Open heart injuries: types, symptoms, emergency care. Open cardiac injury is an acute situation requiring immediate surgery Penetrating cardiac injuries emergency care
HEART
The heart is a hollow muscular organ. The cardiac muscle combines the properties of both striated and smooth muscles and is distinguished as a separate type of muscle. The heart muscle is called the myocardium. In the chest, the heart is located slightly to the left and is surrounded by a pericardium called the pericardium. It is said that the size of the heart corresponds to the size of each person's fist. The average heart weight is 500 g. However, individual variations can be very significant. This largely depends on the person’s lifestyle. With a sedentary lifestyle, the heart becomes smaller. the muscle becomes flabby. During physical training, the heart muscle strengthens and the heart mass increases. The average heart weight is 500 g; in an adult, the heart weight is 0.5% of body weight, and in a newborn - 0.9%. The size of the heart along the vertical axis is 13-15 cm, along the horizontal axis - 8-11 cm. The normal volume of the heart in a healthy person is 600-750 ml. The volume of an athlete's heart can reach 800-1600 ml. The heart volume of the famous cyclist Edi Merzch is 1660 ml.
In men, the weight of the heart after 30 years increases annually by 1 g, in women by 1.4 g. The heart reaches the peak of its productivity by 58 years.
After age 90, heart weight begins to decline (“The Road to Longevity”). It is known that it is never too late to start strengthening the heart muscle. You can start doing this at any age.
Experiments were conducted on pregnant rabbits: one group lived in familiar conditions, in another group the rabbits were limited in their movement, and the third were forced to constantly move. As a result, the heart size of newborn rabbits in the second group was smaller than the control, and in the third group it was significantly larger than in the control. Consequently, physical activity during pregnancy has a beneficial effect on the fetal heart.
Humans have a four-chambered heart: left and right atria and left and right ventricles. The left atrium receives oxygenated blood from the lungs and passes into the left ventricle. From there it enters the aorta, which branches into arteries, arterioles and arterial capillaries. The other end of the capillary is called venous. The venous capillaries merge into venules, veins, and finally the inferior and superior vena cava. Venous blood flows into the right atrium. From there to the right ventricle. From the right ventricle, blood enters the lungs. Blood movement occurs due to the contraction of the heart muscle. The contraction of the heart muscle is reflected on the walls of the arteries as an arterial wave or pulse.
In an adult, the number of such contractions is 70 per minute, in a child - 140.
In 5 contractions, the heart pumps 1 liter of blood, per day 7-9 thousand liters. Hard work increases blood circulation by 2500 liters per hour. There is evidence that in the aorta the speed of the blood impulse is 4 km/h, in the capillaries it moves in millimeter steps. Over 60 years of an ordinary, not very stressful and excited life, the human heart makes more than 2 billion contractions and performs the same work that a tractor would do if it lifted a huge boulder weighing 65 tons from sea level to a height of 5500 m (almost the height of Elbrus). During this time, the heart pumps 224 million liters of blood, which is equivalent to the water flow of a river like the Seine in 10 minutes.
The impulses that cause contraction of the heart muscle come from the so-called pacemakers, capable of working in the autogeneration system, located in the atrium muscle and passing through the muscle fibers of the entire heart. The activities of these centers do not depend on our will. Soviet intelligence officer Richard Sorge was captured and hanged by the Japanese in 1944. After the execution, his heart worked in automatic mode, without support from the brain for almost 29 minutes.
Even 400 years ago, people thought that blood was “cooked” in the heart and thereby warmed the entire body.
In 1551, the “holy” church fathers ordered 42-year-old Miguel Servetus to be burned at the stake for his various ideas, including that blood circulates in the lungs.
In Norway, doctors transplanted a donor heart into the right side of the chest of an 8-year-old boy, Jonas Bjorns, with a congenital heart defect. The doctors left the patient’s own heart in the same place, it contracts, and causes the donor heart to contract. Now there is a person in the world with two simultaneously functioning hearts.
