Cardiac and Pulmonary Injury George C

European Journal of Trauma and Emergency Surgery Focus on Solid Organ Injury Cardiac and Pulmonary Injury George C. Velmahos, Muhammad U. Butt1 Abstract symptoms of PCI, followed by expeditious surgical Cardiac and pulmonary injuries present major chal- intervention, are extremely important [2, 3]. lenges in diagnosis and treatment. Distinct differences between penetrating and blunt trauma of these or- Diagnosis gans exist. Outcomes for severe injuries are still grave. Initial Assessment Organized trauma systems can provide optimal care Penetrating cardiac injury typically presents either by by minimizing prehospital time, allowing easy access signs of cardiac tamponade or hypovolemia (or some to imaging modalities, and offering state-of-the-art combination of the two) [4]. The diagnosis of PCI and treatment strategies. A multidisciplinary approach, the decision to operate are mostly clinical; delays for including surgeons, intensivists, and others, is abso- imaging or other tests are usually detrimental and lutely necessary. possible only in self-selected patients who are not agonal. Beck’s triad is the classic presentation for car- Key Words diac tamponade, but occurs only in 41% of the patients Cardiac trauma Æ Pulmonary trauma Æ Blunt [5]. It consists of jugular venous distention, hypotension trauma Æ Penetrating trauma Æ Gunshot wound and muffled heart sounds. A patient with a precordial Abbreviations: PCI: Penetrating cardiac injury; GSW: stab wound who is hypotensive, diaphoretic, confused, Gunshot wound; CXR: Chest X-ray; EKG: Electrocar- and agitated (due to brain hypoperfusion), is the clas- diogram; FAST: Focused assessment with sonography sically described picture of PCI. It should be remem- for trauma; ER: Emergency room; OR: Operation room; bered that frequently, there is open communication CPR: Cardio pulmonary resuscitation; BCI: Blunt car- between the heart wound and the pleural cavity diac injury; MVA: Motor vehicle accident; ICU: Inten- through a pericardial hole, which allows bleeding into sive care unit; PLI: Penetrating lung injury; NPV: the chest and relief of the tamponade. Under these Negative predictive value; CT: Computed tomography; conditions the patient is more likely to present with VATS: Video-assisted thoracoscopic surgery; ARDS: signs of hypovolemic shock rather than tamponade Adult respiratory distress syndrome physiology. Chest radiographs (CXR) are of limited value although a globular heart or a missile overlying the heart shadow could offer valuable information. Eur J Trauma Emerg Surg 2008;34:327–37 However, a normal pericardial appearance on CXR DOI 10.1007/s00068-008-8099-4 carries little negative predictive value, as an injury may surely exist. At least 250 ml of pericardial fluid is re- quired to detect heart enlargement on CXR. Pneumo- Penetrating Cardiac Injury pericardium is neither common nor pathognomonic. Background Demetriades et al. in a study of 20 PCI patients with Penetrating cardiac injury (PCI) is caused by gunshot pneumopericardium concluded that its presence is not wounds (GSW) in 32–70% of the cases in the USA, an absolute indication for surgery, and that the final although stab wounds are more frequent in other decision should be based on clinical presentation [6]. countries. Although less than 10% of patients with PCI An electrocardiogram (EKG) may show decreased arrive at the hospital alive [1], for those who do there is QRS voltage (cardiac tamponade) or ST segment ele- a significant likelihood for survival. Time is of the es- vation but a normal EKG does not rule out a cardiac sence, and immediate recognition of the signs and injury. The use of transthoracic echocardiography, 1 Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, MA, USA. Received: June 17, 2008; revision accepted: July 2, 2008; Published Online: July 25, 2008 Eur J Trauma Emerg Surg 2008 Æ No. 4 Ó URBAN &VOGEL 327 Velmahos GC, Butt MU. Cardiac and Pulmonary Injury performed by a surgeon or emergency medicine phy- laparotomy incision. After the abdominal injuries are sician as part of a focused assessment with sonography packed to control bleeding, the central tendon of the for trauma (FAST), is considered highly accurate for diaphragm and then the pericardium are opened to hemopericardium with a specificity of 99.3%, sensitivity detect a cardiac injury and prioritize the sequence of of 100%, positive predictive value of 87% and negative surgical interventions in the chest and abdomen. predictive value of 100% [7]. Rozycki et al. [8], have also reported 100% sensitivity and 96.9% specificity Management among 261 patients with penetrating thoracic injuries. Some general principles of management can be stan- However, despite these optimal results, which are dardized