Esophageal perforation: emphasis on management

BACKGROUND: Perforation of the esophagus is a deadly injury that requires expert management for survival. METHODS: We performed a retrospective clinical review of 66 patients treated at Emory University affiliated hospitals for esophageal perforation between 1973 and 1993. RESULTS: Iatrogenic perforations accounted for 48 injuries (73%), barogenic perforations occurred in 12 patients (17%), trauma was causative in 3 (5%), and 3 patients had esophageal infection and other causes. Lower-third injuries occurred in 43 cases (65%), middle third in 14 (21%), and upper third in 9 (14%). Early contained perforations were managed successfully by limiting oral intake and giving parenteral antibiotics in 12 patients. Cervical perforations were drained without attempt at closure of the leak. Perforations with mediastinal or pleural contamination recognized early were managed by primary closure and drainage in 28 patients. Reinforcement of the primary closure using stomach fundus, pleural, diaphragmatic, or pericardial flap was performed in 16 patients. Those perforations that escaped early recognition required thoughtful management, using generous debridement and drainage and sometimes esophageal resection. The esophageal T tube provided control of leaks in 3 of these patients and was a useful adjunct. Using these management principles, we achieved a 76% survival rate for all patients. Six patients with perforations complicating endoesophageal management of esophageal varices were a high-risk subset with an 83% mortality rate. CONCLUSIONS: Esophageal perforation remains an important thoracic emergency. Aggressive operative therapy remains the mainstay for treatment; however, conservative management may be preferred for contained perforations and the esophageal T tube may be used for late perforations.     

Management of external penetrating injuries into the hypopharyngeal-cervical esophageal funnel

OBJECTIVE: To compare outcomes related to observation versus exploration for the hypopharynx and the cervical esophagus as the site of proven external penetrating injuries. METHODS: The records of 70 patients (47 with hypopharyngeal and 23 with cervical esophageal wounds) were retrospectively reviewed. RESULTS: No patient, observed or explored, who sustained a penetration into the hypopharynx above the level of the tips of the arytenoid cartilages of the larynx developed a complication. However, 22% of the patients with a hypopharyngeal injury below this level and 39% of patients with a cervical esophageal injury developed either a deep neck infection that required drainage or a postsurgical salivary fistula. CONCLUSIONS: Overall, the consequences of an external penetrating injury become more serious in the descending levels of the funnel formed by the hypopharynx and cervical esophagus. Injuries located in the upper portion of the hypopharynx can be routinely managed without surgical intervention. Neck exploration and adequate drainage of the deep neck spaces are, however, mandatory for all penetrating injuries into the cervical esophagus and most injuries into the lower portion of the hypopharynx.     

Expression of inducible nitric oxide synthase in the brains of scrapie-infected mice

Thoracic trauma in the elderly population constitutes a major challenge for both thoracic and trauma surgeons as their presentation and outcomes differ from the adult population in addition to their high morbidity and mortality. One hundred and one patients, 60 years of age or older, with thoracic trauma were treated at Dicle University School of Medicine during a 6-year period. Eighty-five per cent were male and 15% were female with a mean age of 64.5 years. The cause of thoracic injury was blunt in 77.2% and penetrating in 22.8% of the patients. Sixty-two patients (61.4%) had isolated thoracic injuries. The median Injury Severity Score (ISS) was 23. The morbidity rate was 23.8%. The mortality rate was 16.8%. Seven of 10 patients (70%) who had an ISS greater than 25 died, whereas six of 24 (25%) patients with an ISS between 17 and 25, and four of 67 (5.9%) patients with an ISS less than 16 died. In the elderly the morbidity and mortality rates were higher for blunt trauma compared with penetrating trauma. For ISS greater than 25 the mortality rate was 71.4% for blunt and 66.6% for penetrating trauma. As the morbidity and mortality rate are significantly higher in the elderly patients the approach to these patients should include recognition of their high risk for morbidity and mortality, especially for those who had an ISS greater than 25.     

