. Poor cardiac output and shock occur rapidly and are related to both compromised atrial filling and depressed myocardial contractility [8]. Cardiovascular stability in this setting is largely dependent on reflexive compensatory mechanisms. These mechanisms include peripheral arterial and venous vasoconstriction, intravascular volume conservation, and increased chronotropism. General anesthesia may inhibit these reflexes and promote cardiac arrest. Rapid relief of the tamponade with control of hemorrhage and replacement of blood volume are essential to a successful outcome. Our protocol, which emphasizes decompression of the tamponade under local or light general anesthesia through a subxiphoid pericardial window, may prevent cardiac arrest during induction of general anesthesia in the compromised patient.

Indications for the use of CPB in the acutely injured patient are proximally injured coronary arteries, such as an injury to the left anterior descending coronary artery proximal to the first septal perforator, removal of intracardiac foreign bodies, and repair of difficult ascending aortic injuries. The use of CPB, however, may lead to severe hemorrhage when associated injuries are present; CPB therefore should be used judiciously in this setting. Factors that may contribute to our low mortality include limited use of CPB and simple repair of cardiac injuries when possible. Although there were four ventricular septal defects and two valvular injuries diagnosed postoperatively, only two of these injuries required reoperative repair, and all of the patients survived. As suggested by our data, valvular injuries, septal injuries, or both may be best repaired electively if indicated.

The most frequently injured cardiac chamber in our series was the right ventricle (42%) followed by the left ventricle (35%). Four of five deaths occurred in patients with thoracic aortic or combined left ventricular and coronary injuries. All patients in our series with isolated cardiac wounds not involving the major coronary arteries survived; in contrast, patients with thoracic aortic or combined ventricular and proximal coronary artery injuries had a high mortality. Likewise, gunshot wounds carried a higher mortality (15%) than stab wounds (3%), which is consistent with other previous reports.

Approach to any trauma victim must be systematic. A majority of patients with intrapericardial injuries sustain associated injuries that can easily be overlooked or undertreated while the more obvious and dramatic intrapericardial injury is treated. A systematic approach to these patients is necessary so that other potentially life-threatening injuries are treated appropriately and in a timely fashion.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Forty-first Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 10–12, 1994.

Address reprint requests to Dr Miller, Department of Cardiothoracic Surgery, University of Texas Hospital, The University of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78284-7841.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Trinkle JK, Toon RS, Franz JL, Arom KV, Grover FL. Affairs of the wounded heart: penetrating cardiac wounds. J Trauma 1979;19:467–72.[Medline]
2. Marshall WG Jr, Bell JL, Kouchoukos NT. Penetrating cardiac trauma. J Trauma 1984;24:147–9.[Medline]
3. Mandal AK, Oparah SS. Unusually low mortality of penetrating wounds of the chest. J Thorac Cardiovasc Surg 1989;97:119–25.[Abstract]
4. Brewster SA, Thirlby RC, Snyder WH III. Subxiphoid pericardial window and penetrating cardiac trauma. Arch Surg 1988;123:937–41.[Abstract]
5. Andrade-Alegre R, Mon L. Subxiphoid pericardial window in the diagnosis of penetrating cardiac trauma. Ann Thorac Surg 1994;58:1139–41.[Abstract]
6. Bolton JWR, Bynoe RP, Lazar HL, Almond CH. Two-dimensional echocardiography in the evaluation of penetrating intrapericardial injuries. Ann Thorac Surg 1993;56:506–9.[Abstract]
7. Harvey JC, Pacifico AT. Primary operative management: method of choice for stab wounds to the heart. South Med J 1975;68:149–52.[Medline]
8. Friedman HS, Lajam F, Gomes JA, et al. Demonstration of a depressor reflex in acute cardiac tamponade. J Thorac Cardiovasc Surg 1977;73:278–86.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Scott B. Johnson James L. Nielsen Edward Y. Sako John H. Calhoon Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Johnson, S. B. Articles by Miller, O. L. Search for Related Content PubMed PubMed Citation Articles by Johnson, S. B. Articles by Miller, O. L. Related Collections Related Article