Objectives: 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 cardiac injuries with a positive PW that resolves with lavage, may be managed with pericardial window, lavage, and drainage (PWLD) and observation. The aim of this study is to describe our institutional experience with penetrating cardiac injuries, management strategies, and outcomes.
Methods: All patients with penetrating chest trauma who underwent PW and/or sternotomy over a 5-year period were identified from the trauma registry at a level 1 trauma center. Demographics, time to operation, imaging findings, and operative interventions were collected to create the database. Patients were stratified by operative intervention [PW + sternotomy vs. PWLD] and compared. Outcome measures include mortality, length of stay (LOS), ICU LOS, ventilator days, complications, and additional interventions. 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. FAST was performed in 88% of patients with 35% interpreted as positive. 23% of patients had preoperative CT imaging, of which 88% had significant findings on CT (pneumopericardium, missile fragment in myocardium, hemopericardium). Patients who underwent PW + sternotomy had a higher ISS and worse base excess compared to patients who underwent PWLD. There was no difference in demographics, LOS, ICU LOS, vent days, or mortality. In the PWLD group, one patient returned to the OR for recurrent pericardial effusion and no patients required sternotomy. Pericardial drains were removed after 2.6 days. 39 patients underwent sternotomy, of which 49% had a positive PW. Ventricular injuries were most common. MLR identified ISS as an independent predictor of therapeutic sternotomy (OR 1.160; 95% CI 1.006 – 1.338, p=0.0416). Interestingly, positive FAST and trajectory of wounds were not predictors of therapeutic sternotomy. In line with classic teaching, there were 7 patients with a left hemothorax and negative FAST found to have a positive PW requiring sternotomy or PWLD.
Conclusion: Penetrating cardiac injury can be managed with pericardial window, lavage, and drainage in select patients. Positive FAST, significant findings on CT imaging, and trajectory of wounds do not mandate sternotomy. A negative FAST in the setting of a hemothorax does not rule out cardiac injury.
