Chapter 26 - McGraw-Hill Professional

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490 Management of Specific Injuries SECTION 3 X A B C D FIGURE 26-3 Temporary techniques to control bleeding. (A) Finger occlusion; (B) partial occluding clamp; (C) Foley balloon catheter; (D) skin staples. ( Copyright © Baylor College of Medicine, 2005. ) to the posterior mediastinal structures and descending thoracic aorta for cross-clamping. Cardiorrhaphy should be carefully performed. Poor technique can result in enlargement of the lacerations or injury to the coronary arteries. If the initial treating physician is uncomfortable with the suturing technique, digital pressure can be applied until an experienced surgeon arrives. Other techniques that have been described include the use of a Foley balloon catheter or a skin stapler ( Fig. 26-3 ). Injuries adjacent to coronary arteries can be managed by placing the sutures deep to the artery ( Fig. 26-4 ). Mechanical support or cardiopulmonary bypass is very uncommonly required in the acute setting. 4 For multiple fragments in stable patients, diagnosis in the past was pursued with radiographs in two projections, fluoroscopy, angiography, or echocardiography. Recently, the multidetector CT scan can be used to diagnose and locate these fragments. The full-body topogram scan can identify all missiles, and then the cross-sectional images can be directed to precisely locate them. Trajectories can be ascertained. Treatment of retained missiles is individualized. Removal is recommended for intracardiac missiles that are left sided, larger than 1–2 cm, rough in shape, or that produce symptoms. Although a direct approach, either with or without cardiopulmonary bypass, has been advocated, a large percentage of right-sided foreign bodies can now be removed by endovascular techniques. Blunt Cardiac Injury Much debate and discussion has occurred about the clinical relevance of “cardiac contusion.” Most trauma surgeons suggest
Heart and Thoracic Vascular Injuries 491 FIGURE 26-4 Injuries adjacent to coronary arteries can be addressed by placing sutures deep, avoiding injury to the artery. ( Copyright © Baylor College of Medicine, 2005. ) that this diagnosis should be eliminated because it does not affect treatment strategies. The majority of these patients seen are normotensive patients with normal initial ECG and suspected blunt cardiac injury. These cases are managed in observation units, with no expected clinical significance. Patients with an abnormal ECG are admitted for monitoring and treated accordingly. Patients who present in cardiogenic shock are evaluated for a structural injury, which is then addressed. 12 ■ Results Many factors determine survival in patients with traumatic cardiac injury including mechanism of injury, location of injury, associated injuries, coronary artery and valvular involvement, presence of tamponade, length of prehospital transport, requirement for resuscitative thoracotomy, and experience of the trauma team. The overall hospital survival rate for patients with penetrating heart injuries ranges from 30% to 90%. The survival rate for patients with stab wounds is 70–80%, whereas survival after gunshot wounds ranges between 30% and 40%. Cardiac rupture has a worse prognosis than penetrating injuries to the heart, with a survival rate of approximately 20%. Complex Cardiac Injuries Complex cardiac injuries include coronary artery injury, valvular apparatus injury (annulus, papillary muscles, and chordae tendineae), intracardiac fistulas, and delayed tamponade. These delayed sequelae have been reported to have a broad incidence (4–56%), depending on the definition. Coronary artery injury is a rare injury, occurring in 5–9% of patients with cardiac injuries, with a 69% mortality rate. 4 A coronary artery injury is most often controlled by simple ligation, but bypass grafting using a saphenous vein may be required for proximal left anterior descending or right coronary artery injuries (with cardiopulmonary bypass). 4 Off-pump bypass can theoretically be used for cases of these injuries in the highly unlikely event that the patient is hemodynamically stable. Valvular apparatus injury is rare (0.2–9%) and can occur with both blunt and penetrating trauma. 4 ,5 The aortic valve is most frequently injured, followed by the mitral and tricuspid valves, though most victims of aortic valve injuries likely die at the scene. These injuries are usually identified postoperatively after the initial cardiorrhaphy and resuscitation have been performed. Timing of repair depends on the patient’s condition. If severe cardiac dysfunction exists at the time of the initial operation, and valvular injury is identified, immediate valve repair or replacement may be required; otherwise, delayed repair is more commonly advised. 8 Intracardiac fistulas include ventricular septal defects, atrial septal defects, and atrioventricular fistulas, with an incidence of 1.9% among cardiac injuries. The management depends on symptoms and degree of cardiac dysfunction, with only a minority of these patients requiring repair. 4 These injuries are also usually identified after primary repair is accomplished, and they can be repaired after the patient has recovered from the original and associated injuries. Echocardiography should be obtained before repair so that specific anatomic sites of injury and incision planning can be accomplished. Dysrhythmias can occur as a result of blunt injury, ischemia, or electrolyte abnormalities and are addressed according to the injury ( Table 26-2 ). Delayed pericardial tamponade is rare. It can occur as early as 1 hour after initial operation and to days after the injury. TABLE 26-2 Dysrhythmias Associated with Cardiac Injury Penetrating cardiac injury Sinus/supraventricular tachycardia ST segment changes associated with ischemia Supraventricular tachycardia Ventricular tachycardia/fibrillation Blunt cardiac injury Sinus tachycardia ST segment, T wave abnormalities Atrioventricular conduction defects, bradycardia Ventricular tachycardia/fibrillation Electrical injury Sinus tachycardia ST segment, T wave abnormalities Conduction/bundle branch delay Axis deviation Prolonged QT intervals Paroxysmal supraventricular tachycardia Atrial fibrillation Ventricular tachycardia, fibrillation Asystole (lightning strike) CHAPTER 26 X
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Chapter 26 - McGraw-Hill Professional

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