Emergency Surgery for Blunt Cardiac Injury: Experience in 43 Cases

Abstract

Background Blunt cardiac injury (BCI) increases with traffic accidents and is an important cause of death in trauma patients. In particular, for patients who need surgical treatment, the mortality rate is extremely high unless the patient is promptly operated on. This study aimed to explore early recognition and expeditious surgical intervention to increase survival. Methods All patients with BCIs during the past 15 years were reviewed, and those who underwent operative treatment were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome.Results A total of 348 patients with BCIs accounted for 18.3% of 1903 patients with blunt thoracic injury (BTI). Of 348 patients, 43 underwent operative treatment. The main cause of injury was traffic accidents, with an incidence of 48.8%. Of them, steering wheel injuries occurred in 15 patients. In 26 patients, a preoperative diagnosis was obtained by echocardiography, CT scanning, etc. In the remaining 17, who had to undergo urgent thoracotomy without any preoperative imaging, a definitive diagnosis of BCI was proven during the operation. The volume of preoperative infusion or crystalloid was \1000 ml in 31 cases. Preoperative pericardiocentesis was not used in anyone. In 12 patients, the operation commenced within 1 h. Overall mortality was 32.6%. The death was caused by BCI in 9. Conclusions Facing a patient with BTI, a high index of suspicion for BCI must be maintained. To manage those requiring operations, early recognition and expeditious thoracotomy are essential. Preoperatively, limited fluid resuscitation is emphasized. We do not advocate preoperative pericardiocentesis.

A narrative review of traumatic mediastinal injuries and their management: the thoracic surgeon perspective

“…Blunt cardiac injury is thought to be one of the main causes of death in trauma, with autopsy reports suggesting a pre-hospital mortality as high as 95% ( 7 , 8 ). A recent retrospective cohort study reviewing blunt cardiac injury over a fifteen-year period at a level 1 trauma centre, examined 348 patients with blunt cardiac injury where only 43 (12.4%) underwent operative treatment ( 9 ). Motor vehicle accidents accounted for 21 (48.8%) of blunt cardiac injuries and were predominantly secondary to steering wheel impact ( 9 ).…”

“…A recent retrospective cohort study reviewing blunt cardiac injury over a fifteen-year period at a level 1 trauma centre, examined 348 patients with blunt cardiac injury where only 43 (12.4%) underwent operative treatment ( 9 ). Motor vehicle accidents accounted for 21 (48.8%) of blunt cardiac injuries and were predominantly secondary to steering wheel impact ( 9 ). The most frequent area of injury found intraoperatively was the right ventricle, shown to be the most common involved chamber in both blunt and penetrating injuries ( 9 , 10 ).…”

“…Motor vehicle accidents accounted for 21 (48.8%) of blunt cardiac injuries and were predominantly secondary to steering wheel impact ( 9 ). The most frequent area of injury found intraoperatively was the right ventricle, shown to be the most common involved chamber in both blunt and penetrating injuries ( 9 , 10 ). Other intraoperative findings were described and included pericardial herniation, heart rotation and significant intracardiac injury.…”

“…Median sternotomy is the definitive incision and intervention of choice for the management of patients with suspicion of cardiac injuries, allowing for access to the right and left hemithoraces ( 9 , 10 , 12 , 13 ). When clinical suspicion is high in the presence of hemodynamic instability, this intervention should not be deferred by first performing pericardiocentesis or pericardial window ( 12 ).…”

“…When clinical suspicion is high in the presence of hemodynamic instability, this intervention should not be deferred by first performing pericardiocentesis or pericardial window ( 12 ). If there is concern for other injuries, cardiac access can be adequately managed through a left anterolateral thoracotomy at the inframammary fold ( 9 , 10 - 13 ). If previous emergency department thoracotomy has been performed, decision to carry this incision toward the right pleural space into a clamshell thoracotomy provides adequate exposure to the heart and mediastinum ( 11 ).…”