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Ann Thorac Surg 2003;76:2043-2047
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Successful diagnosis of penetrating cardiac injury using surgeon-performed sonography

^a Cardiothoracic Surgery, Dallas, Texas, USA
^b General Surgery, Division of Trauma, Baylor University Medical Center, Dallas, Texas, USA

^* Address reprint requests to Dr Patel, Baylor University Medical Center, 3600 Easton Ave, Suite 1201, Dallas, TX 75246, USA
e-mail: anpatel72{at}hotmail.com

Presented at the Forty-ninth Annual Meeting of the Southern Thoracic Surgical Association, Miami Beach, FL, Nov 7–9, 2002.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
BACKGROUND: Patients with penetrating cardiac injuries have a high mortality. The utilization of sonography in these patients may lead to earlier diagnosis and definitive surgical intervention.

METHODS: A retrospective review of all patients admitted to a level I trauma center were examined from March 1996 to March 2001 (17,241 patients). Patients were identified with penetrating thoracic injuries and were evaluated for mechanism of injury, sonographic findings (subxiphoid and parasternal windows), injury severity score, length of stay, and mortality. Surgeons performed all sonography.

RESULTS: There were 478 patients who underwent sonography for penetrating thoracic injuries. Twenty-three patients were identified with positive sonographic findings. Subsequently 20 patients had a cardiac injury at surgery. There were no missed injuries. The 3 patients with false positive findings had congestive heart failure (2 patients) and morbid obesity (1 patient). Mean time to operation was 13 minutes. Mean injury severity score was 33. Mean intensive care unit and hospital stay was 3.1 days and 7.2 days respectively. Sonography had a specificity of 99.3% and sensitivity of 100% for identifying penetrating cardiac injury and a positive predictive value of 87% and negative predictive value of 100%. There were no hospital deaths.

CONCLUSIONS: Early diagnosis and management using surgeon performed sonography may reduce the high mortality associated with penetrating cardiac injury.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Penetrating thoracic injuries have a very high mortality [1]. Early diagnosis and surgical management may lead to improved outcomes [2–4]. The diagnosis of life-threatening injury is very difficult in the emergent situation. The use of subxiphoid pericardial exploration (SXE) has been used successfully to diagnosis cardiac injuries. However there is a very high false positive rate associated with SXE [5]. There is also a significant morbidity and cost associated with SXE [6]. A less invasive and possibly cost-effective means of evaluating patients with penetrating thoracic injuries may be ultrasonography [7–9]. Sonography has been shown to be effective in diagnosing intraperitoneal injuries, leading to a decrease in the number of diagnostic peritoneal lavages required [10, 11]. Similarly transthoracic sonography may alleviate the need to perform SXE for diagnosing penetrating cardiac injuries [8]. The subxiphoid view used to evaluate the pericardial sac has been effective in demonstrating pericardial fluid [7–9]. However performing parasternal views of the pericardium using sonography may improve the diagnosis of cardiac injuries [12]. The goal of our study was to determine if surgeon performed transthoracic sonography could provide an accurate and rapid means to diagnose cardiac injuries sustained from penetrating trauma.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
A retrospective review of all patients (17,241 patients) in the trauma database at Baylor University Medical Center (level I trauma center) was performed from March 1996 to March 2001. There were 620 patients identified with penetrating thoracic trauma. Penetrating thoracic trauma was defined as injury in regions defined by the following landmarks: bilateral clavicles superiorly, bilateral anterior axillary lines, and xiphoid process inferiorly. There were 478 patients who received transthoracic sonography in the emergency department. Sonography was performed by a staff surgeon or a surgery resident under the supervision of a staff surgeon. The staff surgeons were trained in trauma sonography. Sonograms were obtained using both a parasternal and subxiphoid window using a portable ultrasound machine (Sonosite 180; SonoSite, Bothell, WA) as of 1999. Before 1999 we used a bedside ultrasound machine (Siemens AG, Munchen, Germany). A positive sonogram was defined as 5 mm of fluid in the pericardial sac. Study endpoints included the time of positive diagnosis to operative intervention, hospital length of stay, and overall morbidity and mortality. Study variables included mechanism of injury, sonographic findings, and injury severity score.

