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PENETRATING INJURIES TO THE HEART

These pages are excerpted from the Trauma Resident Handbook, Rhode Island Hospital Department of Surgery, Division of Trauma - updated 2001. The policies herein are intended to serve as guidelines only. Individual circumstances need to be considered as there may be times when it is appropriate or desirable to deviate from these guidelines. These educational guidelines will be reviewed and updated routinely.

Clinical signs of pericardial tamponade in penetrating cardiac injuries are the exception, rather than the rule.[1] Paradoxically, pericardial tamponade itself may act protectively, as patients with cardiac injuries and tamponade had a higher survival rate than those presenting without tamponade.[2] Thus, patients who survive the acute stage after penetrating cardiac trauma (i.e., those who make it to the ED alive) are more likely to have tamponade. It is critical to identify patients with cardiac injury (and tamponade) early on, before the “protective” effect is lost.

Pericardiocentesis is unreliable in the acute setting of trauma with a 20% false (+) and false (-) rate. The most sensitive test for post-traumatic tamponade is (subxiphoid) pericardial window. This requires general anesthesia in the operating room.3 In patients who do not require general anesthesia for surgery following penetrating trauma, the best non-invasive test for cardiac or pericardial injury is two-dimensional echocardiography. This test is both sensitive and specific in the patients without hemothorax (100%/89%), yet is less accurate in the setting of hemothorax (56%/93%).[4,5]

Penetrating cardiac injuries can occur without entrance or exit wounds in the “box”- injuries to the heart can occur from a transmediastinal gunshot wound. A small retrospective study on gunshot wounds reveal that 40% of these patients present in extremis with decreased blood pressure and require emergency operation, with 1/3 of these patients having cardiac injury. Approximately 60% of these patients present in stable condition, but anywhere from 20-50% of these patients have injuries to the heart, mediastinal vessels, bronchus or esophagus that will present in a delayed fashion. Evaluation of these injuries requires workup to include echo/pericardial window, angiogram, bronchoscopy and esophagoscopy / barium swallow.[6]

1. Asensio JA, Stewart BM, Murray J, et al. Penetrating cardiac injuries. Surg Clin N Am 1996;76:685.
2. Moreno C, Moore EE, Majune JA, et al. Pericardial tamponade. A critical determinant for survival following penetrating cardiac wounds. J Trauma 1994;36:229.
3. Trinkle JK, Toon R, Franz JL, et al. Affairs of the wounded heart: Penetrating cardiac wounds. J Trauma 1979;19:467.
4. Meyer D, Jessen M, Grayburn P. Use of echocardiography to detect occult cardiac injury after penetrating thoracic trauma: A prospective study. J Trauma 1995;39:902.
5. Nagy KK, Lohmann C, Kim DO, et al. Role of echocardiography in the diagnosis of occult penetrating cardiac injury. J Trauma 1995;38:859.
6. Richardson JD, Flint LM, Small MJ, Gray LA, Trinkle JK. Management of transmediastinal gunshot wounds. Surgery 1981;90:671-676.

Rev. 6/18/01

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