Open access Original article Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2018-000187 on 30 August 2018. Downloaded from Selective use of pericardial window and drainage as sole treatment for hemopericardium from penetrating chest trauma Paul J Chestovich, Christopher F McNicoll, Douglas R Fraser, Purvi P Patel, Deborah A Kuhls, Esmeralda Clark, John J Fildes ► Additional material is ABSTRact Up to 94% of patients with PCI die on the scene published online only. To view Background Penetrating cardiac injuries (PCIs) are prior to hospital presentation,4 and the mortality of please visit the journal online patients arriving at trauma centers with signs of life (http:// dx. doi. org/ 10. 1136/ highly lethal, and a sternotomy is considered mandatory 3 5 6 tsaco- 2018- 000187). for suspected PCI. Recent literature suggests pericardial ranges from 17% to 58%. Due to the life-threat- window (PCW) may be sufficient for superficial cardiac ening physiologic changes caused by these injuries, Division of Acute Care Surgery, injuries to drain hemopericardium and assess for including pericardial tamponade and hemorrhagic Department of Surgery, continued bleeding and instability. This study objective shock, management for PCIs has focused on rapid University of Nevada Las Vegas School of Medicine, Las Vegas, is to review patients with PCI managed with sternotomy assessment and therapeutic maneuvres. Due to Nevada, USA and PCW and compare outcomes. this potential for rapid hemodynamic decline, the Methods All patients with penetrating chest trauma standard management for suspected PCI has been Correspondence to from 2000 to 2016 requiring PCW or sternotomy were a sternotomy to relieve tamponade and repair any Dr Paul J Chestovich; paul. reviewed. Data were collected for patients who had PCW cardiac or great vessel injuries.7 chestovich@ unlv. edu for hemopericardium managed with only pericardial Although many patients die in the field or present Presented on March 7, 2017 drain, or underwent sternotomy for cardiac injuries in extremis, some patients with PCI have a benign at the 47th Annual Meeting of grade 1–3 according to the American Association for presentation and are hemodynamically stable on the Western Trauma Association the Surgery of Trauma (AAST) Cardiac Organ Injury Scale arrival to a trauma center.8 These patients have at the Cliff Lodge in Snowbird, (OIS). The PCW+drain group was compared with the minor cardiac or pericardial injuries resulting in Utah. Sternotomy group using Fisher’s exact and Wilcoxon hemopericardium, but bleed very slowly or stop copyright. Received 24 April 2018 rank-sum test with P<0.05 considered statistically completely. These stable patients allow time for Revised 24 June 2018 significant. more detailed diagnostic workup and less invasive Accepted 25 June 2018 Results Sternotomy was performed in 57 patients for management strategy. Furthermore, a sternotomy is suspected PCI, including 7 with AAST OIS grade 1–3 a highly morbid procedure,4 9 10 and performing one injuries (Sternotomy group). Four patients had pericardial in a trauma patient with benign PCI may subject injuries, three had partial thickness cardiac injuries, two them to unnecessary complications. Recent studies, of which were suture-repaired. Average blood drained including a randomized controlled trial (RCT) was 285 mL (100–500 mL). PCW was performed in 37 performed by Nicol et al,11 have demonstrated patients, and 21 had hemopericardium; 16 patients that patients with PCI and a benign presentation proceeded to sternotomy and 5 were treated with may be successfully managed with PCW provided pericardial drainage (PCW+drain group). All PCW+drain they maintain hemodynamic stability and achieve http://tsaco.bmj.com/ patients had suction evacuation of hemopericardium, cessation of bleeding.11–14 The pericardial window pericardial lavage, and verified bleeding cessation, (PCW) serves to drain the pericardium and relieve followed by pericardial drain placement and admission any potential tamponade. If bleeding ceases and the to intensive care unit (ICU). Average blood drained patient remains stable, sternotomy may be avoided. was 240 mL (40–600 mL), and pericardial drains were Our trauma center has adopted a selective prac- removed on postoperative day 3.6 (2–5). There was no tice of performing initial PCW, lavage, and drainage for patients with suspected PCI, hemodynamic significant difference in demographics, injury mechanism, on September 26, 2021 by guest. Protected Revised Trauma Score exploratory laparotomies, hospital stability, and pericardial fluid on the cardiac view or ICU length of stay, or ventilator days. No in-hospital on the Focused Assessment with Sonography for mortality occurred in either group. Trauma (FAST) examination. This report aims to Conclusions Hemodynamically stable patients with describe our experience in treating this select group penetrating chest trauma and hemopericardium may be of PCI patients and compare outcomes with simi- safely managed with PCW, lavage and drainage with larly injured patients undergoing sternotomy. We © Author(s) (or their documented cessation of bleeding, and postoperative hypothesized that the stable PCI patients under- employer(s)) 2018. Re-use ICU monitoring. going a PCW and drainage would have no differ- permitted under CC BY-NC. No Level of evidence Therapeutic study, level IV. ence in mortality, ventilator days, hospital length commercial re-use. See rights of stay (LOS), or intensive care unit (ICU) LOS and permissions. Published by BMJ. compared with those who underwent a sternotomy. To cite: Chestovich PJ, BACKGROUND McNicoll CF, Fraser DR, et al. Penetrating chest trauma is one of the most lethal METHODS Trauma Surg Acute Care Open mechanisms incurred by patients, and penetrating This project was approved by our Institutional 2018;3:e000187. cardiac injuries (PCIs) are among the most fatal.1–3 Review Board after an expedited review. A waiver Chestovich PJ, et al. Trauma Surg Acute Care Open 2018;3:e000187. doi:10.1136/tsaco-2018-000187 1 Open access Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2018-000187 on 30 August 2018. Downloaded from of informed consent was obtained. The trauma registry at our Table 1 All patients with penetrating chest trauma receiving either a American College of Surgeons-verified level 1 trauma center was pericardial window, sternotomy, or both extracted to create a database including all patients with cardiac injuries from 2000 to 2016. This database was queried for all N=78 patients suffering penetrating chest injury who received a PCW, a Male, n (%) 73 (93.6) median sternotomy, or both. Patients who underwent left antero- Age (years), median (IQR) 29 (24–39) lateral or clamshell thoracotomy, and those who required cardio- Mechanism pulmonary resuscitation prior to intervention, were excluded. Gunshot wound, n (%) 28 (35.9) A review of the medical records obtained additional details of Knife stab wound, n (%) 47 (60.3) the operative procedure(s), cardiac injury, quantity of pericardial drainage, and type of drain(s) placed. The Revised Trauma Score Admission vitals (RTS) was calculated retrospectively.15 For patients who under- Systolic blood pressure, median (IQR) 130 (85–149) went sternotomy, the operative details were reviewed and the Heart rate, median (IQR) 107 (88–121) American Association for the Surgery of Trauma (AAST) Cardiac Glasgow Coma Scale, median (IQR) 15 (9–15) 16 Organ Injury Scale (OIS) was analyzed retrospectively. The Exploratory laparotomy, n (%) 42 (53.8) AAST Cardiac OIS was unable to be analyzed for patients who Hospital LOS (days), median (IQR) 7 (4–11) only underwent PCW and drainage since the heart was not fully ICU LOS (days), median (IQR) 2 (1–5) visualized. Postoperative course and hospital resource utilization details, including use of echocardiogram were enumerated for Ventilator days (days), median (IQR) 0 (0–1) all patients. Hospital mortality, n (%) 16 (20.3) Patients who underwent initial PCW were classified as positive ICU, intensive care unit; LOS, length of stay. on the presence of hemopericardium, or negative for the absence of blood. All patients who had a PCW window and underwent drainage and lavage, but did not require a sternotomy, were patients had suction evacuation of hemopericardium pericardial included in the PCW+drain group. Patients who underwent lavage, and documented cessation of intraoperative bleeding, both pericardial window and sternotomy were included in the followed by pericardial drain placement and admission to ICU. sternotomy group. All PCW+drain patients were hemodynami- Of the 57 patients who required sternotomy, 50 patients had cally stable with systolic blood pressure over 100 mm Hg. Ster- cardiac OIS of 4–6 or suffered other major injuries, and were notomy patients were classified per their AAST OIS. Patients excluded from the sternotomy comparison group. The pathway describing the patients reviewed for this study is illustrated in with AAST OIS 1–3 were included in the Sternotomy group, copyright. and patients with OIS 4–6 were excluded. Patients with OIS 1–3 figure 1. Details of injuries to this group include 26 patients with were included because these are not full thickness injuries and OIS 4, 16 patients with OIS 5, 5 patients with OIS 6, and 2 may not require surgical repair,13 and were suspected to have patients with OIS 0 but had major thoracic vessel injuries (one similar injury pattern to the PCW+drain group. Patients with inferior vena cava, one aorta). extracardiac injuries were included provided they were not Comparisons between the PCW+drain and Sternotomy immediately fatal and adequate surgical repair was achieved. groups are shown in table 2. All patients in the PCW+drain group had their procedure There was no significant difference in age, gender, injury performed in the operating room under general anesthesia. If mechanism, exploratory laparotomies, presentation vital hemopericardium was detected during the PCW, a soft 16 F red signs and Glasgow Coma Scale, and RTS. Outcome measures rubber catheter was inserted into the pericardium, and all blood including hospital or ICU LOS, and ventilator days were also suctioned out.