Tag Archives: cardiac injury

Thorax

Survival After Penetrating Injury To The Heart

Penetrating injury to the chest, and especially the heart, has a high mortality rate. The best way to reduce mortality is rapid pre-hospital transport to a trauma center where life-saving measures can be carried out immediately. Frequently, these measures include resuscitative thoracotomy. The Western Trauma Society has a well-known guideline to help with decision-making in performing this procedure.

The trauma group at Sinai Chicago recently published a paper slicing and dicing the possible predictors of survival after cardiac injury. As I read this paper, I was curious about how this information would change our practice, especially with the decision to open the chest.

The authors performed a retrospective cohort study of patients who had suffered penetrating cardiac trauma over nine years. Here are the factoids:

  • Over 18,000 patient encounters were analyzed (average 2,000 per year), and only 57 penetrating cardiac injuries were identified (3%)
  • Overall survival was 25% (!)
  • Gunshot victims were 3.7x more likely to die
  • Mortality odds ratios for specific injury patterns were as follows:
    • Multiple cardiac chambers injured 11x
    • Thoracic vascular injury 12x
    • Concurrent abdominal injury 4.4x
  • These findings were noted to decrease the likelihood (odds ratio) of death:
    • Isolated cardiac injury 0.2x
    • Spontaneous respirations 0.06x
    • Signs of life on arrival 0.01x
  • Every patient (35) who underwent resuscitative thoracotomy died

The authors suggested that recognizing these factors could help clinicians in decision-making processes during early triage and resuscitation.

Bottom line: When I first read the paper, it seemed that this was all common-sense information and didn’t add much to our body of knowledge. However, upon closer reading, there are some good tidbits here. The work here helps identify which patients are most likely to benefit from opening the chest. It assigns probabilities to anatomic and physiologic criteria, some of which are apparent at the time of patient arrival and are available for decision making. The fact that every patient who underwent resuscitative thoracotomy died is not alarming; it merely reflects the fact that these are patients who are the sickest of the sick. 

So how do we put the information in this paper to use? The resuscitative thoracotomy algorithm from the Western Trauma Association should be utilized first. When the patient is on the cusp of the 15-minute CPR decision point, the odds ratios in this paper might be used to tilt the scales one way or the other. Does the patient also have abdominal injuries? Are there no signs of life? Then perhaps clinician judgment may dictate that the procedure not be performed. Alternatively, if the thoracotomy is carried out in patients and any of the three high-risk anatomic indicators for death are present, they might then choose to terminate the procedure to conserve resources. 

Overall, this paper does not force any major changes in care. It informs the trauma professional and allows them to couple that information with existing algorithms and care processes, so they might either further improve the patient’s probability of survival or conserve scarce resources if survival is unlikely. 

References: 

  1. Predictors of survival after penetrating cardiac trauma: injury patterns and presentation factors. Trauma Surg Acute Care
    Open 2026;11:e002237.
  2. Western Trauma Association Resuscitative Thoracotomy Practice Guideline
Technique

2 Ways To Perform A Pericardial Window For Trauma: Part 2 With Video!

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In my last post, I reviewed the classic, “old-timey” subxyphoid approach to the pericardial window procedure for trauma. Today, I’ll describe the operative approach if you are already in the abdomen managing injuries there.

The same considerations apply to these patients in deciding to perform the window. Either there is a suspicion of actual pericardial tamponade based on physiology or diagnostic imaging, or an injury has been noted in proximity to the heart that raises that suspicion.

If you are already exploring the abdomen, the procedure is much simpler. The instruments required are already in your laparotomy setup:

  • Two toothed forceps
  • Tissue (Metzenbaum) scissors

First, and most importantly, the upper abdomen must be evacuated of all blood. This is critically important since a positive window is solely determined by the presence of blood in the pericardial fluid. If it is contaminated with blood as it flows into the peritoneal cavity, a false positive may result leading to an unneeded thoracotomy or sternotomy.

