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Sternotomy or drainage for a hemopericardium after penetrating trauma: a randomized controlled trial
Andrew J Nicol1, Pradeep H Navsaria, Martijn Hommes
1*Trauma Center, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa; and †Department of Surgery, University of Calgary, Calgary, Canada.
Insights
Stable patients with hemopericardium after chest trauma can be safely managed with pericardial drainage alone. This approach reduces intensive care unit (ICU) and hospital stays compared to traditional sternotomy.
Area of Science:
- Trauma Surgery
- Cardiothoracic Surgery
- Emergency Medicine
Background:
- Current practice for hemopericardium after penetrating chest trauma involves sternotomy and cardiac repair.
- Previous experience suggested sternotomy might be unnecessary in stable patients as cardiac injuries often seal.
- This study investigates an alternative management strategy for hemodynamically stable patients.
Purpose of the Study:
- To evaluate the safety and efficacy of managing stable hemopericardium after penetrating chest trauma with pericardial drainage alone.
- To compare outcomes between pericardial drainage and traditional sternotomy.
- To determine if less invasive management impacts mortality and hospital stay.
Main Methods:
- A single-center, parallel-group randomized controlled study.
- Included hemodynamically stable patients with hemopericardium confirmed via subxiphoid pericardial window (SPW) and no active bleeding.
- Primary outcome: survival to discharge. Secondary outcomes: complications and hospital stay duration.
Main Results:
- 93% of patients undergoing sternotomy had no or tangential cardiac injury; all penetrating cardiac injuries had sealed.
- One postoperative death occurred in the sternotomy group (0.9%).
- Pericardial drainage (SPW) resulted in significantly shorter ICU stays (0.25 vs. 2.04 days) and overall hospital stays compared to sternotomy.
Conclusions:
- Subxiphoid pericardial window (SPW) with drainage is a safe and effective management for stable hemopericardium post-penetrating chest trauma.
- This approach does not increase mortality and leads to reduced ICU and hospital lengths of stay.
- SPW and drainage offers a less invasive alternative to sternotomy in selected trauma patients.
Objective:
To determine if stable patients with a hemopericardium detected after penetrating chest trauma can be safely managed with pericardial drainage alone.
Background:
The current international practice is to perform a sternotomy and cardiac repair if a hemopericardium is detected after penetrating chest trauma. The experience in Cape Town, South Africa, on performing a mandatory sternotomy in hemodynamically stable patients was that a sternotomy was unnecessary and the cardiac injury, if present, had sealed.
Methods:
A single-center parallel-group randomized controlled study was completed. All hemodynamically stable patients with a hemopericardium confirmed at subxiphoid pericardial window (SPW), and no active bleeding, were randomized. The primary outcome measure was survival to discharge from hospital. Secondary outcomes were complications and postoperative hospital stay.
Results:
Fifty-five patients were randomized to sternotomy and 56 to pericardial drainage and wash-out only. Fifty-one of the 55 patients (93%) randomized to sternotomy had either no cardiac injury or a tangential injury. There were only 4 patients with penetrating wounds to the endocardium and all had sealed. There was 1 death postoperatively among the 111 patients (0.9%) and this was in the sternotomy group. The mean intensive care unit (ICU) stay for a sternotomy was 2.04 days (range, 0-25 days) compared with 0.25 days (range, 0-2) for the drainage (P < 0.001). The estimated mean difference highlighted a stay of 1.8 days shorter in the ICU for the drainage group (95% CI: 0.8-2.7). Total hospital stay was significantly shorter in the SPW group (P < 0.001; 95% CI: 1.4-3.3).
Conclusions:
SPW and drainage is effective and safe in the stable patient with a hemopericardium after penetrating chest trauma, with no increase in mortality and a shorter ICU and hospital stay. (ClinicalTrials.gov Identifier: NCT00823160).