Human papillomavirus infection in squamous cell carcinoma of the vulva, in various synchronous epithelial changes and in normal vulvar skin

In patients with inferior vena cava (IVC) injuries, predictors of survival are investigated. From 1987 to 1995, 27 IVC injuries were identified among 514 patients with vascular trauma. The ability of clinical determinants to predict survival were retrospectively assessed. IVC injuries occurred in 7 females and 20 males (mean age, 27.7 +/- 2.5 years) from both blunt (n = 14) and penetrating (n = 13) trauma. The mean revised trauma score was 10.2 +/- 0.6. Injuries were treated by primary repair (n = 22), ligation (n = 4), or prosthetic grafting (n = 1). Thirteen patients died (48%), 10 within 12 hours of admission. Suprahepatic (n = 2), retrohepatic (n = 12), suprarenal (n = 1), and infrarenal (n = 12) injuries were associated with 100, 67, 100, and 20 per cent mortality, respectively. Blood transfusions (16 +/- 4 vs 23 +/- 4 units), coagulation factor replacement (7 +/- 2 vs 7 +/- 2 units), and electrolyte solution use (8.6 +/- 1.4 vs 9.6 +/- 1.4 L) were similar among survivors and nonsurvivors. Four complications [venous hypertension (n = 2), IVC thrombosis (n = 1), and pulmonary embolus (n = 1)] occurred in the 14 survivors (28.6%). Blunt injury, revised trauma score, free perforation, injury location, intraoperative hypotension, and blood loss were predictive of mortality. IVC injuries remain extremely lethal, and improved survival is associated with infrarenal penetrating injuries and a contained hematoma.     

Cervical vascular injuries: a trauma center experience

BACKGROUND: We analyzed 76 patients with cervical vascular injuries from penetrating neck trauma (n = 528) between 1977 and 1990 at a level I trauma center to evaluate the role of angiography in diagnosis and management and to assess the course and outcome of these patients. METHODS: Patients who were hemodynamically unstable underwent immediate surgical exploration. Stable patients were subjected to diagnostic investigation. Angiography was routinely performed to diagnose vascular injury in zones I and III and zone II if the trajectory was in the vicinity of major vessels. Therapeutic embolization was performed when possible at angiography; all other vascular injuries were treated surgically. RESULTS: Thirteen patients (2.5%) died of penetrating neck trauma, in 12 of whom hemorrhage was the contributing factor (12/76; 15.8% of patients with vascular injury). In nine patients who were hemodynamically stable vascular injury was diagnosed by angiography: 5 (6.8%) of 73 in zone I and 3 (5.4%) of 56 in zone III, four of whom underwent therapeutic embolic occlusion of the injured vessel. Injuries to vertebral and subclavian arteries and subclavian and innominate veins were often multiple, causing exsanguination and death (6.8% in zone I). In three patients with no preoperative neurologic deficit, the internal carotid artery was ligated without complication; in all other patients injury to the common carotid or internal carotid artery was repaired, in six of them with polytetrafluoroethylene grafts. CONCLUSIONS: Selective management of penetrating neck trauma should include routine angiography in zones I and III. Injuries to the common and internal carotid arteries should be repaired. The internal carotid artery may be ligated in the absence of preoperative neurologic deficit. Arterial injuries in the neck can be repaired with polytetrafluoroethylene grafts.     

A comparison of artificially-depleted, lyophilized coumarin and fresh coumarin plasmas in thromboplastin calibration. European Concerted Action on Anticoagulation

BACKGROUND/PURPOSE: Pediatric truncal vascular injuries are rare, but the reported mortality rate is high (35% to 55%), and similar to that in adults (50% to 65%). This report examines the demographics, mechanisms of injury, associated trauma, and results of treatment of pediatric patients with noniatrogenic truncal vascular injuries. METHODS: A retrospective review (1986 to 1996) of a pediatric (< or = 17 years old) trauma registry database was undertaken. Truncal vascular injuries included thoracic, abdominal, and neck wounds. RESULTS: Fifty-four truncal vascular injuries (28 abdominal, 15 thoracic, and 11 neck injuries) occurred in 37 patients (mean age, 14+/-3 years; range, 5 to 17 years); injury mechanism was penetrating in 65%. Concomitant injuries occurred with 100% of abdominal vascular injuries and multiple vascular injuries occurred in 47%. Except for aortic and one SMA injury requiring interposition grafts, these wounds were repaired primarily or by lateral venorrhaphy. Nonvascular complications occurred more frequently in patients with abdominal injuries who were hemodynamically unstable (systolic blood pressure [BPS] <90) on presentation (19 major complications in 11 patients versus one major complication in five patients). Thoracic injuries were primarily blunt rupture or penetrating injury to the thoracic aorta (nine patients). Thoracic aortic injuries were treated without bypass, using interposition grafts. In patients with thoracic aortic injuries, there were no instances of paraplegia related to spinal ischemia (clamp times, 24+/-4 min); paraplegia occurred in two patients with direct cord and aortic injuries. Concomitant injuries occurred with 83% of thoracic injuries and multiple vascular injuries occurred in 25%. All patients with thoracic vascular injuries presenting with BPS of less than 90 died (four patients), and all with BPS 90 or over survived (eight patients). There were 11 neck wounds in 9 patients requiring intervention, and 8 were penetrating. Overall survival was 81%; survival from abdominal vascular injuries was 94%, thoracic injuries 66%, and neck injuries 78%. CONCLUSIONS: Survival and subsequent complications are related primarily to hemodynamic status at the time of presentation, and not to body cavity or vessel injured. Primary anastomosis or repair is applicable to most nonaortic wounds. The mortality rate in pediatric abdominal vascular injuries may be lower than previously reported.     

