Practical aspects in the management of stab wounds of the heart

Abstract

1.1. Patients sustaining a stab wound of the heart, in which significant branches of the coronary artery are divided, rarely live long enough to receive medical attention. Should the patient survive such an injury, a hasty hemostatic suture placed by an eager surgeon will not improve the nutrition to the anoxic myocardium distal to its ligation. The results from occlusive disease of the coronaries are quite analogous.2.2. Furthermore, patients with large rents in the cardiac chambers, or major vessels (within the pericardium), rarely survive to reach the hospital because these patients also have large rents in the pericardium. Hemorrhage, not tamponade, is the cause of death in such cases.3.3. An emergency portable chest roentgenogram records and confirms the physical findings of a severe hemothorax as the cause for shock. A severe hemothorax implies significant damage to a cardiac chamber, structures in the hilum of the lung or a significant blood vessel (aorta, mammary or intercostal). Blood replacement provides security for surgical exploration, and surgical exploration provides security for the patient. In the presence of a severe hemothorax, closed thoracotomy may be done as a preparatory procedure to relieve pulmonary collapse which will aid the anesthetist during induction prior to thoracotomy. Blood “outside” the lung has no physiologic function.4.4. The work of Cooley and DeBakey demonstrates the practical importance of treating these patients by the immediate use of intravenous fluids or blood. In so doing, cardiac output is improved and the diminished blood volume is corrected.5.5. The role of tamponade as the cause of death has been overemphasized. As a contributing factor it must not be overlooked. Its presence does not contraindicate the immediate use of intravenous fluids, plasma expanders or blood transfusions. In addition to shock therapy, decompression of the pericardium in the presence of tamponade provides time for additional studies and more accurate evaluation of the patient's condition.6.6. Routine thoracotomy for a hemopericardium is not necessary. Antecedent trauma or a hemopericardium as etiologic factors in constrictive pericarditis are rarely reported. Modern cardiac surgery and experimental work on the surgical management of coronary insufficiency tends to minimize the hazards of a hemopericardium.