2-D echocardiography: emergent use in the evaluation of penetrating precordial trauma

Diagnosis of cardiac injury in stable patients suffering penetrating precordial trauma has relied on observation, subxiphoid window, or exploratory thoracotomy. Previous reports have stressed the need for an alternative noninvasive diagnostic test. Although the use of echocardiography (ECHO) in this patient population has been suggested, to our knowledge no report thus far has presented extensive experience with this technique. We present our experience over 3 years with 36 patients in whom emergent ECHO was used as part of their initial work-up. Injuries included single stab wounds (17), multiple stab wounds (14), and gunshot wounds (5). Four patients (11%) had jugular venous distention, and 12 (33%) were tachycardic. None had a systolic blood pressure below 90 mm Hg. Four ECHOs (11%) were positive for pericardial effusion. No valvular abnormalities were detected. Three of the effusions were small and these patients were triaged to monitored beds and observed. All three effusions resolved on serial echocardiography. The fourth patient underwent an uneventful operative repair of a left ventricular laceration. Although the yield is low, emergent 2-D ECHO is a valuable tool in the triage of stable penetrating trauma patients when cardiac injury is suspected. Patients without effusion can be discharged or triaged to a ward bed. Small effusions can be observed in a monitored setting with serial examinations, while large effusions should be treated surgically. Echocardiography is less expensive than ICU admission and less invasive than either subxiphoid window or thoracotomy. There are no known complications associated with the procedure and it is recommended for emergent use when available.     

Which treatment in pericardial effusion?

BACKGROUND: Pericardiocentesis, pleuro-pericardial window, subxiphoid pericardial drainage and pericardioscopy: which methodology to treat pericardial effusion? Each of these surgical treatments can be effective, depending on clinical factors and history of the patients. We considered pericardial effusions during 5 years. METHODS: We reviewed 64 cases: 14 acute pericardial effusions (5 patients with cardiac tamponade), 39 subacute, 11 chronic. Epidemiology and aetiology: 8 cases were between 20 and 25 years old (all affected by lymphoma), 56 were distributed in every age, especially over 60, and of these 45 were neoplastic and 11 non- neoplastic. Non-neoplastic cases were connectivitis (3 patients), uncertain origin effusion (7 patients), tubercular (1 patient). In neoplastic effusions we found lymphoma (at older age) in 7, small cell lung cancer in 6, NSCLC in 12, mesothelioma in 2, breast cancer in 7. RESULTS: Acute pericardial effusions with cardiac tamponade underwent echo-guided pericardiocentesis. In 43 we had a subxiphoid pericardial drainage, among these cases we performed 4 pericardioscopies. We created a pleuro-pericardial window on VATS in 13, on thoracotomy in 4 for technical reasons. CONCLUSIONS: Pericardiocentesis is to be preferred in acute pericardial effusion with cardiac tamponade to avoid general anaesthesia. Pleuro-pericardial window on VATS is better in chronic pericardial effusion (for infective or systemic disease) and in recurrence, after performing subxiphoid drainage. Subxiphoid drainage is suitable for all neoplastic patients, and in case of unknown aetiology in order to perform a pericardioscopy.     

心脏外科术后心包积液的危险因素与治疗

目的 探讨心脏外科手术后心包积液的危险因素和治疗方法.方法 回顾分析22 462例患者临床资料,定义心包积液诊断标准.观察心包积液患者与无积液患者的临床表现,对症治疗,分析危险因素.结果 509例(2.3％)患者有心包积液262例有临床特殊症状,其中51例有心包压塞的临床表现.有、无心包积液的患者年龄、性别、冠心病史等因素差异无统计学意义(P＞0.05);而大体重、瓣膜病、主动脉阻断和体外循环时间差异有统计学意义(P＜0.05).结论 心包积液的危险因素有大体重,术前心功能Ⅲ、Ⅳ级,瓣膜病,先天性心脏病,大血管疾病,体外循环和主动脉阻断时间延长.超声引导下的心包积液穿刺引流是安全有效的.     