Immediate surgical treatment of major renal trauma

Of the 77 cases of renal trauma treated at Oulu University Central Hospital during the years 1965--1975, 60 injuries were minor and 17 severe. 73 of these injuries were closed and 4 penetrating. The rate of operative treatment in severe renal injuries was 88% minor renal injuries being treated conservatively. Primary exploration was done in 18 of the 77 cases and in all patients with penetrating injuries. Only 7 of the 73 patients with blunt trauma and one of the 4 patients with penetrating injury required nephrectomy, including one patient with renal carcinoma. 6 of the 77 patients died, most as a result of severe associated injuries, giving a mortality of 8%. None of the surviving patients treated for renal trauma suffered from major complications. In 13 of the 18 patients operated upon, renal injury was the main indication for operation. Operation was performed in 5 of the 18 patients after immediate radiological evaluation. The advantages of immediate surgical management in severe renal injuries are early and final treatment, short hospital stay, and low incidence of complications. Qualifications for emergency surgery are access to renal angiography and familiarity with reparative renal procedures.     

Writing in aphasia rehabilitation: cursive vs manuscript

An analysis of 100 patients sustaining multiple injury and pancreatic trauma was completed. Sixteen patients with penetrating injury died within the first 24 hours, 14 of whom died intraoperatively from major hepatic and/or retroperitoneal venous injury. Eighty-four patients survived long enough to permit evaluation of treatment. There was no statistically significant relationship between mode (p = 0.3) or anatomic area (p = 0.5) of injury and death. However, death was more common in the presence of duct injury (p less than 0.0001). Thirty-nine patients were determined to have duct injury and 45 did not. These two groups were equivalent, with the exception of a higher incidence of concomitant bowel injury (p less than 0.05) in those with duct violation. Combined sump and Penrose drainage was found to be adequate treatment of both proximal and distal nonductal injury with no significant difference in mortality or morbidity rates (p = 0.5). Resection of distal ductal injuries as opposed to drainage alone resulted in significantly lower morbidity and mortality rates (p less than 0.05), comparable to those of drained nonductal injuries. No conclusions could be made relevant to proximal duct injuries, except that drainage alone is inadequate. Seventeen (20 percent) of the 84 patients evaluated died. Pancreatic related mortality rate was 17 percent (14 patients). Two of 23 patients with blunt injury (9 percent) and 12 of 61 patients with penetrating injury (20 percent died). Gram-negative sepsis (82 percent) was the most common cause of death (p less than 0.01), and sepsis was correlated with the presence of pancreatic duct (p less than 0.0001) and bowel (p less than 0.001) injury.     

Gallbladder injury in abdominal trauma: analysis of 32 cases

Gallbladder lesion is infrequent, occurring in approximately 0.5 to 8.5% of all patients with blunt and penetrating abdominal trauma. The incidence of gallbladder injury in such cases is low. This study reviewed 32 patients with gallbladder injury due to abdominal trauma over a 6-year period to determine the complications, associated injuries, and mortality rate.     