according to the five types of patients with produced by highly trained experts, FAST remains PCI, as grouped according to clinical presentation. operator-dependent and often unreliable. Multiple Controversies and recommended management are investigators, with adequate training and trauma vol- described in table 1. These groups do not include all umes, have shown that the true sensitivity and speci- the variations in which PCI patients can present. ficity of FAST is probably lower than what was initially reported [9, 10]. In a study of 372 patients Miller et al. Prehospital Management [9] demonstrated that FAST had a sensitivity of 42% Most patients experiencing PCI die before reaching the and specificity of 98%. Similarly, in another study of 75 hospital. Paramedics play a critical role in those who patients Udobi et al. [10] also showed that FAST had a survive. There is controversy about the role of prehos- sensitivity of 46% and a specificity of 94%. Formal 2D pital endotracheal intubation. Although this interven- echocardiography performed by a radiologist may im- tion may be reasonable in a patient who is losing all prove the accuracy, but takes longer and – most vital signs and is at risk of brain anoxia, the best reac- importantly – is rarely available when trauma occurs, tion by the paramedics is to waste no time for any i.e., off regular working hours. intervention and to try to shorten the prehospital time Pericardiocentesis as a diagnostic tool is mentioned to an absolute minimum. No endotracheal tube can only to be condemned. The insertion of a needle in the reverse the bleeding from a cardiac hole. The only life- narrow pericardial space will only serve to injure the saving intervention on a PCI patient is the relief of heart and produce hemopericardium, if it does not al- tamponade and control of bleeding [12], interventions ready exist. A pericardial window is of limited value in which cannot usually be offered in the prehospital the era of echocardiography. A vertical incision is environment. The same principles apply for intrave- made under the xiphoid extending for a few centime- nous line placement. If this can be performed rapidly, ters toward the umbilicus. The linea alba is opened and preferably during transport, then it may be of value. But the preperitoneal space entered with attention to avoid it should in no way delay the process. The value of fluid opening the peritoneum inadvertently. By dissecting resuscitation is controversial. In a study of delayed the preperitoneal fat inferiorly, the heartbeat is rec- resuscitation, patients with penetrating torso injuries ognized and the diaphragm opened at that point. Then randomized to receive fluid resuscitation after opera- the pericardium is opened. Care must be taken to tive bleeding control had improved survival compared isolate the area from surrounding bleeding from tissues to those randomized to full fluid resuscitation during because it is essential to inspect carefully the color of the prehospital and in-hospital preoperative phase [13]. the fluid which exits the pericardial sac upon opening. We believe that there is more benefit than risk to forego Blood or blood-tinged fluid indicates a cardiac injury line insertion in order to gain valuable time and reach and the operation continues with a sternotomy. Al- quickly to the place of definitive care, i.e., the hospital. though this technique was useful in the past, there are only a few reasons to do it today. If a patient is stable Emergency Room Management enough to be taken to the operating room simply for If the patient is hemodynamically stable upon arrival, a diagnostic purposes, then the patient can afford the detailed evaluation, CXR, FAST, and possibly a for- time for a detailed echocardiogram, which is noninva- mal echocardiography are in order. Fluids should be sive and highly accurate. A pericardial window is still kept under control, as it is easy to allow indiscrimi- of value when performed as an emergency procedure nately high volumes to be infused in short times, con- in a patient taken to the operating room for a lapa- verting a clotted perforation to a gushing wound. rotomy. On these patients, who have abdominal inju- Similarly, it is important to avoid anxiety- and pain- ries and a possible coexisting cardiac injury, the provoking procedures, which may raise the patient’s window is performed transperitoneally through the blood pressure with the same results. At the other end, 328 Eur J Trauma Emerg Surg 2008 Æ No. 4 Ó URBAN &VOGEL Velmahos GC, Butt MU. Cardiac and Pulmonary Injury Table 1. Classification and management of penetrating cardiac injury [11]. Category Clinical presentation Main controversies Recommended management Category

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