Penetrating cardiac injury and the significance of chest computed tomography findings

Abstract

In rare circumstances, hemodynamically stable patients can harbor serious penetrating cardiac injuries. We hypothesized that chest computed tomography (CCT) is potentially useful in evaluation. The records of all patients admitted to our center with wounds to the precordium or who sustained a hemothorax or pneumothorax after penetrating torso injuries over a 48-month period were reviewed. Those having an admission CCT were studied. The potential diagnostic value of hemopericardium (HPC) and pneumopericardium (PPC) on CCT was examined. Most of the 333 patients were male [293 (88.0 %)] with a roughly equal distribution of gunshot [189 (56.8 %)] and stab [144 (43.2 %)] wounds. Mean age was 28.7 ± 12.6 years. Thirteen (3.9 %) patients had cardiac injuries that were operatively managed. Eleven (3.3 %) CCT studies demonstrated HPC and/or PPC. Ten of these patients had an injury with one false positive. Retained hemothorax and proximity findings on the three false negative CCT studies led to video-assisted thoracoscopic surgery or subxiphoid exploration with diagnosis of the injury. HPC and/or PPC on CCT had a sensitivity of 76.9 %, specificity of 99.7 %, positive predictive value of 90.9 %, and negative predictive value (NPV) of 99.1 % for cardiac injuries. However, including all findings that changed management, CCT had a sensitivity and NPV of 100 %. CCT is a potentially useful modality for the evaluation of cardiac injuries in high-risk stable patients. The presence of HPC and/or PPC on CCT after penetrating thoracic trauma is highly indicative of a significant cardiac injury.

A concealed atriopleural fistula resulting from a cardiac stab wound

“…Pericardial tamponade is the most frequent mechanism that leads to secondary clinical instability. 3,6 However, if the patient remains hemodynamically stable, it is possible to underestimate the severity of the lesions and the associated risk. Internal bleeding can manifest differently from bleeding from the heart to the pleura.…”

Possibilities of videothoracoscopy for penetrating thoracic injuries

“…Примером такой так-тики является атипичная торакотомия при низких ранах груди [1]. При планировании эндохирургиче-ского вмешательства пациенты нуждаются в деталь-ном обследовании с целью исключения непроявив-шихся тяжелых повреждений [10,15,21].…”

“…5, при стабильной ге-модинамике имеется достаточно времени для пол-ноценного дооперационного обследования. В слу-чае если рутинное ультразвуковое исследование не свидетельствует о наличии гемоперикарда и необхо-димости торакотомии, то целесообразно выполнить комплекс дополнительных обследований [8,21,23,25], поскольку выявить до операции гемоперикард малого объема традиционными методами удавалось редко. Если при эхокардиографии или компьютер-ной томографии в полости перикарда выявляют ми-нимальное количество жидкости, то для исключе- ния гемоперикарда целесообразно выполнение ВТС и перикардиотомии [5].…”

Penetrating Injuries to the Lung and Heart: Resuscitation, Diagnosis, and Operative Indications

“…In addition to providing excellent anatomic information regarding chest wall, pulmonary, and pleural space injuries, a recent study by Plurad et al demonstrates that CCT is also highly sensitive for PCI. They examined 333 patients with penetrating thoracic injuries and found that, as with ultrasound, the finding of hemopericardium or pneumopericardium on CCT had a sensitivity of 76.9 % for PCI [21]. When they further investigated the patients with Bfalse-negative^CCT, all of them had CT findings that prompted emergent surgical exploration and prompt diagnosis of the injury, including the presence of large caked hemothorax, pneumomediastinum, mediastinal hematoma, or visible tracts in close proximity to the heart.…”

“…When they further investigated the patients with Bfalse-negative^CCT, all of them had CT findings that prompted emergent surgical exploration and prompt diagnosis of the injury, including the presence of large caked hemothorax, pneumomediastinum, mediastinal hematoma, or visible tracts in close proximity to the heart. Thus, when factoring in all of the clinically significant findings that changed management, they felt that CCT had a sensitivity of 100 % [21].…”