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Ann Thorac Surg 1995;60:120-121
© 1995 The Society of Thoracic Surgeons
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Introduction |
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 Top Introduction |
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DR JAMES W. PATE (Memphis, TN):
I enjoyed this beautifully presented paper on an experience with a uniquely low mortality rate. Mortality between series varies tremendously, a fact primarily reflecting weapons used and delays. Our experience leads me to raise a few points.
Is the use of a pump-oxygenator necessary in emergency management of cardiac injuries? I think not; there are catastrophes when patients are transferred to a ``heart center.'' In the last 200+ patients when a pump-oxygenator has been available to our trauma center, it has been used two times for cardiac injuries. In 1 other patient, it may, in retrospect, have been of value. In this smaller series, the authors used extracorporeal circulation in 4 patients. In 1 patient, it was found to be unnecessary, as the foreign body turned out to be loose in the pericardium; in another, an intracardiac foreign body was removed as an emergency (of our six intracardiac foreign bodies, only one embolized, and that occurred late). One patient had aortic penetration and another, injury to the right coronary, which was repaired. There were 4 other patients with coronary injury that was not repaired or bypassed; 2 died before surgical intervention and 2 had ligation without complication. I must conclude that the data do not support the necessity for a pump-oxygenator in the emergency management of cardiac injuries.
Second, is pericardiocentesis useful? There was a dramatic improvement in survival with the introduction of pericardiocentesis for tamponade in the late 1940s. Pericardiocentesis and the indwelling catheter are extremely valuable in buying time and ameliorating shock prior to repair.
Third, is pericardial window useful? It appears that every patient having a window had ``positive'' findings, eg, blood. Almost all had major exploration after the window. Therefore, I am not clear as to the value of the window.
DR JOHNSON:
To address your second question, a total of 2 patients underwent an attempt at pericardiocentesis in the emergency room. One was false-negative and the other, false-positive, with slight improvement in the vital signs noted; however, both patients sustained arrest on arrival in the operating room, thus necessitating incisions under semisterile conditions. We believe that pericardiocentesis has no value in the acute trauma situation.
DR PATE:
The question really is, what is to be gained by doing a pericardial window and then opening the chest?
DR JOHNSON:
It is hard to say exactly how the data would be different if we had not done the pericardial window; however, we think that the pericardial window is not only diagnostic but also therapeutic in that we are able to relieve the tamponade and its myocardial depressant effects and thereby prevent any deterioration in the patient's cardiac status with the initiation of general anesthesia. We think this is probably one of the major contributing factors to our low mortality. However, this was not randomized, and hence it is difficult to say that for sure.
DR FREDERICK L. GROVER (Denver, CO):
I enjoyed your paper very much and compliment you on your presentation. I appreciated the opportunity to review your manuscript in advance and have a couple of points to make.
Although 75% of these injuries were stab wounds and only 25% were gunshot wounds, a mortality rate of only 6% among all patients with some sign of life when taken to the emergency room is very good. As described in the manuscript, the sickest group of patients had a transport time from the scene to the emergency room of 18 to 22 minutes and an average time of 13 minutes from arrival in the emergency room to skin incision. This emphasizes the importance of a well-organized team that can treat such patients very quickly and highlights a major point of Dr Gene Moore's 1994 presidential address to the American Association for the Surgery of Trauma—the importance of having emergency centers that specialize in taking care of acutely injured, very high risk emergency patients. I congratulate you on your results.
DR SAFUH ATTAR (Baltimore, MD):
I congratulate Dr Johnson and associates on their excellent results. My colleagues and I presented our experience in penetrating cardiac injuries at this Society's meeting in 1990. We had 109 penetrating cardiac injuries; 49 were gunshot wounds and 60, stab wounds. Thirty-eight patients were lifeless on admission to the emergency room, 16 were agonal, 33 were in shock, and 22 were in stable condition. Fifty-five patients underwent emergency room thoracotomy with 21 survivors (38%). The survival rate among patients with gunshot wounds was (41%) (20/49) compared with 78% (47/60) for patients with stab wounds.
Dr Johnson, how many agonal or lifeless patients were in your series, how were they treated, and what were the results? Our philosophy at University of Maryland School of Medicine and Hospital, which includes a shock trauma unit as well as the university hospital, is to handle the emergency operation in the emergency room, resuscitate the patient, including emergency thoracotomy, and finish the cardiac repair in the operating room. It is evident that patients with stab wounds who undergo repair in the operating room have a higher survival rate, in our case an 87% survival (47/54) versus a 38% survival (21/55) for patients who required emergency room thoracotomy.
I disagree with your conclusion that your survival rate is due to the pericardial window. I believe that the pericardial window is useless. We have given it up completely except in patients with multiple injuries, where it is done so as not to miss a pericardial or intracardiac injury. Otherwise we consider it a waste of time, and these patients, especially the agonal and the very sick, need immediate attention.
DR JOHNSON:
Patients seen in unstable condition would not undergo pericardial window. They would have either immediate sternotomy or thoracotomy. As for the number of patients reaching our emergency room who were agonal or essentially lifeless on arrival, I cannot answer that. The numbers I quoted were only for those patients who reached the operating room with some signs of life. In our series, three emergency room thoracotomies were performed. We were able to get vital signs back for all 3 and take them to the operating room. Only 1 survived.
DR WATTS R. WEBB (New Orleans, LA):
I second the thoughts of Dr Pate and Dr Attar. My associates and I have had a much higher mortality than Dr Johnson because most of our patients have been wounded by assault weapons. Compared with Dr Johnson, we have seen very few stab wounds.
I compliment Dr Johnson on being able to do the pericardial window safely in this group of patients. Virtually all of our patients are drunk or have a drug overdose, and it is nearly impossible to do anything under local anesthetic. We have not found the pericardial window to be a very useful procedure. We find it takes 10 to 20 minutes, even in skilled hands, and often it is not done by the most skilled hands in the middle of the night. We have had much better success going immediately to thoracotomy, right if the wound is on the right side and left or for median sternotomy if it is on the left side. We use pericardiocentesis as the primary method of evacuating blood to gain a few minutes.
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