The incidence and significance of early pericardial effusion after open heart surgery

The presence and severity of postoperative pericardial effusions were studied echocardiographically in 114 consecutive patients (70 males, 44 females; mean age 56 +/- 10 years). An effusion was present in 35 patients at 3-5 days. An effusion was less common when a drainage tube was inserted for 24-36 h in the posterior as well as the anterior mediastinum than when only an anterior drain was used. Patients with effusions differed from those without in having more supraventricular arrhythmias, more wound infections, smaller total blood drainage and longer postoperative hospital stay. Three patients with posterior pericardial effusions developed cardiac tamponade 5-18 days postoperatively. The data show that pericardial effusions are associated with postoperative complications and suggest that effusion formation can be reduced by using posterior as well as anterior chest drains.     

Delayed tamponade and traumatic myocardial contusion: evaluate the risk after blunt chest trauma

Cardiac contusion is frequently found in patients with blunt chest trauma. It is important to note that even if there is a low incidence of pericardial effusion, iterative echocardiography should be used to provide essential information for the diagnosis of cardiac tamponade which can be life-threatening during hospitalisation. The case has been reported of a 17-year-old patient with blunt thoracic trauma in whom the introduction of anticoagulant treatment induced a delayed cardiac tamponade with myocardiac failure 3 weeks after a cardiac contusion. Thoracic computed tomography confirmed the diagnosis and moreover, revealed a pleural effusion with pulmonary embolism. The drainage of the pericardial effusion (700 ml) rapidly restored haemodynamic stability and as such has been proved to be life-saving.     

Penetrating cardiac trauma: management strategy based on 129 surgical emergencies over 2 years.

Between 1986 and 1988, 129 patients with stab wounds to the heart were referred from the emergency room of our institution for a thoracic surgical procedure. Multiple entrance wounds of the heart were present in 12 patients, and through-and-through stab wounds were encountered in another 10. The overall hospital mortality rate was 8.5% (11/129), which includes a 54% mortality rate for the 13 patients undergoing emergency room thoracotomy. These patients were pulseless and unconscious either on arrival (n = 8) or soon thereafter (n = 5). Cardiopulmonary bypass was not used during the primary operation, although 7 patients underwent subsequent intracardiac repair with bypass without hospital mortality. Important aspects of our preoperative management strategy include: (1) aggressive transfusion to improve the central venous pressure/intrapericardial pressure gradient; (2) rapid drainage of the pleural and pericardial spaces to reduce intrapericardial pressure; (3) empirical partial correction of metabolic acidosis with sodium bicarbonate; and (4) emergency operation without unnecessary cardiac imaging. Patients suspected of having penetrating cardiac trauma and cardiac tamponade are best managed by aggressive primary intervention and immediate operation.     

Penetrating thoracic injury

PURPOSE To clarify the clinical aspects of penetrating thoracic injury. PATIENTS AND METHODS: Eighteen patients with penetrating thoracic injury treated from 1987 to 2005 were evaluated. There were 13 men and 5 women. The age distribution was 8 to 69 years, with an average of 36.7 years. RESULTS: There were 14 patients with stab wound and 4 with impalement injury. Five patients with stab wound were those who attempted suicide. In 4 patients with impalement injuries, the cause was fall in 2, traffic accident in 1 and sports injury in 1. The calculated injury severity score (ISS) was over 15 in 4 patients, 6 to 14 in 12, and under 5 in 2. Thoracotomy was performed in 2 patients with cardiac tamponade, 3 with massive hemothorax and 1 with an impalement injury caused by an iron bar. All of them were rescued and got well. In the other cases, after cleansing and debridement, the wound was closed and thoracic drainage was performed. Only 1 patient with cardiac arrest on arrival died within 24 hours after reviving. CONCLUSIONS: Emergent thoracotomy is indicated for patients with massive bleeding including shock, continuous air leakage and cardiac tamponade. Since cardiac arrest is difficult to cure, appropriate cooperation with the rescue team is necessary to avoid preventable trauma death.     