Statistical definitions
True positive was defined as having 5 mm of fluid identified on the sonogram either by a parasternal or subxiphoid view and an injury identified at surgery. False positive was defined as having 5 mm of fluid identified on the sonogram either by a parasternal or subxiphoid view and no injury identified at surgery. True negative was defined as having no fluid identified on the sonogram either by a parasternal or subxiphoid view and no injury identified throughout the patients hospital stay, through other imaging modalities or surgery. False negative was defined as having no fluid identified on the sonogram either by a parasternal or subxiphoid view and an injury identified throughout the patients hospital stay, through other imaging modalities or surgery.

Method of sonography
The patient was placed supine on a trauma table and water-soluble imaging jelly was placed on the subxiphoid region and the parasternal and left chest of the patient. A portable 2 to 5 MHz probe was used to obtain the images, which were then printed and placed in the patient's medical record. The parasternal imaging was obtained by placed the probe at a 90-degree angle to the chest, scanning the left and right parasternal region from the second to the sixth rib. The images of the heart and lungs were obtained through the intercostal spaces. The subxiphoid images were obtained by placing the ultrasound probe at a 30- to 45-degree angle to the skin. The subxiphoid region was depressed and images of the heart and surrounding structures was obtained and recorded. Both thoracic cavities were also evaluated for pleural effusions. Figure 1 shows a positive sonographic exam of intrapericardial fluid. Figure 2 shows a negative study.

View larger version (177K): [in this window] [in a new window]   Fig 1. Positive findings of intrapericardial fluid.

View larger version (164K): [in this window] [in a new window]   Fig 2. Negative findings of intrapericardial fluid.

	Results

Top Abstract Introduction Patients and methods Results Comment Discussion References

	Comment

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Penetrating cardiac injuries are associated with a very high mortality [1]. Early diagnosis and management can lead to improved patient outcomes. The use of surgeon-performed transthoracic sonography is rapid and accurate in the diagnosis of penetrating cardiac injury [2, 8, 9]. It is a noninvasive imaging modality that is portable and easy to use [13]. In our experience there were no patients in the series of 478 who had a missed injury. This is very fortunate. However there were 3 patients who had false positive sonographic examinations. It was later determined that 2 of these patients had a history of congestive heart failure and the third patient was morbidly obese with a body mass index of 56. These findings may have contributed to the false positives. Our findings are similar to that of Rozycki and associates [8] who in a multicenter study of 261 patients found a sensitivity of 100% and a specificity of 96.9%. These patients if hemodynamically stable may be better evaluated with computed tomography or arteriography based on clinical suspicion of injury.

The 142 patients (23%) who did not receive sonograms very early in the database were because the trauma surgeon on call did not have sonographic training. These patients were evaluated clinically. Computed tomography or arteriography was performed if the patients were stable. Unstable patients were taken to the operating room for subxiphoid exploration. If the subxiphoid exploration was negative, then a diagnostic peritoneal lavages or upper midline laparotomy was performed based on if the patient was still hemodynamically unstable. The mean time of arrival to emergency department to operation for 5 patients who were hemodynamically stable and had cardiac injury found on either imaging modality was 67 ± 21 minutes. One of these patients died in the operating room. There were 3 hemodynamically unstable patients who went directly to the operating for subxiphoid exploration; only 1 patient had blood in the pericardium. However only a small laceration to right ventricle was identified and did not need require further repair. Overall the patients without sonography required more time to obtain diagnosis. As all the trauma surgeons became trained, sonography was routinely performed.

