Subxiphoid pericardial window to exclude occult cardiac injury after penetrating thoracoabdominal trauma

Hommes, Martijn; Nicol, Andrew; Stok, Johan van der; Kodde, Izaäk F.; Navsaria, Pradeep

doi:10.1002/bjs.9241

Cited by 26 publications

(20 citation statements)

References 19 publications

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“…This is particularly true for patients with essentially “incidental” findings of pericardial fluid. This is important because while pericardial window is the gold standard for definitive diagnosis, this procedure is not risk-free 13, 14 and inherently requires significant use of hospital resources.…”

Section: Introductionmentioning

confidence: 99%

Management of pericardial fluid in blunt trauma

Witt

Linnau

Maier

et al. 2017

Journal of Trauma and Acute Care Surgery

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Background The objectives of this study were to assess current variability in management preferences for blunt trauma patients with pericardial fluid, and to identify characteristics associated with operative intervention for patients with pericardial fluid on admission computed tomography (CT) scan. Methods This was a mixed-methods study of blunt trauma patients with pericardial fluid. The first portion was a research survey of members of the Eastern Association for the Surgery of Trauma conducted in 2016, in which surgeons were presented with four clinical scenarios of blunt trauma patients with pericardial fluid. The second portion of the study was a retrospective evaluation of all blunt trauma patients ≥14 years treated at our Level I trauma center between 1/1/2010 and 11/1/2015 with pericardial fluid on admission CT scan. Results For the survey portion of our study, 393 surgeons responded (27% response rate). There was significant variability in management preferences for scenarios depicting trace pericardial fluid on CT with concerning hemodynamics, and for scenarios depicting hemopericardium intraoperatively. For the separate retrospective portion of our study, we identified 75 blunt trauma patients with pericardial fluid on admission CT scan. Seven underwent operative management; six of these had hypotension and/or electrocardiogram changes. In multivariable analysis, pericardial fluid amount was a significant predictor of receiving pericardial window (relative risk for one category increase in pericardial fluid amount: 3.99, 95% CI 1.47-10.81) but not of mortality. Conclusions There is significant variability in management preferences for patients with pericardial fluid from blunt trauma, indicating a need for evidence-based research. Our institutional data suggest that patients with minimal to small amounts of pericardial fluid without concerning clinical findings may be observed. Patients with moderate to large amounts of pericardial fluid who are clinically stable with normal hemodynamics may also appear appropriate for observation, although confirmation in larger studies is needed. Patients with hemodynamic instability should undergo operative exploration. Level of Evidence Level IV, Therapeutic/Care Management

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Section: Introductionmentioning

confidence: 99%

Management of pericardial fluid in blunt trauma

Witt

Linnau

Maier

et al. 2017

Journal of Trauma and Acute Care Surgery

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“…36 Although this technique has a sensitivity and negative predictive value of nearly 100%, with a low complication rate (2% in their series), we continue to advocate for the transdiaphragmatic approach in this population. Transdiaphragmatic pericardial window is easily learned; requires no additional retraction, skin incision, or further dissection; and can be very quickly performed by a single surgeon with minimal disruption to the flow of abdominal exploration.…”

Section: Discussionmentioning

confidence: 94%

The peril of thoracoabdominal firearm trauma

Berg

Inaba

Okoye

et al. 2014

Journal of Trauma and Acute Care Surgery

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“…When FAST (Focused Assessment with Sonography in Trauma) detects an intra-pericardial effusion, a quick thoracic X-ray should be performed to avoid missing a cardiac wound if the pericardium has ruptured into the mediastinum [12]. If it is not possible to perform a FAST or if results are equivocal, the pericardium and/or heart must be explored via a sub-xiphoid route [13] or via a trans-diaphragmatic approach [4,8] during laparotomy or via a thoracotomy [7,14]. Cardiac repair is performed with mattress sutures, often with the help of transitory occlusion of the wound with a Foley catheter balloon [7] or by using mini-suction cups [15].…”

Section: Discussionmentioning

confidence: 99%

Management of penetrating abdominal and thoraco-abdominal wounds: A retrospective study of 186 patients

Barbois

Abba

Guigard

et al. 2016

Journal of Visceral Surgery

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This is a single center retrospective review of abdominal or abdomino-thoracic penetrating wounds treated between 2004 and 2013 in the gastrointestinal and emergency unit of the university hospital of Grenoble, France. This study did not include patients who sustained blunt trauma or non-traumatic wounds, as well as patients with penetrating head and neck injury, limb injury, ano-perineal injury, or isolated thoracic injury above the fifth costal interspace. In addition, we also included cases that were reviewed in emergency department morbidity and mortality conferences during the same period. Mortality was 5.9% (11/186 patients). Mean age was 36 years (range: 13-87). Seventy-eight percent (145 patients) suffered stab wounds. Most patients were hemodynamically stable or stabilized upon arrival at the hospital (163 patients: 87.6%). Six resuscitative thoracotomies were performed, five for gunshot wounds, one for a stab wound. When abdominal exploration was necessary, laparotomy was chosen most often (78/186: 41.9%), while laparoscopy was performed in 46 cases (24.7%), with conversion to laparotomy in nine cases. Abdominal penetration was found in 103 cases (55.4%) and thoracic penetration in 44 patients (23.7%). Twenty-nine patients (15.6%) had both thoracic and abdominal penetration (with 16 diaphragmatic wounds). Suicide attempts were recorded in 43 patients (23.1%), 31 (72.1%) with peritoneal penetration. Two patients (1.1%) required operation for delayed peritonitis, one who had had a laparotomy qualified as "negative", and another who had undergone surgical exploration of his wound under general anesthesia. In conclusion, management of clear-cut or suspected penetrating injury represents a medico-surgical challenge and requires effective management protocols.

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Subxiphoid pericardial window to exclude occult cardiac injury after penetrating thoracoabdominal trauma

Abstract: The SPW is a useful technique at laparotomy to identify cardiac injuries in patients with penetrating thoracoabdominal injuries.

Cited by 26 publications

References 19 publications

Management of pericardial fluid in blunt trauma

Management of pericardial fluid in blunt trauma

The peril of thoracoabdominal firearm trauma

Management of penetrating abdominal and thoraco-abdominal wounds: A retrospective study of 186 patients

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