Knowledge about the human body was accumulated not only in European but also in other countries. However, when studying the history of science, we, as a rule, refer mainly to the discoveries of European scientists, and in a later period - American scientists. But already in 7 AD. The Chinese described the systemic and pulmonary circulation. In the West, this discovery is attributed to the Englishman Harvey, which he made much later, having previously visited China.
It was found that the state of the circulatory system is subject to seasonal and daily fluctuations. The lumen of the capillaries in the morning is smaller than in the evening.
Between September and January, capillary spasms are observed. It is believed that this phenomenon underlies the seasonal manifestations of diseases, in particular hypertension.
Much attention is paid to cardiovascular diseases and their prevention in society. Very often new recommendations appear that refute previously established ideas. Thus, it was believed that alcohol is enemy number one for the cardiovascular system. But recently they have increasingly begun to talk about the benefits of small quantities of grape wine and cognac for the heart. For example, the journal Medical News reported that an inverse relationship was found between wine consumption and coronary heart disease.
In 1959, Stefan Fagar from Prague showed in an experiment that a person, through an effort of will, can cause a rise in blood pressure in another person.
Douglas Dean of the College of Engineering in Newark found that long, persistent thoughts about a friend lead to the fact that the latter's blood pressure rises, regardless of where he is ("Romeo's Mistake").
American psychologist Michael Argyle believes that cynics are more likely to suffer from cardiovascular diseases. Potential “core people” are distinguished by the desire to succeed at any cost, competitiveness, tough, aggressive behavior, the desire to do everything at an accelerated pace, and high efficiency.
These individuals, according to Michael Argyle, are twice as likely to suffer from heart attacks (“Diena” Riga).
Norman Kanzis, in his book The Healing Heart, wrote about how he survived a heart attack: faith, hope, love, determination to survive, good spirits, a sense of humor, the need to believe, the ability to fool around - all these qualities are valuable for health. They excite positive emotions, help to survive and maintain health.
Man is a social being. But communication is not about chatter, but about actions. A person leading a secluded lifestyle quickly worsens his condition, both mental and physical. People who are less sociable are more likely to develop cardiovascular diseases.
As already mentioned, constant stress is very dangerous for people. Scientists have found that up to 80% of residents of developed countries are in a state of chronic stress (depression). In depression, the level of endorphins in the blood turned out to be incredibly low. Economists in the US have found that widespread stress is disrupting the US economy and costing firms $150 billion a year. The same applies to Japan. According to WHO, by the end of the 80s, Japan came out on top in the world in the purchase of medicines per capita, which is $116 per year, and in the United States people spend $110 per year on medicines per capita, regardless of age.
This information should be on the table for the editors of most Ukrainian publications: they should think that the easy success of publishing hot facts, or the health of the nation, is more important.
Help relieve stress: pets cats, dogs, parrots, fish; art therapy: drawing, sculpture, collecting, calligraphy. It has been found that when writing hieroglyphs, the heart rate decreases.
Doctor and artist Nikolai Tokmanov offered 250 watercolor miniatures. With different colors. When laid out in front of the patient in a certain order, they help relieve fatigue.
To eliminate the cause of stress, P.V. Simonov suggests “unwrapping the cabbage head,” getting to the root cause, looking for the chain of events that led to stress, and as soon as the root cause is found, it will become clear what needs to be eliminated.
Physical activity, particularly running, can transform a person and relieve stress. During exercise, endorphins are released into the blood, and this provides a dramatic improvement in both the mental and physical state of a person.
Acupuncture can also be used to combat stress. A good specialist knows the “magic points” on the human body. You can often observe how, after inserting needles into certain points, the patient falls asleep almost instantly. Acupuncture has been shown to release endorphins into the blood. Therefore, it can be an effective tool in the prevention of stress and cardiovascular diseases.
Many problems can be solved by moving away from petty conflicts. Get out without losses - don't get involved. Develop your sense of humor. You shouldn’t rush and take on another without finishing one. You need to learn to say "NO".