Congenital myopathy with excess of thin myofilaments

Twenty eight patients who had subclavian, axillary, and brachial artery injuries were studied. Sixteen (57%) sustained blunt trauma and 12 (43%) sustained penetrating trauma. Motor cycle accidents were the most common cause of injuries (43%). Twenty patients (71.4%) were transferred from other hospitals. Nine patients (32%) were in shock on arrival. All patients had radial pulse abnormalities (3 decreased, 25 absent) of the affected limbs. Eighteen patients (64%) had associated injuries to other parts of the body. Eighteen patients (64%) also had associated nerve injuries, 7 of them had complete brachial plexus injuries from motor cycle accidents. Twelve patients (43%) had preoperative angiography. Twelve patients (43%) had brachial, 10 (35.7%) had axillary, 2 (7%) had axillary-subclavian, and 4 (14%) had subclavian artery injuries. Eight patients (28.6%) had concomitant venous injuries. Resection of the injured artery and reversed saphenous vein graft were performed in 23 patients (82%). The remaining had resection and end to end anastomosis in 3 patients (10.7%), lateral repair in 2 patients (7%), and ligation in 1 patient (3.6%). Concomitant venous repairs were performed in 5 patients. Fasciotomies were performed in 2 patients (7%). Excellent results of vascular repairs were obtained in all patients. Long-term disability occurred in patients who had associated nerve injuries. Avulsion injury of the brachial plexus usually resulted in severe impairment of limb function.     

Malformations of neocortical development: magnetic resonance imaging correlates

BACKGROUND: The objective of this study was to assess the diagnostic and therapeutic effectiveness of videothoracoscopy in thoracic trauma patients. METHODS: The design was a retrospective review. The setting was a major trauma center at an urban county hospital. Forty-one hemodynamically stable patients sustaining thoracic trauma were reviewed (34 penetrating and 7 blunt injuries). In the acute setting (< 24 h), videothoracoscopy was used for continued bleeding(6) and suspected diaphragmatic injury(17). Thoracoscopy was used in delayed settings (> 24 h) for treatment of thoracic trauma complications(18) including clotted hemothorax(14), persistent air leak(1), widened mediastinum(1), and suspected diaphragmatic injury(2). RESULTS: The average Injury Severity Score (ISS) of these patients was 18.9 +/- 10.0. Three of 6 patients (50%) with continued bleeding were successfully treated thoracoscopically. Nine of 10 (90%) diaphragmatic injuries were confirmed by thoracoscopy, and 7 of these 9 patients (77%) were repaired thoracoscopically. Thirteen of 14 patients (93%) with clotted hemothoraces and one with a persistent air leak were treated successfully using thoracoscopy. An aortic injury was ruled out in one patient. CONCLUSIONS: Videothoracoscopy is a safe, accurate, minimally invasive, and potentially cost-effective method for the diagnosis and therapeutic management of thoracic trauma patients.     

Pancreatic injuries resulting from penetrating trauma: a multi-institution review

Pancreatic injury from penetrating trauma continues to be a source of significant morbidity and mortality, with questions remaining regarding optimal treatment of injuries. Our goal was to evaluate current trends in the operative management of these injuries. Our patient population comprised all patients admitted to one of three Level I trauma centers over an 8-year period that had sustained penetrating pancreatic trauma. The study was a retrospective chart review. Sixty-two patients were identified. All had associated abdominal injuries, with the liver and stomach being the most commonly injured organs. There were 14 deaths (mortality 22.6%), 10 within the first 48 hours due to associated vascular injury. In the 52 patients surviving beyond 48 hours, there were 19 patients with injuries to the main pancreatic duct and 33 with parenchymal injuries only. Pancreatic resection was carried out for all patients with ductal injury except for one, who later required distal pancreatectomy for pseudocyst and pancreatic fistula. Significant pancreatic fistulae developed in five patients, three in patients treated by drainage and two in patients treated by resection. The incidence of fistula formation was significantly higher for drainage versus resection in the patients with ductal injuries. The incidences of other complications were not affected by type of pancreatic injury, associated injuries, or method of management. We conclude that the majority of deaths in patients with penetrating pancreatic trauma are due to associated organ or vascular injuries. Appropriate management of the pancreatic injury can reduce the long-term complications. These results support treating patients with suspected ductal injuries by appropriate resection. Drainage should probably be sufficient for most nonductal pancreatic injuries.     

Mechanical penetrating esophageal injuries

Results of combined treatment of 850 patients with penetrating mechanical injuries of the esophagus are presented. 368 patients had instrumental lesions, 328--foreign bodies, 53--spontaneous and hydraulic ruptures, 83--gun-shot and cut wounds. Complex of roentgenologic, endoscopic, ultrasound and immunologic methods of examination were used for diagnosis of penetrating injuries of the esophagus and their complications. The authors have developed indications for conservative and operative methods of treatment. 650 patients underwent surgery. In 388 patients drainage procedures were used, other procedures used were suturing of defect of esophageal wall (288p), exclusion of distal part of the esophagus (30p). Mortality rate in such operations made up, respectively, 33, 11.8 and 6.6%. Methods of active drainage were successfully used in treatment of complication in ruptures of the esophagus (mediastinitis, empyema of the pleura). The most severe complications of the ruptures of the esophagus and mediastinitis were arrosion bleedings and esophageal fistulas. Methods of treatment of these complications are described.     

