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Factors Affecting Prognosis with Penetrating Wounds of the Heart

Tyburski, James G. MD; Astra, Louis MD; Wilson, Robert F. MD; Dente, Christopher MD; Steffes, Christopher MD

Journal of Trauma-Injury Infection & Critical Care:
Annual Meeting Articles
Abstract

Objective: To determine factors affecting prognosis for patients with penetrating wounds of the heart.

Methods: A retrospective review of 302 patients with penetrating heart wounds undergoing emergency thoracotomy (August of 1980 through June of 1997) in a Level I trauma center.

Results: There were 148 patients with gunshot wounds (GSW) and 154 patients with stab wounds with 23% and 58% survival rates, respectively. Of 43 patients having no signs of life at the scene, 5 patients (12%) achieved some cardiac activity and were brought to the operating room (OR), but none survived. Of 67 patients “arresting” in the ambulance, 23 got to the OR, but only 3 patients (4%) survived. Of 27 patients “arresting” in the emergency department (ED), 18 patients reached the OR, but only 5 patients (19%) survived. Of 15 patients having an ED thoracotomy because of rapid deterioration there, 4 patients (27%) survived. Thus, of the 152 patients with an ED thoracotomy, 93 patients had gunshot wounds and none survived; of the 59 with stab wounds, 12 (20%) survived (p < 0.001). Of 150 patients having an OR thoracotomy, 111 (74%) survived. Single-chamber injuries had a survival rate of 51% (112 of 219 patients), but multiple chamber and/or intrapericardial great vessel injuries had only a 13% survival rate (11 of 83 patients) (p < 0.001). Intrapericardial aortic injuries were uniformly fatal in 15 patients. In patients with stab wounds, pericardial tamponade was associated with a higher survival rate (66%; 56 of 84 patients) than in those without tamponade (47%; 33 of 70 patients).

Conclusion: The physiologic status of the patient at presentation, mechanism of injury, and presence of a tamponade were significant prognostic factors in this series of penetrating cardiac injuries. Multiple-chamber injuries, especially with great vessel involvement, were associated with a high mortality rate. ED thoracotomies for gunshot wounds of the heart were uniformly fatal.

Penetrating cardiac wounds represent an ongoing clinical challenge to trauma surgeons. A large variation in survival rates, ranging from 19 to 65% is reported. 1–5 Several factors including the patient’s physiologic status at admission, presence of tamponade, mechanism of injury, type and number of cardiac chambers involved, injury severity score, and site of thoracotomy (emergency department [ED] vs. operating room [OR]) all have an effect on prognosis. 1–9 To determine the relevant features that predicted survival, we reviewed our experience at Detroit Receiving Hospital with 302 consecutive patients who had intrapericardial cardiac wounds requiring an emergency thoracotomy.

Author Information

From Wayne State University School of Medicine (J.G.T., L.A., R.F.W., C.D., C.S.), and Detroit Receiving Hospital (J.G.T.), Detroit, Michigan.

Address for reprints: James G. Tyburski, MD, Detroit Receiving Hospital, 4201 Street Antoine, Suite 4S-13, Detroit, MI 48201.

Submitted for publication September 25, 1999.

Accepted for publication January 6, 2000.

Presented at the 59th Annual Meeting of the American Association for the Surgery of Trauma, September 16–18, 1999, Boston, Massachusetts.

© 2000 Lippincott Williams & Wilkins, Inc.