Damage control in penetrating cardiac trauma

Abstract

Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients.

Management of contained penetrating cardiac injury in a patient with prior cardiac surgery

“…These manoeuvres can also be performed immediately after an ER thoracotomy. Furthermore, in the case of uncontrolled haemorrhage, Sauerbruch grip or manoeuvre can be used 2. This involves temporary total cardiac occlusion by compressing the junction between the vena cava and the right atrium.…”

“…RV was repaired with 4-0 prolene pledgeted suture in horizontal mattress fashion 1. The VSD was repaired with 4-0 prolene pledgeted suture in horizontal mattress fashion from the LV (Left Ventricle) side, under the LAD, and incorporated the VSD to approximate it to the anterior wall 2. LAD, left anterior descending; RV, right ventricle.…”

“…In the USA, the percentage of penetrating cardiac trauma (PCT) caused by gunshot wounds is equal to or higher than that from stab wounds 1. Conversely, in underdeveloped countries, stab wounds comprise most of PCT 2. In the past 10 years, PCT has grown proportionately compared with blunt cardiac injury and carries a higher mortality rate 3.…”

“…PCT to the cardiac box typically results in haemopericardium from ventricular rupture, with more complex injuries including septal rupture, damage to coronary vasculature or valvular damage. These patients usually require emergent operative intervention via median sternotomy or left thoracotomy 1–4. If a patient arrives haemodynamically stable, the picture is less clear.…”

I LIVRO DA ABLAC-BR: A Cirurgia Sob as Lentes das Ligas Acadêmicas

“…Esse fenômeno ocorre quando a incisão da esternotomia mediana é fechada prematuramente, causando uma elevação imediata da pressão nas vias aéreas e colapso hemodinâmico rápido do paciente. A herniação e torção cardíaca iatrogênica podem ocorrer após incisões laterais do pericárdio deixadas abertas, apresentando sinais e sintomas como arritmia, isquemia miocárdica e hipotensão (GONZÁLEZ-HADAD et al, 2021).…”