Transmediastinal and Transcardiac Gunshot Wound with Hemodynamic Stability

Abstract

Cardiac injuries caused by knives and firearms are slightly increasing in our environment. We report the case of a 43-year-old male patient with a transmediastinal gunshot wound (TGSW) and a through-and-through cardiac wound who was hemodynamically stable upon his admission. He had an entrance wound below the left clavicle, with no exit wound, and decreased breath sounds in the right hemithorax. Chest X-ray showed the bullet in the right hemithorax and large right hemothorax. The ultrasound revealed pericardial effusion, and a chest tube produced 1500 cc. of blood, but he remained hemodynamically stable. Considering these findings, a median sternotomy was carried out, the through-and-through cardiac wounds were suture-repaired, lung laceration was sutured, and a pacemaker was placed in the right ventricle. The patient had uneventful recovery and was discharged home on the twelfth postoperative day. The management and prognosis of these patients are determined by the hemodynamic situation upon arrival to the Emergency Department (ED), as well as a prompt surgical repair if needed. Patients with a TGSW have been divided into three groups according to the SBP: group I, with SBP >100 mmHg; group II, with SBP 60–100 mmHg; and group III, with SBP <60 mmHg. The diagnostic workup and management should be tailored accordingly, and several series have confirmed high chances of success with conservative management when these patients are hemodynamically stable.

Transmediastinal Gunshot Wound in a Pregnant Patient with Stable Hemodynamics

“…6 However, according to some authors, more than half of the patients with TGW are hemodynamically stable, and more than between 60 and 70% of these patients do not need surgery, and are treated with conservative approach. 7 The approach to penetrant injury and resuscitation in pregnancy is of greater importance owing to the presence of the fetus and physiological and anatomical gestational alterations. The management of penetrant injury in pregnancy requires a multidisciplinary approach comprising the anesthesiologist, obstetrician, neonatologist and trauma surgeon.…”

“… 6 However, according to some authors, more than half of the patients with TGW are hemodynamically stable, and more than between 60 and 70% of these patients do not need surgery, and are treated with conservative approach. 7 …”

Innocuous cardiac gunshot that proved fatal: A bitter lesson learned

“…It is in these patients the management remains challenging. In literature, such patients were managed conservatively with no adverse outcomes 2, 3…”

Lesiones transmediastinales. Revisión de la literatura y una visión de lo que se debe de hacer

“…; un ultrasonido realizado por alguien con la habilidad suficiente, cuenta con sensibilidad por arriba de 95% para diagnosticar hemopericardio, y la necesidad de llevar a cabo una ventana pericárdica se torna obsoleta. 5,6…”