It appears from our results that the learning curve for transthoracic and subxiphoid ultrasonography is reasonable. After taking one training course our surgeons were able to successfully perform or supervise thoracic sonography [14]. There are many different recommendations for training of nonradiologic physicians in the use and interpretation of emergent sonography [11, 15]. Our training involved a 2-day course with didactic and clinical training along with both positive and negative subjects. There was a written and practical examinations at the end of the training. The ultrasound probe used in our emergency department does not adequately enable the surgeon to diagnosis valvular injury. A more specific cardiac probe is available. The problem with cardiac specific probes is that they do not allow adequate examination of the abdomen. If there is a high suspicion of intracardiac injury, then a transesophageal echocardiogram is required. This can be performed in the operating room at the time of subxiphoid exploration.

Recently a study by Boulanger and colleagues [10] demonstrated that only 58% of the designated trauma centers in the United States and Canada perform sonography in patients with penetrating trauma. The study also found that only 39% of surgeons perform sonography in trauma patients [10]. Significant improvement in education is needed to teach surgeons the benefits of sonography in diagnosing injuries in their trauma patients. The American College of Surgeons course on the management of trauma, Advanced Trauma Life Support, mentions teaching sonography as part of evaluating trauma patients. Hopefully that will impact the number of trauma centers that have trained sonographers.

The early diagnosis of cardiac trauma using sonography may lead to better outcomes because of the early management of potentially life-threatening injuries [2]. The hemodynamics of the patients did not play a role in the diagnosis of an injury made using the sonography. All patients who were brought to the emergency department with a blood pressure and a pulse after sustaining a penetrating thoracic injury were examined with sonography. The limitation of sonography is that it is still both user dependent for image quality and interpretation in this emergent setting. Obese patients are very difficult to examine owing to the body habitus making the depth of penetration from ultrasound unable to obtain clear images for interpretation. If a negative sonographic examination is obtained, patients are followed up clinically [16]. Any negative changes in hemodynamic parameters immediately warrant repeat sonography or urgent surgical examination [17]. Patients with equivocal pericardial findings receive computed tomography (CT) of the chest and abdomen if they are hemodynamically stable. If the CT scan is negative, then the patients are monitored for hemodynamic changes. However if they are going to the operating room for abdominal findings on sonography, then a pericardial window is also performed. Problems related to the evaluation of the pericardium may also occur if there is a left-side chest pleural effusion [9]. This finding may blunt the pericardial border, leading to the inability to differentiate intrapericardial fluid from extrapericardial. In patients with this finding a left-sided tube thoracostomy may be performed first to drain the fluid leading to a clear border along the pericardium. If complete drainage is not possible and the patient is hemodynamically stable then a CT scan is required.

The role of ultrasonography in the management of penetrating thoracic injuries has been demonstrated [8, 9, 13]. It is now important to realize that surgeon-performed sonography should be a part of the primary survey in the management of patients with penetrating thoracic injuries.

	Discussion

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
DR CONSTANTINE MAVROUDIS (Chicago, IL): That was a very nice presentation. Of all those thousands of patients that presented and had sonography, there were some data that I was interested in. Did any of your patients have emergency room thoracotomy before sonography could be done? In other words was sonography done on everybody regardless of what kind of vital signs they had?

And the other one is, of those who had sonography and had a positive study, did any of those patients have emergency room thoracotomy? I was curious—13 minutes to the operating room was quite fast. I wonder if you included those with emergency room thoracotomy.

I enjoyed your paper, I thought it was very well presented and I would be interested to hear the answers to my questions.

DR PATEL: There were a few patients early in our experience who did get ER thoracotomies without an ultrasound. Our current routine allows for a rapid trauma assessment and concurrent sonography during the first 1 to 2 minutes after arrival to the ER even in patients with no vital signs.

The 13-minute time gap from diagnosis to operative intervention includes only patients who are taken to the operating room. It does not include ER thoracotomy. The sonogram allows for an immediate decision to operate rather than wait for a CT scan or deterioration.