Eleven years' experience with pericardial-peritoneal window in the management of malignant and benign pericardial effusions

Background: Before 1983 we routinely used subxiphoid drainage for the management of pericardial effusions. Pericardial-pleural window through a left anterior thoracotomy was used in selected patients. Due to frustration over the rate of recurrent pericardial effusions with subxiphoid drainage alone and concern over the higher morbidity with thoracotomy, the creation of a 3-cm pericardial-peritoneal window in the fused portion of the pericardium and diaphragm overlying the left lobe of the liver was added to subxiphoid drainage in 1983. Methods: This study is a retrospective chart review of the 33 patients undergoing pericardial-peritoneal window from 1983 through 1993. Eighteen patients had malignancies, mainly lung and breast, and 15 had benign pericardial effusions. Results: The procedure was well tolerated, with a 30-day mortality of 9%; however, no deaths were directly related to the pericardial effusion or the procedure. No patient developed peritoneal carcinomatosis or diaphragmatic hernia. One patient developed recurrent pericardial effusion during follow-up, and two required pericardiectomy for constrictive disease. Among those with malignancies, patients with breast cancer had the longest survival after pericardial-peritoneal window. Conclusions: Pericardial-peritoneal window is a simple, safe, and effective procedure and applicable to most patients with malignant and noninfectious benign pericardial effusion, including those with tamponade. Presented at the 47th Annual Cancer Symposium of The Society of Surgical Oncology, Houston, Texas, March 17–20, 1994.     

Postpericardiotomy syndrome after minimally invasive repair of pectus excavatum

Minimally invasive repair of pectus excavatum (MIRPE) was first reported in 1998 and has gained wide acceptance since then. A 17-year-old girl who had undergone thoracotomy and cardiac surgery for transposition of great vessels at the age of 18 months presented with a deep, long pectus excavatum with asymmetry. After initial uneventful postoperative clinical course after MIRPE, the patient had bilateral pleural and pericardial effusion on the sixth postoperative day. Suspecting postpericardiotomy syndrome, systemic steroids were administered, and the symptoms resolved without affecting wound healing. Manifestation of a pericardial effusion combined with bilateral pleural effusion after MIRPE, especially in patients after cardiac surgery, may indicate a postpericardiotomy syndrome that can be treated successfully by intravenous steroids.     

Transthorakale Echokardiographie bei thorakaler Messerstichverletzung

Penetrating chest trauma involving the heart is usually known with a high mortality rate. Neither the absence of hemodynamic depression nor ECG changes exclude a potential fatal injury to the heart. We report on the diagnosis and definitive treatment of a stab wound injury with transected coronary artery, concomittant ventricular penetration, and pulmonary injury.A 37-year-old female was admitted to our emergency room with multiple left-sided gashes (cheek, neck, upper extremity) and a single stab wound in the left thorax. At the scene of the accident the patient's hemodynamic condition was stable with no signs of shock or shortness of breath. Auscultation revealed regular respiratory sound on both lung sides. Hospital transfer by ground was uneventful. Chest X-ray showed left pleural effusion with no signs of pneumothorax. ECG demonstrated regular sinus rhythm without repolarization changes or low voltage. Transthoracic echocardiography revealed pericardial effusion with a swinging heart. The patient was electively intubated in the emergency room and transferred to the operating room for pericardial paracentesis. Median sternotomy was necessary due to extensive bleeding in the drain. Examination of the heart showed a laceration of the left coronary artery (LAD), left ventricle, and upper lobe of the left lung. Cardiopulmonary bypass was instituted and the LAD was ligated proximal to the penetration. The left internal thoracic artery was used for coronary revascularization of the LAD. Postoperative ECG and creatine kinase evaluations excluded myocardial ischemia. The patient was discharged from hospital at POD 10 fully recovered. Transthoracic echocardiography in the emergency room is the diagnostic tool of choice to exclude/confirm a potential cardiac injury. In the case of pericardial effusion, paracentesis sometimes followed by thoracotomy should be performed. The importance of rapid diagnosis and intervention should be emphasized to reduce mortality due to cardiac tamponade or acute myocardial infarction as illustrated by this case.     