Pancreatic trauma: a ten-year multi-institutional experience

Our objective was to determine the incidence, management, and outcome of traumatic pancreatic injury. A retrospective review was performed of all patients with pancreatic injury admitted to two Level I trauma hospitals over a 10-year period. Comparisons were made with Chi square or Fisher's exact tests. Of 16,188 trauma admissions, 72 patients (0.4%) had pancreatic injury. The mean age was 30 years, and 30 patients (69%) were male. Mechanism of injury was gunshot in 32 (45%), blunt in 27 (37%), and stab wound in 13 (18%). The pancreas was involved in 1.1 per cent of patients with penetrating injuries compared to 0.2 per cent with blunt injuries (P < 0.01). There were 18 grade I (25%), 32 grade II (45%), 16 grade III (22%), and 5 grade IV (7%) injuries. Initial diagnosis was made intraoperatively in 63 patients and by computed tomography in 8. The mean injury grade was significantly lower on computed tomography compared to surgical exploration (0.4 vs 2.0; P < 0.05). Operative procedures included distal pancreatectomy in 23 (32%), exploration only in 22 (31%), external drainage in 13 (18%), pancreatorrhaphy in 4, internal drainage in 2, and proximal resection in 2. Mortality was 16.6 per cent and was not related to the mechanism or grade of injury. Mean Injury Severity Score and transfusion requirements were significantly greater in patients who died (P < 0.05). Morbidity occurred in 30 patients (42%), including pancreatic fistula (11%), pancreatitis (7%), and pancreatic pseudocyst (3%). Six patients (8%) developed intra-abdominal abscesses, and all had associated liver or intestinal injuries. In patients with grade I and II injuries, morbidity was higher with external drainage compared to exploration without drainage. Pancreatic injury is infrequent and is more often associated with penetrating trauma. Diagnosis is most commonly made by exploration and cannot be excluded by computed tomography. Drainage of low-grade injuries may not be necessary. Morbidity and mortality in patients with pancreatic trauma is significant and is primarily due to associated injuries.     

Results of reconstruction in major pelvic and extremity venous injuries

PURPOSE: Outcome and venous patency after reconstruction in major pelvic and extremity venous injuries was studied. METHODS: We retrospectively reviewed 46 patients with 47 venous injuries. RESULTS: Injuries were caused by penetrating trauma in 37 extremities, blunt trauma in 6 patients, and were iatrogenic in 4 patients. Pelvic veins were injured in 4 patients, lower-extremity veins were injured in 39 limbs in 38 patients, and upper-extremity veins were injured in 4 patients. Concomitant arterial injuries occurred in 37 patients. Venous repairs were mostly of the complex type and included spiral or panel grafts in 15 (32%) reconstructions, interposition grafts or patch venoplasty in 19 (40%) reconstructions, end-to-end and lateral repair in 11 patients, and ligation in 2 patients. Two patients underwent early amputation. Early transient limb edema occurred in 2 patients, and postoperative venous occlusions were documented in 4 patients. Full function was regained in 39 (81%) extremities. No variable, including 4 retrospectively applied extremity injury scores (mangled extremity severity score [MESS], limb salvage index [LSI], mangled extremity syndrome index [MESI], predictive salvage index [PSI]), correlated with outcome. High values on all 4 scores were significantly associated with reexplorations (P <.02), which were done in 8 patients for debridement (5), arrest of bleeding (2), and repair of a missed arterial injury (1). Follow-up of 28 +/- 6 months on 27 patients (57%; duplex scan in 18, continuous-wave Doppler and plethysmography in 9, and venography in 3) showed 1 occlusion 6 weeks after the injury and patency of all other venous reconstructions. CONCLUSION: Reconstructions of major venous injuries with a high rate of complex repairs result in a large proportion of fully functional limbs and a high patency rate. A high extremity injury score predicts the need for reexploration of the extremity. Mostocclusions occur within weeks of injury, and the subsequent delayed occlusion rate is very low.     

Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury

A prospective trial of videothoracoscopy was conducted at an urban trauma center between February 1992 and February 1993 to determine the efficiency of this less invasive method of evaluation and treatment. Twenty-four consecutive patients with chest trauma (penetrating, n = 22; blunt, n = 2) were examined thoracoscopically for clotted hemothorax that otherwise would have been treated with thoracotomy (n = 9), suspected diaphragmatic injury (n = 10), and continued bleeding (n = 5). To ensure maximal exposure, general anesthesia with a double-lumen endotracheal tube was used in each patient. Clotted hemothorax was successfully evacuated in eight of nine patients (89%). Diaphragmatic laceration was suspected in 10 patients (2 abnormal chest radiographs, 8 proximity penetrating wounds) and confirmed thoracoscopically in 5. In four patients, diaphragmatic lacerations were successfully repaired with thoracoscopic techniques. Five patients underwent thoracoscopy for continued hemorrhage (greater than 1,500 mL per 24 hours) after tube thoracostomy. Intercostal artery injury was confirmed in all patients, and diathermy provided hemostasis in three patients without thoracotomy. No complications occurred. These data suggest the following: (1) Videothoracoscopy is an accurate, safe, and minimally invasive method for the assessment of diaphragmatic injuries, control of continued chest wall bleeding, and early evacuation of clotted hemothorax. (2) This technique should be used more frequently in patients with thoracic trauma. (3) Technical advances may expand the therapeutic role of thoracoscopy.     

Cervicothoracic vascular injuries

Arterial and venous trauma of the cervicothoracic region continues to present challenging problems for the surgeon, despite advances in vascular diagnostics and surgical technique. Whether due to penetrating or blunt mechanisms, overall incidence of these injuries is low, whereas morbidity and mortality remain high. Despite collective experience from busy trauma centers, there still remain controversies regarding diagnostic evaluation, operative approach, and surgical treatment of these potentially devastating injuries. Therefore, this article compares and contrasts recent literature and controversies surrounding the treatment of cervicothoracic trauma. Pros and cons of duplex ultrasonography and angiography in the diagnosis of carotid and vertebral artery injury are highlighted, and selective versus mandatory neck exploration for zone II penetrating injuries are discussed. Increasing awareness of blunt carotid artery injury is emphasized, including management dilemmas that frequently accompany this type of injury. In addition, we review interventional radiological techniques for the management of vertebral artery injury and surgical approaches for aortic arch branch vessel or major cervicothoracic vein injury.     

Embolization therapy as an alternative to thoracotomy in vascular injuries of the chest wall

Hemothorax and persistent thoracic bleeding is frequently an indication for thoracotomy after trauma. Unfortunately, the source of the hemorrhage is often not identified. Presently, selective arteriography and transcatheter embolization (SATE) offers a good and safe alternative to localize and control hemorrhage from arterial injuries in selected patients. The records of eight patients who underwent SATE were reviewed. There were six blunt and two penetrating chest injuries. Four patients had significant preexisting medical comorbidities. Three patients with blunt injuries had undergone exploratory thoracotomy, but continued to bleed postoperatively. In three patients, angiography was indicated for associated thoracic and pelvic injuries, and five patients had SATE specifically due to thoracic hemorrhage. In all patients, SATE was effective to diagnose and control the hemorrhage. There were no complications related to the SATE procedure. Two patients died secondary to severe cerebral injuries. Given hemodynamic stability, SATE can be considered in patients who have already had a thoracotomy, have significant associated medical conditions, or those in need of other angiographic studies. Careful technique and a readiness to abandon SATE in unstable patients or when a suitable catheter position cannot be achieved are important technical points.     

Use of cardiopulmonary bypass to salvage patients with multiple-chamber heart wounds

BACKGROUND: The need for cardiopulmonary bypass in the treatment of penetrating heart injuries is debated. OBJECTIVES: To review our experience with penetrating heart injuries and determine the indications and outcome for cardiopulmonary bypass. DESIGN: Retrospective review. SETTING: A university-based, level I trauma center. PATIENTS: All victims of penetrating heart injury presenting between July 1, 1989, and December 31, 1995. METHODS: Medical records were reviewed for demographic and physiological data, operative findings, and outcome. RESULTS: Overall survival for 106 patients with penetrating heart injury was 55%. In an effort to resuscitate the heart, 4 patients with unresponsive cardiogenic shock were placed on cardiopulmonary bypass; none survived. Of 30 patients with multiple-chamber injuries, 11 presented with signs of life and 7 survived. Cardiopulmonary bypass was essential to repair complex injuries in 2 of the 7 survivors. CONCLUSION: Cardiopulmonary bypass was ineffective in salvaging patients with cardiogenic shock but was essential in some patients with complex multiple-chamber cardiac injuries that could not be exposed and repaired by other means.