The midline incision must extend to the xiphoid process in order to get adequate exposure of the diaphragm. The left lobe of the liver is retracted downwards by your assistant, and the two of you can then grasp an area of the pericardial portion of the diaphragm with the toothed forceps. As it is tented away from the heart, the scissors are used to dissect through both the diaphragm and pericardium. Although some use cautery for this, I’m a weenie using electricity near the heart.

The diaphragm is thick, so expect to cut through several mm of tissue before you see pericardial fluid. Watch the color of the fluid carefully. If it is the least bit blood tinged, the result is positive. And be sure to watch for 15-30 seconds. Sometimes the initial fluid is amber, but it becomes bloody as more is drained.

Bloody fluid equals positive result. This means that a thoracic procedure is indicated to evaluate the heart and repair the injury. The choice of sternotomy vs thoracotomy is determined by mechanism, foreign body trajectory, and suspected area of injury on the heart.

If the result is negative, you may close the hole with your suture of choice. If the abdomen is contaminated from a bowel injury, I recommend you use the traditional subxiphoid approach separate from the laparotomy incision to avoid contaminating the pericardial sac.

Here’s a YouTube video of a transdiaphragmatic window created laparoscopically. Since abdominal explorations for major trauma seldom lend themselves to laparoscopy, don’t get any ideas from watching this!

YouTube player
Technique

2 Ways To Perform A Pericardial Window For Trauma: Part 1 with Video!

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In this two-part post, I’ll describe two ways to perform a pericardial window for trauma. The pericardial window should be considered in any trauma patient who has one of the following:

  • A suspected diagnosis of pericardial tamponade. These patients do not yet have classic signs and symptoms. If they did, a thoracotomy or sternotomy is in order, not a window.  But they do have a mechanism that could produce bleeding into the pericardial sac, and a positive imaging study. Typically, this study is a FAST exam of the heart. Occasionally, pericardial fluid may be seen on chest CT. This is uncommon but significant when detected.
  • An injury in proximity to the heart that is of concern for cardiac injury with a negative or indeterminant FAST. These are typically penetrating injuries so close to the heart that it’s hard to believe it wasn’t injured. If the FAST is not helpful, a window will make the definitive diagnosis.

Pericardial window is a very invasive procedure. For trauma, it is usually performed in the operating room and requires general anesthesia. It could be performed in the ED if the patient is already intubated and sedated.

There are two ways to perform this procedure. Today, I’ll discuss the old-timey subxiphoid approach.  The equipment required is minimal:

  • Scalpel
  • Tissue (Metzenbaum) scissors
  • Once or two toothed forceps
  • Your finger
  • Good lighting

A 4-8 cm incision is made extending from the top of the xiphoid, extending about 4 cm down onto the abdominal midline. Enter the retrosternal space with your finger, and head to the heart. Usually, some fatty tissue must be bluntly dissected out of the way. Note: the heart is frequently further away than you think!

Sweep the fat out of the way, exposing the pericardium. Grasp the pericardium with the toothed forceps and tent it away from the heart. Use the Metzenbaum scissors to incise the pericardium immediately adjacent to the forceps. If this is difficult, then have an assistant grasp the pericardium with another pair so a short line of pericardium is elevated. (Note: sometimes having a second set of forceps in the incision makes it too difficult to see, which is why I prefer the single forceps technique).

Make sure that the wound is bloodless when you incise the pericardium! There is always at least a small amount of pericardial fluid that will squirt out, and you are looking at its color. If it is anything but amber, you have a positive result. If you have a bloody field that contaminates the fluid, a false positive diagnosis could occur leading to an unnecessary thoracotomy.

If the window is positive, cover the wound and head immediately to the OR if your’re not already there. Your patient has a cardiac injury until proven otherwise. If negative, then close the skin wound with your sutures / staples of choice. Do not attempt to close the tiny pericardial hole!

Here’s a video that shows the basic technique. The procedure depicted is being performed for non-trauma, so the operator takes his time. He has the luxury of dissecting and exposing the field well. But in trauma, we don’t usually have time to resect the xiphoid or take 10 minutes to dissect out the field.

YouTube player

In my next post, I’ll discuss the technique that is used if you already find yourself in the abdomen when a cardiac injury is suspected.