RESUMEN

This is a report of a 22-year experience with penetrating cardiac trauma at a single urban Level I trauma center. We conducted a retrospective chart review supplemented by computerized patient log. Comparisons of mortality between Period 1 (1975-1985; 113 patients) and Period 2 (1986-1996; 79 patients) were by chi2 or Fisher's exact tests. Statistical significance was defined as P < or = 0.05. From 1975 to 1996, 192 patients (mean age, 32 years; 88% male) with penetrating cardiac stab wounds (68%) or gunshot wounds (32%) were treated. The most common initial clinical presentation was cardiac tamponade, and most patients (54%) were hypotensive (systolic blood pressure 30-90 mm Hg). The most common initial intervention in the emergency center was tube thoracostomy. The use of pericardiocentesis as a diagnostic and therapeutic modality in the emergency center virtually disappeared in Period 2, as compared with Period 1. Since 1994, surgeon-performed cardiac ultrasound has been performed and has correctly diagnosed hemopericardium in 12 patients (100% survival). The overall mortality for all patients during the 22-year study interval was 25 per cent and was not significantly different between Period 1 (27%) and Period 2 (22%). The mortality associated with gunshot wounds was increased compared with that of stab wounds. Similarly, mortality for patients who arrested in the emergency center was increased compared with those patients who did not arrest. We conclude: 1) cardiac tamponade is the most common presentation in patients with cardiac wounds; 2) pericardiocentesis in the emergency center has essentially disappeared; 3) surgeon-performed ultrasound of the pericardium should improve survival of future patients who are normotensive or mildly hypotensive; 4) over the last 11 years, there has been a substantial decrease in mortality in patients with stab wounds and a statistically significant decrease in arrested patients; and 5) overall mortality for penetrating cardiac trauma has not changed during the 22-year interval.

Asunto(s)

RESUMEN

BACKGROUND: Rupture of the heart is usually a fatal injury in patients sustaining blunt trauma. Those arriving in the emergency department alive can be saved with prompt diagnosis and treatment. METHODS: We describe the cases of 4 consecutive patients with rupture of the free cardiac wall whom we treated at Grady Hospital. Two had a tear of the right ventricle, 1 had a tear of the right atrium, and 1 had two tears of the left atrium. All patients were involved in motor vehicle accidents. The diagnosis was made by ultrasound in 3 patients and during exploratory surgical intervention in the other. All tears were repaired primarily without the aid of cardiopulmonary bypass. RESULTS: Three of the patients survived, and 1 died. CONCLUSIONS: Rarely are patients with rupture of the free cardiac wall seen in an emergency department. The improvements in the prehospital care and the transportation may result in an increase in the numbers of such patients. Physicians treating patients with blunt trauma must suspect the presence of cardiac rupture. Immediate use of ultrasonography will establish the diagnosis and prompt repair of the injury may improve overall survival.

Asunto(s)

RESUMEN

BACKGROUND: Rupture of the ascending aorta caused by blunt trauma rarely has been diagnosed and treated. As a result, the clinical manifestations and management of this injury have not been clearly defined. METHODS: We describe the clinical presentation, diagnosis, and management of 3 consecutive patients with ascending aortic rupture treated during the last 3 years. We also review the cases with this injury reported in the English-language literature until 1996. RESULTS: The predominant clinical manifestations of all patients, including reviewed case reports, were those of other organ injuries, and 5 had signs of aortic regurgitation and 1 of cardiac tamponade. The mediastinal silhouette was normal in 6 and widened in 14 patients, 1 of whom had also rupture of the subclavian artery. The aortic tears were managed with primary repair or with graft interposition and the valve injury with replacement or repair. Three of 20 patients died, for an overall mortality of 15%. CONCLUSIONS: Ascending aortic rupture should be considered in any patient with severe blunt trauma who has widened mediastinum or cardiac tamponade, as well as in patients with associated major thoracic injuries. Absence of a widened mediastinal silhouette does not exclude the diagnosis. The repair is relatively straightforward, but survival depends primarily on the severity of associated injuries.

Asunto(s)

RESUMEN

Delayed aorto-pulmonary artery fistula represents an uncommon delayed sequelae of penetrating cardiac trauma. A case is presented that demonstrates the need for a high index of suspicion, follow-up, and a complete evaluation of the patient who survives a penetrating heart injury. The mechanisms of delayed presentation, diagnosis, and management of the fistula are discussed.

Asunto(s)

RESUMEN

Failure of a pacemaker to capture may be related to several factors. This report describes a case with loss of capture of a unipolar pacemaker following the development of subcutaneous emphysema. Once the diagnosis is established, treatment options include tube thoracostomy, pressure dressing, aspiration of air or fluid from the pocket, or insertion at a new site.

Asunto(s)

RESUMEN

A missile in the cardiovascular system is a rare complication of a projectile wound. A missile in the heart should be suspected in the patient with a projectile wound of the thorax and in whom, on chest radiography, a missile is seen in the cardiac silhouette. A missile should be suspected in the patient with a projectile wound elsewhere with similar radiographic findings, no exit wound, and no missile in the area of injury. A missile in the arterial system should be suspected when no exit wound and no projectile are seen in the traumatized area. In such a case, radiography of the entire body should be done. The diagnosis of a suspected missile in the cardiovascular system is confirmed by echocardiography or angiography. Treatment should be individualized according to the clinical manifestations of the patient and the site of the missile.