儿童简单先天性心脏病直视手术后不预防性放置引流的临床研究(附200例报告)

目的探讨儿童简单先心病直视手术后不预防性放置外科引流的可行性与安全性。方法先天性心脏病患儿200例,年龄1~5岁,经胸骨正中切口进行心脏直视手术,右侧心包开窗后不放置引流管关胸。术后观察临床表现以及恢复情况。术后随访一月。结果术后2周随访,4例患儿发现右侧胸腔中~大量积液,其中室间隔缺损2例,房间隔缺损2例,均重新入院,行右侧胸腔闭式引流术。首日引流量为300~800 ml,总引流量为400~1 500 ml,引流时间3~7 d。4例患儿术后1月复查均未再发现心包和胸腔积液。结论儿童简单先天性心脏病直视手术后患儿,通过实施右侧心包开窗,可以不预防性放置外科引流。该技术能够避免外科引流所引起的疼痛及相关并发症,有利于术后护理和康复;能够避免因放置外科引流管所引发的不良医疗事件;能够避免术后急性心包填塞,预防迟发性心包积液可能导致的心包填塞。     

Volumetry of pleural effusion in multi-morbidity, postoperative patients of a surgical intensive care unit. Comparison of ultrasound diagnosis and thoracic bedside image

Aim of this study was to evaluate the importance of chest ultrasound and chest x-ray for the indication of thoracic drainage of pleural effusions in patients of an operative intensive care unit. Between December 1996 and June 1997 21 patients were included in a prospective trial in the operative intensive care unit. 26 thoracic drainages were used to drain pleural effusions. In all patients chest radiography in supine position and chest ultrasound were performed to assess the need of pleural drainage. Pleural fluid measured radiologically was categorized into 3 groups: pleural fluid less than 500 ml, 500 to 1,000 ml or more than 1,000 ml. The amount of the pleural effusion was sonographically determined by a standardized formula. After complete drainage of the pleural space the real volume of the fluid was measured and compared with the estimated value. The real amount of the fluid was correctly determined by chest radiographs in 16 cases (62%) and by chest ultrasound in 18 patients (69%). Pleural effusions less than 600 ml sonographically correlated much better with the real amount of the fluid than pleural effusions above 600 ml. In 8 cases (31%) ultrasound provided an additional information for correct indication of drainage. Considering both x-ray of the chest in supine position and chest ultrasound the correct indication to drain the pleural effusion was achieved in 25 cases (96%). In this prospective trial we compared chest ultrasound and chest radiography and demonstrated that ultrasound is more suitable to determine the amount of pleural effusions than radiography. In case of clinical and radiological suspicion on pleural effusion demanding for drainage a chest ultrasound should be performed to avoid underestimation of pleural fluid.     

Malignant pericardial effusion--an uncommon complication of multiple myeloma: case report

Multiple myeloma is a condition usually associated with lesions of the skeleton. However, under rare circumstances, the malignant plasma cells may infiltrate the pericardium, resulting in an effusion. If left untreated, the abnormal accumulation of pericardial fluid will result in cardiac tamponade, requiring drainage. The following report describes a multiple myeloma patient who developed secondary pericardial and pleural effusions, which were surgically drained via a pleuropericardial window.     

Injuries of the heart and para-cardiac large vessels

Myocardial contusion is the most common manifestation of cardiac trauma; the true heart rupture or posttraumatic aneurysms are rare. Pericardial rupture can lead to cardiac strangulation; haemorrhagic pericardial effusion following trauma requires surgical drainage. Constrictive pericarditis occurs rarely after pericardial injury. Valve injury causes always the incompetence: traumatic aortic and mitral incompetence occur with both blunt and penetrating injury. In penetrating heart trauma a surgical revision is almost always necessary, to perform hemostasis and to decompress pericardial tamponade. Traumatic rupture of the descending thoracic aorta is amenable to immediate surgical treatment; end-to-end-anastomosis with simple aortic cross-clamping is the method of choice. Pump oxygenator is rarely necessary in treatment of cardiac trauma; emergency surgery--pericardial decompression, hemostasis and bilateral chest drainage--is performed in primary trauma center.     

