[Interdisciplinary management of perforating heart injuries]

Abstract

Penetrating cardiac injuries are being observed in urban regions with increasing frequency; due to improved advanced trauma life support ascending numbers of trauma victims are reaching the trauma centers still alive. The main pathophysiological determinant is acute pericardial tamponade. The time course of the patients' circulatory state cannot be predicted due to the nonlinear course of the pressure-volume relationship. Thus only after clinical diagnosis is made and if the circulation is poor should on-the-spot emergency subxiphoidal pericardiocentensis be considered and endotracheal intubation is indicated restrictively. The concept of clinical emergency room management is as follows: (1) Under stable circulatory conditions urgent exploratory pericardiotomy should be performed following sonographic confirmation; (2) in compensated state of shock and with clinical signs of tamponade immediate pericardiotomy should be done simultaneously with induction of anesthesia, abstaining from any diagnostic procedures; (3) in life-treating situations or under resuscitation emergency sternotomy should be performed by the surgeon present, aiming to control bleeding. Reconstruction can be done in cooperation with the cardiothoracic surgeon. The operative techniques used may extend from simple suturing of the myocardial injury to emergency aortocoronary bypass grafting. By quick interdisciplinary emergency management including basic cardiac surgical techniques (performed ideally by the trained general or trauma surgeon) even penetrating cardiac injuries can be treated with acceptable prognosis.