Asunto(s)

RESUMEN

From 1967 to 1993, 21 patients underwent surgical repair of aortic left ventricular discontinuity as a result of acute bacterial endocarditis. Repair of the defect between the aorta and left ventricle was usually with interposition of a patch (prosthetic patch or autologous pericardium), using a continuous monofilament suture. Interrupted pledgetted stitches were used when the ventricular tissue appeared friable. A valve prosthesis was then sewn to the patch and remaining annulus. Three patients died in the immediate perioperative period. Long follow-up ranging from 5 to 142 months (mean 36 months) is available on 17 of 18 survivors. There were six deaths in this group from 11 to 142 months (mean 67 months) from initial surgery. Of 11 long-term survivors (5 to 61 months (mean 21 months) after operation), nine have had event-free courses. Two cases of recurrent subacute bacterial endocarditis occurred 3 and 52 months after surgery in patients who were intravenous drug abusers, both of whom were managed medically. It is concluded that while aortic left ventricular discontinuity remains a potentially lethal complication of acute bacterial endocarditis, débridement of infected necrotic tissue, patch repair of the defect, and prosthetic valve replacement offer satisfactory immediate and late results.

Asunto(s)

RESUMEN

Pneumocephalus resulting from a subarachnoid-pleural fistula most commonly occurs after trauma. Such a complication is very rarely seen after thoracotomy alone, with 15 cases reported to date in the literature. We report a case of pneumocephalus and subarachnoid-pleural fistula that developed secondary to thoracotomy. It was diagnosed by postmyelography computed tomography and treated with open surgical repair after a trial of conservative therapy failed. The presenting symptoms and signs, diagnostic methods, and options for therapy are reviewed.

Asunto(s)

Asunto(s)

RESUMEN

Tracheobronchial rupture from blunt trauma is usually single and transverse but may be longitudinal or complex, a combination of various sites and forms of rupture. From 1970 to 1990, 183 cases of rupture of the airways were reported in the literature: 136 (74%) transverse, 33 (18%) longitudinal, and 14 (8%) complex. During the same 20 years at Grady Memorial Hospital, 6 patients with such injuries were treated. One had complex injury consisting of rupture of the distal trachea and both main bronchi, 1 had a longitudinal tracheal rupture and rupture of the innominate artery, and 4 had a transverse rupture, 1 of whom also had a traumatic false aneurysm of the left pulmonary artery. Cardiopulmonary bypass was used only for the repair of the complex injury, whereas the repair of the left main bronchial rupture associated with a false aneurysm of the left pulmonary artery was done with standby cardiopulmonary bypass. All 6 patients had satisfactory results from the correction of their lesions except 1 child in whom stenosis developed at the rupture site. This study suggests that complex injuries are rarely seen, and their repair is often quite involved. In some of these cases, the use of cardiopulmonary bypass increases the margin of safety during operation and may encourage repair rather than resection of the affected lung.

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

We prospectively studied 126 asymptomatic patients who had a total of 144 stab wounds (average size, 2 cm) to the chest to determine their need for hospitalization. Their average age was 32 years; 102 of them were men. Four left against medical advice. The remaining 122 patients were judged to be asymptomatic when inspiratory and expiratory chest roentgenograms, recorded serially over a 24-hour period, revealed no intrathoracic trauma. Subcutaneous air was found in five of the patients, and an aorto-right ventricular fistula was found in one patient during his follow-up visit to the clinic a week later. The fistula was repaired uneventfully. No late-developing complications were detected in a review of the charts a year later. We believe a patient with a stab wound to the chest but with no evidence of intrathoracic injury may be appropriately managed with limited observation, including serial inspiratory and expiratory roentgenograms of the chest.

Asunto(s)

RESUMEN

The management of spontaneous rupture of the esophagus (SRE) is still somewhat controversial, but primary repair, with or without suture line plication, remains the backbone of therapy. Although the short-term results of the surgical therapy of SRE have been widely published, reports of the long-term follow-up have been scarce. The short- and long-term results of the treatment of 18 patients presenting with SRE over the sixteen-year period, 1971-1987, are reviewed. The general approach has been to perform a primary repair, with or without suture line plication, depending on whether, after debridement, the tissues appear adequate enough to hold sutures. Fifteen patients underwent primary repair. One patient underwent cervical esophagostomy in continuity and exclusion of the repair. One was managed with chest tube drainage, while another was treated with T-tube drainage of the rupture. Those undergoing surgery within 12 hours of rupture are termed "early" (E), all others "late" (L). Eight primary repairs were plicated with gastric fundus with six recoveries (three "E", three "L"); three with a pleural flap with one recovery (one "L"); and four were not plicated with three recoveries (two "E," one "L"). Follow-up with esophagogram in eight of 11 survivors ranged from 6 weeks to 8 years (mean 28 months). Four patients with fundoplication and one without plication had normal esophagography. Two patients with fundoplication had stricture in the lower esophagus. In both, the fundoplicated segment had been left above the diaphragm. The patient whose repair was excluded just above the stomach had stenosis at that level. Three of the 11 survivors were lost to follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Asunto(s)