Prehospital resuscitative thoracotomy for cardiac arrest after penetrating trauma: rationale and case series

OBJECTIVE: The purpose of this study is to present the rationale for an algorithm that describes the place of resuscitative thoracotomy in the prehospital management of a patient with penetrating chest injury, and to review a 6-year experience using this algorithm. METHODS: This study was a retrospective review of all cases where a prehospital thoracotomy was performed by the medical teams of the London Helicopter Emergency Medical Service. RESULTS: Thirty-nine prehospital thoracotomies were performed. Four (10%) patients survived, one with long-term disability. Factors associated with survival were stab wound, single cardiac wound, cardiac tamponade, and loss of pulse in the presence of an experienced prehospital doctor. CONCLUSION: Current evidence suggests that patients who suffer a cardiac arrest more than 10 minutes away from emergency room thoracotomy are very unlikely to survive. Prehospital thoracotomy is associated with a small number of survivors. This intervention should be considered if there is an appropriately experienced, trained, and equipped doctor present, who is acting within a trauma system with ongoing training and quality assurance.     

血小板检测对儿童肺吸虫病患者的诊断价值

目的分析血小板（PLT）检测在儿童肺吸虫病患者临床诊断中的价值。 方法回顾性分析2010年1月至2017年12月十堰市人民医院感染性疾病科和儿科住院确诊的19例儿童肺吸虫病患者的临床表现、PLT计数、白细胞（WBC）、嗜酸性粒细胞计数（EOS）、胸肺部螺旋X线计算机断层摄影（MSCT）以及浆膜腔彩色多普勒超声检查结果。分析PLT变化与肺吸虫病临床表现和影像学变化间的相关性。根据PLT水平是否高于正常值分为PLT升高组（12例）和PLT正常组（7例）。 结果PLT升高组患者呼吸系统症状、体征异常者12例次,MSCT显示该组病例均有肺部病灶（其中9例患者伴有双侧胸腔积液、3例患者伴有单侧胸腔积液）。PLT正常组患者呼吸系统症状、体征异常者1例,MSCT显示1例患者有胸腔积液。治疗后PLT升高组患者随肺部病灶消退、PLT恢复正常;PLT正常组患者治疗前后无变化。WBC水平变化：16例患者WBC正常,3例患者WBC水平升高。WBC水平升高患者合并扁桃腺细菌感染、肠道感染、肺内感染者1例,抗菌药物治疗后WBC水平恢复正常。入组患者使用吡喹酮治疗期间未发现WBC异常。EOS变化：EOS显著升高,升高至15.9%～54.8%。驱虫疗程结束EOS比率降低至正常值上限的2倍以下,EOS疗程结束1个月后降至正常。胸部MSCT：发现肺部病灶13例次（其中PLT升高12例次、PLT正常1例次）、胸腔积液13例次（PLT升高组12例次中双侧胸腔积液9例次、单侧3例次;PLT正常组患者中单侧胸腔积液1例）;心包积液2例（两组各1例）;纵膈和腋下淋巴结肿大4例次（PLT升高组和正常组各2例次）。随着驱虫治疗显效,MSCT显示胸部病变消退。胸肺型肺吸虫病是肺吸虫病的主要类型。彩色多普勒超声浆膜腔检查：胸腔积液13例次（其中双侧9例次、单侧4例次）、心包积液2例次、腹腔积液2例次。胸肺型、腹型肺吸虫病发生胸腔和腹腔积液比较常见;随着驱虫效果显效,浆膜腔积液亦消退。 结论PLT水平升高对胸肺型肺吸虫病的诊断具有提示意义,结合EOS变化,对肺型肺吸虫病诊断提示意义更高。     

穿透性心脏损伤急诊室剖胸五例穿透性心脏损伤急诊室剖胸五例

目的探讨在急诊室剖胸对危急心脏穿透伤的疗效。方法在急诊室紧急开胸５例，４例濒于死亡，１例已无生命体征；火器伤２例，锐器伤３例；心脏压塞型２例，失血休克型３例。结果全组死亡３例，存活２例（２／５）；火器伤２例均无存活（０／２），锐器伤２例存活（２／３）；压塞型１例存活（１／２），失血休克型１例存活（１／３）。结论急诊室剖胸是救治危急心脏穿透伤的有效手段，濒于死亡的心脏穿透伤特别是锐器伤部分可能获救     