Compared to balanced people, people who react violently to a stressful stimulus have 4 times more heart attacks. Valerian root tincture helps calm the nervous system. It contains substances that slow down the transmission of nerve impulses to the central nervous system, which allows you to calm down.
To prevent situations leading to a heart attack, you need to use psychological tests and use these tests to determine what needs to be done at the moment. Do auto-training. A very effective effect on the subconscious in the prevention of cardiovascular diseases for everyone: suggestion at the time of going to bed or waking up.
You can influence emotional states with the help of facial expressions, and also induce certain psychophysiological states in yourself by imagining them.
You can regulate your own state with the help of color, says Yu.A. Andreev. You need to imagine a lettuce leaf shining through in the sun. Its color, veins, etc. Then imagine a red tulip petal with all the details, veins, shades.
Compare which was easier for you to imagine. If there is salad, then you are tired, if there is a tulip, then excitement prevails. But in any case, you need to imagine what is difficult for you to imagine now. If it was easier for you to imagine a salad, then you need to cheer up your nervous system.
And for some time you have been trying very carefully to imagine a tulip flower with a transition from red to black at the bottom of the petal, stamen, etc.
It turned out that the heart and blood vessels react very sensitively to music, and different music can cause different effects.
Just like the heart, the stomach cannot tolerate loud hard music. It has been shown that pop musicians often suffer from cardiovascular diseases and stomach ulcers. One of the US fact sheets provided data that the sounded wheat contained 20 times more vitamin A, 5 times more vitamin C and B6 compared to the control. The overall yield of alfalfa green mass increases. Plant leaves respond well not only to music, but also to the chirping of birds. Music and birdsong can be used to treat cardiovascular diseases. However, the forest is different from the forest. It has been established that many cores do not perceive the proximity of pine forests well. This is apparently due to the presence of a large amount of ozone in the air of the pine forest.
According to research by the chief cardiologist of the Volgograd region, Yuri Lopatin, there are 5 people living in the region with a heart located on the right side. This does not affect their health. Lopatin believes that 1 in 10,000 people are born with this arrangement of the heart.
One of the most important indicators of the state of the cardiovascular system is blood pressure. However, it should be noted that this is a dynamic indicator that is constantly changing. Even when a person speaks, his blood pressure rises, and when he listens, his blood pressure drops (Science News).
Vascular tone and heart function determine blood pressure. The level of blood pressure in the body is monitored by the neuro-endocrine system. It was recently discovered that not only the endocrine glands take part in the production of regulatory hormones, but also the heart itself, which produces the hormone that regulates blood pressure (DPA Agency, Hamburg). The receptors for this hormone are concentrated in the filtering apparatus of the kidneys - the glomeruli. The main function of the hormone is to enhance the filtering ability of the kidneys, i.e. enhance the removal of water from the body, and with it sodium ions. The hormone is released into the blood when atrial pressure increases. After the onset of its action, urine output increases and blood pressure decreases (J. of Biological Chemistry).
An increase in blood pressure (hypertension) sharply impairs the supply of oxygen to tissues, a person’s health worsens, and their performance deteriorates. But the worst thing is that it can all end in a stroke or heart attack.
American researchers have shown that in young people predisposed to hypertension, after they drink black coffee, cortisol levels in the plasma increase, which ultimately contributes to the development of hypertension.
American cardiologists have found that people of short stature (up to 154 cm) are more susceptible to heart attacks than people taller than 183 cm. Moreover, the worst situation is for people whose growth slowed down in childhood due to poor living conditions.
If oxygen were dissolved in the blood, and not bound by hemoglobin in red blood cells, then the heart, in order to ensure tissue respiration, would have to beat 40 times faster than it beats (The Secret Wisdom of the Human Body).
The issue of organ revitalization has become particularly important today. Thus, an isolated frog heart can be revived after several tens of hours. The calf's heart can be revived after 6 hours. This issue has become relevant in connection with the development of organ transplantation. But it is just as important in cases of human resuscitation. The clinic managed to restart the heart of twenty-year-old Canadian Jean Jobone, which was without movement for 3 hours and 32 minutes before its work was restored by a medical team consisting of 26 people from the Winnipeg Medical Center (Guinness Book of Records).