RESUMEN

The management of retained missiles in the heart is still controversial. In an attempt to define the issue more clearly, the reported cases in the English literature from 1940 to 1988 (group 1) and our experience from 1968 to 1988 (group 2) were reviewed. In group 1 there were 222 missiles retained in the hearts of 201 patients. The retained missiles were 45 bullets in 45 patients, 109 shrapnel in 99 patients, 18 pellets in 7 patients, and 50 unidentified missiles in 50 patients. Thirteen of the missiles were completely embedded intramyocardial missiles, 122 were partially intramyocardial, 47 were free in a cardiac chamber, and 40 were intrapericardial. One hundred four of the missiles were removed and 118 were left in place. In group 2 there were 24 missiles, 18 bullets, 1 bullet fragment, and 5 pellets retained in the hearts of 24 patients. Ten missiles were removed, no attempt was made in 13 patients, and an unsuccessful attempt was made to remove one other. From group 1 patients, 6 died, 2 with intracavitary missiles, 3 patients with partially intramyocardial, and 1 patient with an intrapericardial missile, all of whom had either unsuccessful or no attempt to remove the missile. Twenty-seven patients had symptoms, all of whom, except two, had either unsuccessful or no attempt to remove the missile. All group 2 patients did well and had been free of symptoms related to the missiles. This review suggests that the management of missiles in the heart should be individualized according to the patient's clinical course, the site, shape, and size of the missile, and that in selected patients missiles in the heart are tolerated well.

Asunto(s)

RESUMEN

The records of 24 patients who had a missile retained in the heart and who were treated at Grady Memorial Hospital from 1968 to 1987 were reviewed. In 22, the missile lodged in the heart after its direct injury and in the remaining 2, after the bullet injured a systemic vein. Immediately after the cardiac injury, 7 of the 22 patients were seen with cardiac tamponade (3 also had hemothorax), 11 were seen with hemothorax, 5 were asymptomatic, and 1 was in shock. Seven patients underwent emergency thoracotomy; the bullet was removed in 3, but in the remaining 4 patients, it was not located. In the other 17 patients and in the 4 in whom the bullet could not be found during emergency thoracotomy, the diagnosis was suspected from the chest roentgenograms and confirmed by cardiac fluoroscopy or angiocardiography. Eight patients with retained bullets underwent elective operation; the bullet was removed from 7 and in 1 it was left embedded in the right ventricular septum. All 10 patients who underwent excision of the missile recovered without complication except 1 in whom pericarditis developed, and all were followed for up to 17 years. All 14 patients with a retained missile in the heart had no cardiac symptoms referable to the bullet and were followed for up to 15 years. This experience suggests that the management of patients with a bullet of .38 caliber or smaller that is retained in the heart should be individualized according to the patient's clinical course and the site of the bullet and that in select patients, bullets left in the heart are tolerated well.

Asunto(s)

Asunto(s)

RESUMEN

A high index of suspicion of the presence of post-traumatic residual sequelae usually leads to early diagnosis of these lesions. The type and site of the traumatic impact and the presenting symptoms and signs frequently suggest the type of problem. The use of the appropriate diagnostic tests and the institution of suitable therapy will protect the patients from more serious subsequent complications and frequently will result in the restoration of their health to its preinjury status.

Asunto(s)

RESUMEN

In general, appropriate use of tube thoracostomy results in complete drainage of the collected air and fluid in the pleural space and allows full expansion and occupation of the entire pleural space by the lung, thus protecting the lung and pleural space from subsequent complications. In addition, the drainage of the pleural space with a tube thoracostomy allows more accurate monitoring of the rate of accumulation of air and blood in the pleural space. Thus, it provides valuable information for the subsequent management of some patients, such as those with traumatic hemothorax.

Asunto(s)

RESUMEN

The coagulation system was investigated in five dogs undergoing autotransfusion from experimental hemothorax. One fourth of the blood volume was bled into the pleural space, drained, and autotransfused. The hemothorax blood showed: very prolonged PT and PTT; very low platelets and fibrinogen; midly elevated FDP; very low coagulation factors VIII, and V; reduced XII, prothrombin, X, XI, and VII. Partial clotting, mild fibrinolysis, and fibrin deposition over the pulmonary pleura seemed to cause incoagulability of hemothorax blood. Post autotransfusion arterial blood showed: normal PT and PTT; 25% decrease in platelets, and 31% decrease in fibrinogen from baseline values. There was also an overall 20% reduction of fibrinogen from baseline values. There was also an overall 20% reduction of all clotting factors, but their levels remained above 50% activity. It was concluded that autotransfusion from a hemothorax of 25% the blood volume in dogs causes a mild loss of hemostatic components, but does not significantly compromise the clotting mechanism.

Asunto(s)