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KEY POINTS

KEY POINTS Injury to the Heart

  • Avoid overaggressive resuscitation with crystalloid solutions in patients with suspected cardiac/vascular injuries.

  • The pericardial view of the focused assessment with sonography for trauma examination provides a rapid and accurate diagnosis of a hemopericardium.

  • The majority of penetrating wounds to the heart can be managed with suture repair of the myocardium.

  • An injury adjacent to a coronary artery is repaired with deep mattress sutures passing underneath the vessel.

  • Complex cardiac injuries involving the cardiac valves or the atrial/ventricular septa are extremely uncommon and are usually repaired with cardiopulmonary bypass in a subacute manner.

  • Consider pericardial tears and possible cardiac herniation with high-energy lateral blunt trauma and posttrauma positional hypotension.

  • Screening for blunt cardiac injury involves history and physical examination, electrocardiogram, and in some centers, measurement of troponin I.

Injury to the Thoracic Vessels
  • Contrast-enhanced computed tomography (CT) of the chest can be a useful screening test for stable patients with the following injuries: penetrating wound with mediastinal traverse; any thoracic trauma and mediastinal or supraclavicular hematoma; and blunt trauma with symptoms or signs or x-ray findings of an injury to the descending thoracic aorta.

  • Anatomic and physiologic classification of blunt injury to the thoracic aorta guides therapy, particularly recognizing that small, stable injuries can be observed.

  • The management of blunt injury to the descending thoracic aorta has evolved, with CT of the chest the most common screening test, endovascular repair the most common technique of repair, and delayed repair often employed.

  • For endovascular repair of blunt injury to the descending thoracic aorta, it is important to understand issues of room setup, vascular access, device sizing, seal zones, injury configuration, and vascular anomalies.

  • Many patients with penetrating thoracic vascular injuries are unstable and have the diagnosis made during an emergent exploration, usually via a left anterolateral thoracotomy, bilateral anterolateral thoracotomy, or less commonly, a median sternotomy.

  • Endovascular repair of thoracic outlet vascular injuries performed in an operating room with imaging capability permits the application of this technology to complex and unstable patients. The endovascular snare technique allows through-and-through access for even transected vessels permitting nonsurgical repair of these complex injuries.

INTRODUCTION

The heart, the thoracic aorta, and its tributaries are enclosed in the thoracic skeleton composed of the manubrium, sternum, clavicles, rib cage, and vertebral bodies. This rigid cage protects the heart, lungs, and great vessels. The bony structures can also create unique forms of injuries as they cause deflection of bullets, altering vectors of the original direction of penetration or by secondary fragments.

Blunt forces can lead to crushing, traction, or torsion injuries to the heart and great vessels from deceleration. Penetrating trauma to the heart and great vessels usually leads to immediate tamponade or exsanguination but may follow a pattern of injury similar to blunt trauma, including partial transection with formation of a traumatic false aneurysm, an intimal flap, thrombosis, or a rare arteriovenous fistula.

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