War injuries of heart and mediastinum

Management of Penetrating Cardiac Injuries With Pericardial Window and Drainage in Select Patients

BACKGROUND

Management of penetrating chest injuries with a positive pericardial window (PW) are presumed cardiac injuries and traditionally result in sternotomy. However, there is some evidence in the literature that select patients can be managed with PW, lavage, and drainage (PWLD).

METHODS

All patients with penetrating chest trauma who underwent PW and/or sternotomy over a 5-year period were identified. Patients were stratified by operative intervention [PW + sternotomy vs PWLD] and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of therapeutic sternotomy.

RESULTS

Of the 146 patients who underwent PW and/or sternotomy included in the study, 126 patients underwent PW, 39 underwent sternotomy, and 10 underwent PWLD. There was no difference in demographics, LOS, ICU LOS, vent days, or mortality in patients who underwent PW + sternotomy, compared to patients who underwent PWLD. In the PWLD group, one patient returned to the OR for recurrent pericardial effusion and no patients required sternotomy. Multivariable logistic regression identified ISS as an independent predictor of therapeutic sternotomy (OR 1.160; 95% CI 1.006-1.338, P = .0616). Interestingly, positive FAST, significant CT findings, and trajectory were not predictors of therapeutic sternotomy. There were 7 patients with a left hemothorax and negative FAST found to have a positive PW and cardiac injury mandating sternotomy and repair.

CONCLUSION

Penetrating cardiac injury can be managed with PWLD in select patients. Positive FAST, significant findings on CT, and trajectory do not mandate sternotomy. A negative FAST in the setting of a hemothorax does not rule out a cardiac injury.

Penetrating cardiac injury: a review

Cardiac injury presents a great challenge to the emergency resident because these injuries require urgent intervention to prevent death. Sometimes serious cardiac injury may manifest only subtle or occult symptoms or signs. As there is an epidemic of cardiac injuries in Kashmir valley due to problems of law and order, we herein present a review on management of such injuries.

Diagnostic challenges and treatment options of a suspected pericardial metallic projectile foreign body in a dog

OBJECTIVE

To describe a case of a suspected pericardial metallic projectile foreign body in a dog with a history of trauma to the left shoulder and to review the literature regarding the management of cardiac and intracardiac foreign bodies.

CASE SUMMARY

A 3-year-old male, neutered Brittany spaniel presented with a 10-day history of decreased activity and partial anorexia. Serial thoracic radiographs identified a migrating pericardial metallic projectile foreign body and an echocardiogram diagnosed pericardial effusion and abdominal ultrasound identified the presence of ascites. Concern for a possible effusive-constrictive pericarditis prompted a subphrenic pericardectomy performed via thoracoscopy. The foreign body was not recovered. Six months postsurgery, the dog remained asymptomatic.

NEW OR UNIQUE INFORMATION PROVIDED

Considering the high rate of complications that develop in human patients where the foreign bodies are not removed, veterinarians should be aware of risks associated with long standing pericardial foreign bodies even when no clinical signs are present. Guidelines from the human literature may be considered for investigation of, and treatment options for, cardiac and intracardiac metallic projectile foreign bodies in dogs.

Conservative management of retained cardiac missiles: case report and literature review

Intracardiac foreign bodies may be caused by direct penetrating trauma, embolization from injury to another area of the body, or iatrogenically from fragments of intravascular access devices. Penetrating cardiac trauma commonly presents with a hemodynamically unstable patient necessitating emergent life-saving procedures. Missile embolization to the heart can occur after injury to systemic and pulmonary veins. Central venous access devices may fracture after placement and embolize. Especially in the setting of penetrating cardiac trauma, these intracardiac foreign bodies require expeditious removal. Limited data exist regarding the conservative management of intracardiac material after trauma. We present the case of a 42-year-old male soldier injured in a mortar blast in Iraq who suffered multiple injuries to include a right hemopneumothorax and soft tissue injuries to the chest and both lower extremities that was found to have a 2-cm by 2-mm intracardiac metal fragment. Additional imaging revealed a metallic fragment localized to the interatrial septum. The patient suffered no adverse sequelae from nonoperative management. A review of the world literature regarding the subject of posttraumatic retained cardiac missiles (RCMs) is also included to help future surgeons in the management of this rare entity.

Needle embolus causing cardiac puncture and chronic constrictive pericarditis

We present a case in which a needle broke off during intravenous injection and embolized to the right heart. After cardiac perforation, the needle entered the pericardial space and ultimately caused chronic constrictive pericarditis, which presented as congestive heart failure. Pericardectomy and removal of the foreign body via a median sternotomy were successful. Early surgical removal of contaminated intrapericardial foreign bodies remains a safe and effective approach to preventing such complications.

Acute mediastinitis. What to do when the cause is nonsurgical

Acute mediastinitis is a serious disease that requires prompt diagnosis and aggressive treatment. In each case, treatment should be individualized to the clinical presentation and suspected cause. The authors presented a general therapeutic scheme that may be used in the initial management of patients with acute mediastinitis from nonsurgical sources.

Cardiac Injuries *

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