Damage control in penetrating cardiac trauma

Abstract

Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients.

Keywords: Damage Control Surgery; Penetrating cardiac trauma; Thoracic Ultrasound; advanced trauma life support care; cardiac tamponade; chest tubes; death, sudden; hemothora; negative-pressure wound therapy; pericardial window techniques; pericardiectomy; pneumothorax; sternotomy; thoracotomy.

Figure 1. Cardiac Injuries. A. Cardiac injury of the ventricle with perilesional clot but not extending through the endocardium. B. Penetrating cardiac injury extending through the endocardium.

Figure 2. Damage control techniques in Cardiac Trauma. A. In cardiac injuries extending through the endocardium a Foley catheter should be inserted into the wound, inflated and gently retracted to achieve hemorrhage control. B. Hemorrhage control with sutures placed parallel to the wound then cross and/or tight. C. Temporal hemorrhage control with skin Stapler.

Figure 3. Hemorrhage control with Sauerbruch Grip. If the hemorrhage is so severe that the surgeon is not able to visualize the source, then this grip should be applied to achieve total inflow occlusion by compressing the vena cava at the junction with the right atrium.

Figure 4. Surgical techniques in Cardiac Trauma  A. Simple suture repair without Teflon pledgets in <5mm ventricular wounds. B. Simple suture repair with Teflon pledgets in older patients with >5mm ventricular wound. C. U-Stitch adjacent to a coronary artery. D. Prompt placement of a Satisnky Clamp for temporal hemorrhage control.

Figure 5. Surgical techniques in Cardiac Trauma. A. Continuous Suture Repair of Atrial Wound with a Satinsky clamp. B. Continuous suture repair of >2cm cardiac injury. C. Cardiac Lift for Posterior Injuries, which should be performed carefully and quickly due to potential rhythm disorders, sudden drop in cardiac output or sudden cardiac arrest.

Figure 6. Surgical Management Algorithm for Penetrating Precordial Injuries

Figura 1. Heridas Cardiacas. A: Lesión en el ventrículo cardiaco menor sin extensión al endocardio y formación de coagulo perilesional. B: Lesión del ventrículo cardiaco perforante con compromiso del endocardio.

Figura 2. Técnicas de Control de Sangrado en Trauma Cardiaco. A. En heridas que comprometen hasta el endocardio, puede ser controlado con la inserción de una sonda Foley y haciendo una leve tracción. B. Técnica de control con el uso de puntos de sutura paralelos y a cada lado de la herida cardiaca que posteriormente se elevan y se cruzan para lograr un control de sangrado. C. Control Temporal con uso de grapas de piel.

Figura 3. Control del Sangrado general con la Maniobra de Sauerbruch. Se usa en caso de hemorragia severa y no se visualiza la fuente del sangrado. El cirujano posiciona su tercer dedo posterior a la vena cava y su segundo dedo anterior a esta y realizar compresión interdigital

Figura 4. Técnicas de Reparo de Lesión Cardíaca. A. Reparo con Sutura Simple sin Pledget de Teflon se indica en heridas ventriculares < 5 mm. B. Reparo con Sutura Simple con Pledget de Teflon se indica en heridas > 5 mm y paciente mayores. C. Reparo con Punto en U adyacente a vaso coronario se realiza para heridas contiguas a un vaso coronario. D. Colocación temprana de Pinza Satinsky en heridas de aurícula permite el control temporal de la herida.

Figura 5. Técnicas de Reparo Cardiaco. A. Reparo en sutura continua sobre trayecto de la herida en aurícula aislada por una pinza de Satinsky. B Reparo sutura continua en caso de heridas mayores a 2 cm. C. Elevación cardiaca se recomienda realizar para descartar heridas posteriores de manera rápida por riesgo de trastornos del ritmo, caída súbita en el gasto o paro cardiaco súbito.

Figura 6. Algoritmo manejo quirúrgico para heridas precordiales penetrantes