Sometimes it happens that when the heart is wounded, a person remains alive. It is known from history that one duelist, wounded in the heart, chased his opponent for 200 meters.
A twelve-year-old schoolboy came to one of the regional hospitals and complained of weakness and dizziness. During the examination, it was found that the boy had a gunshot wound to the heart. During the operation, it was found that the bullet passed through the right lung, wounded the right ventricle of the heart, and, having pierced the heart septum, ended up in the left ventricle. The blood flow carried the bullet into the aorta. Moving with the blood, the bullet hit the carotid artery, where it stopped.
In the history of medicine, about 30 cases have been described in which a wounded heart threw out foreign bodies that had entered it. They were later found in various parts of the body.
Grigory Olkhovsky received a through bullet wound to the heart during World War II and survived.
Front-line soldier Vasily Alekseevich Bryukhanov was wounded in the heart. Doctors determined that the bullet was in the heart, but they could not remove it. For several decades after the war, Bryukhanov lived with a bullet in his heart.
Mikhail Mizanov has lived for 50 years with a German bullet in his heart. The bullet was lodged in the left ventricular muscle. Mikhail was injured at the age of 19. After that, he went to the hospital several times, but it didn’t come to the point of surgery (Rabochaya Gazeta).
A bullet can travel throughout the body even if it hits other parts of the body that do not have large arteries.
For 44 years, a bullet wandered in the body of the Chinese Gao Rong. By chance he found it near his ankle. Gao was wounded in the groin during the war, but doctors did not find the bullet at the time.
I knew a Russian soldier, Moisei Vasilyevich Tarasenko, whose bullet was felt in different places on his body for 30 years after World War II until it was removed.
Grigory Ivanovich Chetkovsky, Hero of the Soviet Union, was wounded in the heart during World War II. He was considered dead.
20 years after the Victory I saw my name in one of the museums among the dead Panfilov’s men. However, back in 2001 he was alive and lived in a village in the Lugansk region (Ukraine).
At the Moscow Institute of Emergency Medicine named after. Sklifasovsky calculated that in the event of a heart injury and timely provision of medical care to the victim, only 22% of the victims die, more than 2/3 of such wounded survived. This occurs due to the high vitality of the human heart.
Open and closed cardiac injuries have long attracted the attention of practitioners due to the severity of the injuries and high mortality. Attempts at surgical treatment of heart injuries in the recent past often ended in disastrous outcomes. Therefore, conservative therapy for a long time remained the only remedy on which surgeons pinned some hope.
The gradual accumulation of experience has made it possible to increase surgical activity for cardiac injuries and significantly reduce postoperative mortality. This was largely facilitated by the achievements of recent decades in biology and medicine, the rapid development of anesthesiology, resuscitation and cardiac surgery, equipping clinics, hospital departments, trauma centers, etc. with the latest equipment.
Nevertheless, a number of issues regarding the pathogenesis, clinical picture and diagnosis of heart damage still remain insufficiently studied. Hence, the methods of treating patients often suffer from their imperfections. In particular, this concerns the assessment of the role of metabolic disorders in the genesis of pathological disorders arising in the heart, the question of choosing the correct treatment tactics; The operational technique cannot be considered perfect either.
It is quite obvious that when providing assistance, it is necessary to take a differentiated approach to assessing the condition of victims, taking into account a number of specific features of open and closed heart injuries. Each of these groups has its own characteristic features of the clinic, the mechanism of disorders, diagnosis and specific treatment, which forces us to consider the victims of these two categories separately.
OPEN HEART INJURY
Open heart injuries often result in death before the victim is admitted to a medical facility. According to the nature of the wounding weapon, they are divided into stab and gunshot weapons. In wartime, gunshot (more severe) heart injuries predominate, and in peacetime, those caused by knives predominate.
