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Does hemopericardium after chest trauma mandate sternotomy?
Chad M Thorson1, Nicholas Namias, Robert M Van Haren
1Division of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center/Jackson Memorial Hospital, Miami, Florida 33136, USA.
Insights
Trauma-induced hemopericardium does not always require sternotomy. Some stable patients with chest trauma and hemopericardium can be managed nonoperatively, avoiding unnecessary sternotomies.
Area of Science:
- Trauma Surgery
- Cardiothoracic Surgery
- Emergency Medicine
Background:
- Chest trauma can lead to hemopericardium, a condition where blood accumulates in the pericardial sac.
- The necessity of sternotomy for trauma-induced hemopericardium has been debated.
- Previous nonoperative management of hemopericardium after severe chest trauma prompted further investigation.
Purpose of the Study:
- To evaluate the hypothesis that trauma-induced hemopericardium mandates sternotomy.
- To determine the appropriate management for patients with chest trauma and hemopericardium.
- To identify predictors of therapeutic sternotomy in trauma patients.
Main Methods:
- Retrospective review of patients with chest trauma and pericardial window or median sternotomy at a Level I trauma center (December 1996 to November 2011).
- Analysis of patient demographics, injury mechanisms, hemodynamic status, diagnostic procedures (focused cardiac ultrasound), and surgical interventions.
- Statistical analysis, including multiple logistic regression, to identify predictors of therapeutic sternotomy.
Main Results:
- Of 377 patients with positive pericardial window, 55 (15%) proceeded to sternotomy, predominantly due to penetrating trauma (89%).
- Hypotension on arrival or during resuscitation was observed in 35% of patients.
- Ventricular injuries were common, but 38% of patients undergoing sternotomy had no repairable cardiac or great vessel injury, indicating nontherapeutic sternotomies.
Conclusions:
- Hemopericardium alone may be an oversensitive indicator for cardiac or great vessel injury after chest trauma.
- Selected stable patients with blunt or penetrating trauma and hemopericardium without ongoing bleeding may avoid nontherapeutic sternotomies.
- Nonoperative management should be considered for selected trauma patients with hemopericardium to prevent unnecessary surgical intervention.
Background:
Recently, three patients with hemopericardium after severe chest trauma were successfully managed nonoperatively at our institution. This prompted the question whether these were rare or common events. Therefore, we reviewed our experience with similar injuries to test the hypothesis that trauma-induced hemopericardium mandates sternotomy.
Method:
Records were retrospectively reviewed for all patients at a Level I trauma center (December 1996 to November 2011) who sustained chest trauma with pericardial window (PCW, n = 377) and/or median sternotomy (n = 110).
Results:
Fifty-five (15%) patients with positive PCW proceeded to sternotomy. Penetrating injury was the dominant mechanism (n = 49, 89%). Nineteen (35%) were hypotensive on arrival or during initial resuscitation. Most received surgeon-performed focused cardiac ultrasound examinations (n = 43, 78%) with positive results (n = 25, 58%). Ventricular injuries were most common, with equivalent numbers occurring on the right (n = 16, 29%) and left (n = 15, 27%). Six (11%) with positive PCW had isolated pericardial lacerations, but 21 (38%) had no repairable cardiac or great vessel injury. Those with therapeutic versus nontherapeutic sternotomies were similar with respect to age, mechanisms of injury, injury severity scores, presenting laboratory values, resuscitation fluids, and vital signs. Multiple logistic regression revealed that penetrating trauma (odds ratio: 13.3) and hemodynamic instability (odds ratio: 7.8) were independent predictors of therapeutic sternotomy.
Conclusion:
Hemopericardium per se may be overly sensitive for diagnosing cardiac or great vessel injuries after chest trauma. Some stable blunt or penetrating trauma patients without continuing intrapericardial bleeding had nontherapeutic sternotomies, suggesting that this intervention could be avoided in selected cases.
Level Of Evidence:
Therapeutic study, level III.
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