High-velocity penetrating thoracic trauma with suspected cardiac involvement in a combat support hospital

The most common cardiac injuries in the United States are blunt trauma from motor vehicle accidents or low-velocity trauma from stabbings. During military conflict, high-velocity injuries, including gunshot wounds (GSW) and fragment injury from improvised explosive devices (IED), are relatively more common.

This is a retrospective review of cases with high-velocity penetrating injury and suspected myocardial involvement during a 6-month period in Baghdad, Iraq, at a United States Army hospital during Operation Iraqi Freedom.

Eleven cases survived to admission (GSW in 5, IED in 6). The mean age of the all-male cohort was 27 years (range, 3-54 years). Eight of the 11 patients (73%) were victims of polytrauma. The entrance involved the right ventricle (n = 3), right atrium (n = 2), left ventricle (n = 1), or mediastinum and pericardial reflections (n = 5). Echocardiography was performed in all 11 patients. In 7 patients, no foreign body was identifiable, and in 2 patients the foreign body was identified within the pericardial fat pad. Three patients were identified as having a suspected ventricular septal defect, ranging in size from 2 to 8 mm. The most common electrocardiographic abnormality was atrioventricular block and right bundle branch block. In 4 patients, the management of the chest injury was nonsurgical, and in 1 patient the treatment was a chest tube only. Four of the patients underwent median sternotomy, 1 underwent emergent lateral thoracotomy, and 1 underwent an infradiaphragmatic approach.

This case series is too small to draw definitive conclusions; however, a multidisciplinary approach to high-velocity injuries with potential for cardiac involvement augments preoperative assessment for myocardial injury and may allow selective nonoperative management.