Depending on the depth of passage of the wounding projectile, non-penetrating (tangential) and penetrating wounds into the cavity of the heart are distinguished, which in turn can be blind or through. Blind gunshot wounds are much more common than tangential and through wounds; The prognosis for these injuries is more favorable.
During the Great Patriotic War, the mortality rate for blind wounds of the heart was 13.5%, and for through wounds - 39.1% [Kolesnikov I. S., Smirnova A. P., 1950]. The overall mortality rate in wounded with heart damage according to military operations in Afghanistan was 25.5% [Bisenkov L.N., Tynyankin N.A., 1989].
In most cases, cardiac injuries are accompanied by damage to the lungs and pleura with the development of hemothorax or hemopneumothorax. Extrapleural isolated wounds of the heart are much less common. We observed 43 victims with heart injuries. In more than half of the patients (35 people), cardiac injuries were combined with lung injuries, open pneumothorax was detected in 7 victims, hemopneumothorax was observed in 38 people.
The entrance wound hole is most often located on the anterior surface of the left half of the chest between the parasternal and middle axillary lines. Other localizations of wounds are possible, including the upper half of the abdomen, but they are much less common. Of the 43 victims, skin wounds, mostly single, were located in 38 - on the left side of the chest, usually in the third to seventh intercostal spaces. Only 5 patients had right-sided localization of wounds.
The size of wound defects of the chest wall is usually small (1-2 cm in diameter), and there is usually no significant damage to the chest bones.
According to the Institute of Emergency Medicine named after. Yu. K). Janelidze, of all the victims, the majority (70-80%) had injuries to the ventricles of the heart, mainly the left (40-45%). Atrial damage was less common. Multiple heart injuries were found in 2% of cases.
It should be emphasized that the nature of knife and gunshot wounds of the heart is significantly different [Bisenkov L.N. et al., 1989]. With knife injuries, as a rule, there are linear myocardial wounds measuring no more than 0.8-1.5 cm. At the same time, with gunshot wounds, up to 1.5-2 cm in diameter and usually of irregular shape. It is these victims who have a more severe condition due to the extent of myocardial damage and significant blood loss.
Clinic and diagnostics. According to the majority of domestic and foreign surgeons, diagnosing open heart injuries does not present any great difficulties [Magomedov A. 3. et al., 1977; Potemkina E.V. et al., 1981; Trinkle Z. K. et a1, 1979]. In the acute period, general symptoms usually consist of signs of internal or external bleeding and cardiac tamponade. The victim's marked anxiety, severe weakness, pain in the heart area, difficulty breathing, pallor and cyanosis of the skin, frequent small pulse, progressive decrease in blood pressure in the presence of a skin wound on the surface of the chest give reason to consider the diagnosis of a heart injury to be quite reasonable.
It should be noted that, despite the similarity of the general symptoms of heart wounds, careful observation of patients still reveals some significant features, depending on the nature and location of myocardial wounds and the intensity of bleeding. The size of the traumatic defect in the pericardium is of direct importance. With relatively small wound holes in the pericardium, blood accumulates in the heart sac, causing compression of the heart or tamponade. Such injuries usually occur with knife stab wounds or gunshot wounds with small fragments. The diagnosis here, as a rule, is not in doubt. Rapid deterioration of the general condition of patients against the background of severe hypotension, increasing shortness of breath, bluish-purple complexion, swollen veins of the neck, increased venous pressure, percussion-determined expansion of the borders of the heart in diameter, together with other signs, indicate progressive compression of the heart.
According to our data, in 65% of victims with large pericardial defects (2-3.5 cm), blood flowed freely into the pleural cavity and did not cause difficulty in the functioning of the heart. To the fore when This was a clinical picture of severe ongoing internal bleeding. Therefore, only in a small proportion of patients in this group the diagnosis of heart damage can be established before surgery. In such cases, surgeons do not set themselves the task of clarifying the source of bleeding, but usually decide on the indications for emergency thoracotomy.
To clarify the diagnosis, in addition to clinical signs of open cardiac injury, chest radiography, electrocardiography and ultrasound echolocation can be very useful. However, the extreme severity of the condition of many patients and the need to provide them with urgent surgical care often do not allow the widespread use of these diagnostic methods.