A prospective evaluation of ultrasonography for the diagnosis of penetrating torso injury

BACKGROUND: Ultrasound (US) is commonly used for the diagnosis of hemoperitoneum after blunt abdominal trauma, but the value of US as an aid for identification of operative lesions after penetrating trauma is not well documented. The purpose of this investigation was to determine the accuracy of US for the evaluation of penetrating torso trauma and to assess the impact of this information on patient management. METHODS: We conducted a prospective cohort observational study of consecutive penetrating torso patients at a Level I trauma center. RESULTS: During the 6-month trial period, 177 victims of penetrating torso trauma were assessed by our trauma teams. Ninety-two patients had stab wounds, 84 patients had gunshot wounds, and 1 patient had a puncture wound. All 28 patients with positive US examination had an exploratory laparotomy or thoracotomy (one patient had more than one procedure), resulting in 26 therapeutic operations. There were 149 negative US examinations, but in this group, 36 patients underwent laparotomy or thoracotomy, and 28 had therapeutic operations. The overall accuracy of the US examination was therefore 85%, the sensitivity was 48%, and the specificity was 98%. There were only three patients who had their initial management altered by a positive US examination. CONCLUSION: The US examination lacks sensitivity to be used alone in determining operative intervention after gunshot or stab wounds. Rarely does US information contribute to the management of patients with penetrating abdominal injuries.     

Massive primary chylopericardium: a case report

A large pericardial effusion was discovered in an asymptomatic 12-year-old boy admitted for an elective orthopedic procedure. On physical examination, heart rate was 96 and blood pressure was 130/70 without paradox. The neck veins were not distended, but heart tones were distant. Chest roentgenogram (CXR) showed an enlarged cardiac silhouette. Echocardiogram showed a massive pericardial effusion compressing the right atrium, with depressed ventricular contractility. Pericardiocentesis yielded 450 mL of chylous fluid. A percutaneous pericardial drain was placed and drained another 400 mL of chyle. Pericardial fluid reaccumulated even though the patient was on a low-fat diet, and 1 week after admission left thoracotomy was performed with partial pericardiectomy and pericardial window. There was 1 L of chyle in the pericardial sac; frozen section of the pericardium showed lymphangiectasia. Chest tube drainage diminished rapidly and the patient was discharged. Follow-up CXR at 1 week showed fluid in both pleural spaces requiring bilateral tube thoracostomies again draining chyle. Even with total parenteral nutrition (TPN), 500 mL/d of chyle drained from the pleural tubes. Right thoracotomy with ligation of the thoracic duct was performed after 1 week of TPN. Pleural drainage abruptly dropped, and there has been no reaccumulation in either the pleural spaces or pericardium at 6-month follow-up. This case dramatically supports early thoracic duct ligation and partial pericardiectomy as the treatment of choice for primary massive chylopericardium.     

Diagnostic pericardial window. A safe alternative to exploratory thoracotomy for suspected heart injuries

During a five-year period, 104 patients underwent a pericardial window procedure to diagnose possible cardiac injury. Eighty-eight procedures were performed by a subxiphoid approach, and 16 were transdiaphragmatic in combination with an exploratory laparotomy. There were 51 patients with stab wounds, 45 with gunshot wounds, and eight with blunt trauma. All penetrating wounds were near the heart. In seven patients the window disclosed cardiac damage with no clinical signs of tamponade or shock. Fifty-one patients had signs of tamponade; however, only 12 of them had a cardiac injury diagnosed by pericardial window. Nineteen patients had cardiac injuries. One examination had false-negative results and one study had false-positive results. Cardiac wounds repaired included the right ventricle (eight), left ventricle (three), right atrium (five), and cardiac vein or pericardial wounds (three). Complications were negligible and consisted of minor wound infections (two) and postpericardiotomy syndromes (two). The pericardial window provides a rapid and safe means of diagnosing cardiac injuries in patients with equivocal signs of heart injury while sparing the patient without a heart wound a major operation.