DR FREDERICK L. GROVER (Denver, CO): I enjoyed your paper very much also. We have written a lot about this in my San Antonio years and starting off with a subxiphoid pericardial window, particularly in those patients presenting with tamponade, and obviously a number of those patients didn't actually have tamponade so they ended up in the operating room with I guess you might say a procedure that wasn't totally necessary. And what you are describing here is a way of alleviating that type of unnecessary procedure.

I would be interested however in how long it takes to get the sonogram done in terms of getting it down. You do it yourself—I am sure it is pretty expeditious—but I think that plays in. What is your treatment algorithm? If you have a patient in shock, do you put in chest tubes first if you think there is a high likelihood they are bleeding? If they are in tamponade and in shock with a high CVP, low pressure, do you sometimes skip this and move straight up to the operating room? What is your basic logistic algorithm for taking care of these folks?

DR PATEL: Thank you, Dr Grover. For these patients the ultrasound machine is so portable it is literally in the trauma bay beside their bed. As the patients are coming in they get evaluated immediately with a chest x-ray and portable sonography. A chest tube is placed to drain pleural effusions. If there is a left-sided pleural effusion and you try to perform a portable ultrasound you may have a false negative, which can really be deleterious to your patient. In these patients the sonogram is then repeated to further demonstrate pericardial fluid.

The algorithm is that immediately on arrival as we are forming our ABCs it is ABC plus ultrasound all at the same time. The overall time to perform this takes roughly 30 to 60 seconds; it is very quick to get both views, subxiphoid and parasternal, using a small cardiac probe.

DR WILLIAM A. COOK (North Andover, MA): About 37 or 38 years ago Dr Webb and I and our group had a look at the heart wounds in Dallas for a 2-year period. There were 410 cases of penetrating cardiac injury. One of the things that we found most important to do with these people was to move them directly into the operating room rather than stop them in the emergency room. Anybody who had a serious wound to the chest in the area of the heart went directly to the OR. They were set up and ready for surgery. So you could do your sonography in that setting I suppose, and maybe you do.

A question arose in my mind, with your sonography were you able to detect intracardiac injury in some of these penetrating injuries?

And then finally I can't believe that you had no cardiac deaths from penetrating cardiac injury in Dallas. Either the violence of the injuries or the expertise of the wounders has changed dramatically in the last 37 years because we had plenty of patients who died.

DR PATEL: The study only included patients who made it to the emergency department with positive vital signs. So if they made it alive to the hospital, they actually remained alive if the diagnosis was successfully made.

The diagnosis of actual intracardiac injuries using the current portable ultrasound that we have at our hospital would be very difficult. There is a newer generation ultrasound that the cardiologists are using that has a 10 to 15 megahertz transducer that can actually detect valve abnormalities. Unfortunately the sensitivity of finding intraabdominal injury is decreased with this probe. The trauma team must use a probe that can screen for both thoracic and abdominal injury. Intraoperative probes could be used to further characterize the valves if needed.

DR JOHN M. KRATZ (Charleston, SC): I enjoyed your talk. The diagnosis of cardiac tamponade in the cardiac intensive care unit can be a difficult episode even with the cardiologists doing an echocardiogram. Have you given any consideration or have any experience with using a device such as this in the cardiac intensive care unit on a postoperative group of patients?

DR PATEL: We actually looked at using this device in postoperative patients; it was a very small number. Unfortunately it is very difficult using this portable device to look past the chest tubes and the sternal wires.

	References

Top Abstract Introduction Patients and methods Results Comment Discussion References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Amit N. Patel Michael L. Foreman Richard E. Wood Harold C. Urschel, Jr Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Patel, A. N. Articles by Urschel, H. C. Search for Related Content PubMed PubMed Citation Articles by Patel, A. N. Articles by Urschel, H. C., Jr Related Collections Cardiac - other