Reassessing the cardiac box

Jhunjhunwala, Rashi; Mina, Michael J.; Roger, Elizabeth I.; Dente, Christopher J.; Heninger, Michael; Carr, Jacquelyn S.; Dougherty, Stacy D.; Gelbard, Rondi B.; Nicholas, Jeffrey M.; Wyrzykowski, Amy D.; Feliciano, David V.; Morse, Bryan C.

doi:10.1097/ta.0000000000001519

Cited by 21 publications

(6 citation statements)

References 24 publications

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“…16,17 Recent studies have provided further details regarding the influence of the mechanism of injury and the number of wounds on cardiac injury. [18][19][20] To rule out a cardiac injury in the initial assessment, eFAST plays a prominent role in the initial patient assessment. 21,22 A systematic review and meta-analysis published in February 2021 concluded that the use of ultrasound was 79% sensitive and 92% specific for detecting occult penetrating cardiac injuries in hemodynamically stable patients with PTI.…”

Section: Discussionmentioning

confidence: 99%

“…Although cardiac box wounds are potentially acknowledged as cardiac injuries, the evidence to support this association is lacking 16,17 . Recent studies have provided further details regarding the influence of the mechanism of injury and the number of wounds on cardiac injury 18–20 . To rule out a cardiac injury in the initial assessment, eFAST plays a prominent role in the initial patient assessment 21,22 .…”

Section: Discussionmentioning

confidence: 99%

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Surgical exploration for stable patients with penetrating cardiac box injuries: When and how? A cohort of 155 patients from Marseille area

Vasse

Belaroussi

Avaro

et al. 2022

J Trauma Acute Care Surg

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BACKGROUND:The management of penetrating thoracic injuries in moribund or unstable patients is clearly described in contrast to that of stable patients, particularly for those with a cardiac box injury. This anatomic location suggests a potentially lethal cardiac injury and requires urgent therapeutic decision making. The present study aims at determining when surgical exploration is beneficial for stable patients presenting with penetrating cardiac box injuries (PCBIs). METHODS:This was a retrospective study of stable civilian patients with PCBI referred to level I trauma centers in the Marseille area between January 2009 and December 2019. Using post hoc analysis of the management outcomes, patients whose surgery was considered therapeutic (group A) were compared with those whose surgery was considered nontherapeutic and with nonoperated patients (group B). RESULTS:A total of 155 patients with PCBI were included, with 88% (n = 137) of stab wound injuries. Overall, surgical exploration was performed in 54% (n = 83), considered therapeutic in 71% (n = 59), and performed by video-assisted thoracoscopy surgery in 42% (n = 35) with a conversion rates of 14% (n = 5). Initial extended fast assessment with sonography for trauma revealed the presence of hemopericardium in 29% (n = 29) in group A versus 9.5% (n = 7) in group B, p = 0.010, and was associated with a negative predictive value of 93% regarding the presence of a cardiac injury. Chest tube flow was significantly higher in patients who required surgery, with a median (interquartile range) of 600.00 (350.00-1200.00) mL versus 300.0 (150.00-400.00) mL ( p = 0.001). CONCLUSION:Extended fast assessment with sonography for trauma and chest tube flow are the cornerstones of the management of stable PCBI. Video-assisted thoracoscopy represents an interesting approach to check intrathoracic wounds while minimizing surgical morbidity.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Surgical exploration for stable patients with penetrating cardiac box injuries: When and how? A cohort of 155 patients from Marseille area

Vasse

Belaroussi

Avaro

et al. 2022

J Trauma Acute Care Surg

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“…Historically, a penetrating wound to the “cardiac box” (between midclavicular lines from clavicles to tip of xiphoid process) or any other transmediastinal wound was considered to be a likely cause of a cardiac injury. Of interest, one recent clinical and autopsy study documented that changing the cardiac box from the anterior to posterior midline on the left side had a positive predictive value of 41% with a sensitivity of 90% for a cardiac injury 10 . Therefore, the definition of the cardiac box is likely to change in future publications 11,12 …”

Section: Presentation Diagnosis and Management In The Emergency Depar...mentioning

confidence: 99%

“…62 Abnormalities included the following: pericardial effusion (9), abnormal wall motion (8), decreased ejection fraction <45% (8), intramural thrombus (4), valve injury (4), cardiac enlargement (2), conduction abnormality (2), left ventricular pseudoaneurysm (1), right ventricular aneurysm (1), and septal defect (1). No patient underwent a reoperation, although 11 were under medical management (10) or required cardioversion (1). There were two patients with late deaths (injuries to left ventricle and right ventricle, respectively), but the causes were not listed.…”

Section: Indications For Cardiopulmonary Bypassmentioning

confidence: 99%

“…Of interest, one recent clinical and autopsy study documented that changing the cardiac box from the anterior to posterior midline on the left side had a positive predictive value of 41% with a sensitivity of 90% for a cardiac injury. 10 Therefore, the definition of the cardiac box is likely to change in future publications. 11,12 Management of patients who present in extremis with a potential injury to the heart still follows the Advanced Trauma Life Support protocol of ABCs (airway, breathing, circulation), although there is interest in converting this to CABs in some trauma centers.…”

Section: Presentation Diagnosis and Management In The Emergency Depar...mentioning

confidence: 99%

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Treatment of penetrating cardiac wounds for the general surgeon on call

Khaitan

Feliciano

Rozycki

et al. 2022

J Trauma Acute Care Surg

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Scoop and run" approaches for severely injured patients have been adopted by emergency medical services over the past 40 years. This has resulted in more patients with severe injuries including penetrating cardiac wounds arriving at trauma centers and other acute care hospitals. General surgery trauma teams and general surgeons taking trauma call are the first responders for diagnosis, resuscitation, and operative management of injured patients. By natural selection, 96% to 98% of patients with signs of life on arrival to the trauma center after sustaining a penetrating cardiac wound have injuries that are amenable to repair by a general surgeon, fellow, or senior surgical resident without the need for a cardiothoracic surgeon or cardiopulmonary bypass.This literature and experience-based review summarizes the diagnostic and operative approaches that should be known by all trauma teams and general surgeons taking trauma call. In addition, it describes when a cardiothoracic surgeon should be consulted and briefly reviews how complex penetrating cardiac injuries are repaired.

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Cardiac Injury: Techniques

Tesoriero

2020

The Shock Trauma Manual of Operative Techniques

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Reassessing the cardiac box

Abstract: Therapeutic/care management, level IV.

Cited by 21 publications

References 24 publications

Surgical exploration for stable patients with penetrating cardiac box injuries: When and how? A cohort of 155 patients from Marseille area

Surgical exploration for stable patients with penetrating cardiac box injuries: When and how? A cohort of 155 patients from Marseille area

Treatment of penetrating cardiac wounds for the general surgeon on call

Cardiac Injury: Techniques

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