Radiographs show a uniform expansion of the heart shadow in diameter and hemopneumothorax. There are usually no noticeable electrocardiographic changes in patients with cardiac stab wounds. On the contrary, with gunshot wounds of the heart, signs of damage to the myocardium and pathways are almost always recorded. The nature of changes in the ECG always depends on the location of the heart injury and the size of the contused area of the myocardium due to the lateral impact of a bullet or shrapnel. The majority of these victims experience sinus tachycardia, elevation or decrease in the ST segment, decreased voltage and deformation of the P wave. Group ventricular or atrial extrasystoles and atrial flutter are sometimes recorded.
A promising method, which significantly complements the data of other studies, for cardiac injuries is ultrasonic echolocation. It is performed in any position of the patient without special preparation. On the echoscope screen, you can detect even a small amount of fluid in the pericardial cavity, determine zones of myocardial dyskinesia and akinesia, prolapse of the valve leaflets, and a decrease in the amplitude of pulsation of the left ventricular wall. Ultrasound examination can also detect radiopaque foreign bodies.
Treatment of heart wounds. All victims with suspected heart injuries, bypassing the emergency department, must be taken to the operating room, where they undergo the necessary treatment and diagnostic measures.
Treatment of heart wounds should only be surgical. Emergency intervention is not only the main, but also the only therapeutic measure that saves the life of the wounded. There are no contraindications to the operation. Even an extremely serious condition should not serve as a reason to refuse urgent surgical intervention.
Only in cases where the diagnosis of a heart injury is in doubt, and the condition of a patient with a penetrating chest injury is relatively satisfactory and there is no significant hemodynamic disorder, is the so-called expectant-palliative tactics of dynamic monitoring of the patient possible [Wagner E. A., 1981; Bulynin V.I., 1989], the use of hemostatic and hemotransfusion therapy, puncture of the pleural cavity, etc.
In recent years, some foreign surgeons have proposed not thoracotomy and cardiorrhaphy for cardiac injuries, but constant drainage of the pericardium or systematic puncture of the cardiac sac. However, domestic surgeons and most foreign authors prefer surgery.
Urgent thoracotomy with suturing of the heart wound ensures reliable stopping of bleeding, helps to remove the patient from a serious condition and prevents the subsequent development of cardiac aneurysm and adhesive process in the pericardium.
In cases of established cardiac injury, wound suturing (cardiorrhaphy) is indicated. Intensive therapy, including primarily intravenous administration of plasma replacement solutions, blood and vasoactive agents, is carried out during the preparation of the patient for the intervention and further during the operation.
Before induction of anesthesia in all victims with signs of cardiac tamponade and hemopericardium, a preliminary puncture of the pericardium is required, which improves cardiac activity and prevents possible asystole. Pericardial decompression is necessary because during induction of anesthesia and intubation, intrathoracic pressure changes, the effect of tamponade increases, which often causes cardiac arrest at this moment. Removing even a very small (20-30 ml) amount of blood from the pericardial cavity prevents asystole.
The puncture technique is as follows. Under local anesthesia, with the wounded lying down, the superficial layer and the rectus abdominis muscle are pierced in the angle formed by the left costal arch and the xiphoid process. Then the syringe is lowered to the abdominal wall and the needle is advanced towards the right shoulder joint at an angle of 45º to the horizontal surface. After the needle enters the pericardial cavity, the blood is sucked out.
If the patient has hemopneumothorax, especially with simultaneous damage to the lung, it is also necessary to drain the pleural cavity with a wide-bore tube, followed by reinfusion of blood.
The best access to the heart is a left anterolateral thoracotomy in the fourth or fifth intercostal space. This incision is usually completed within a few minutes and provides good access to almost all parts of the heart. If necessary, the breast incision can be expanded by cutting one or two costal cartilages or the sternum in the transverse direction. After opening the pleural cavity, the edges of the wound are widely spread with a dilator. The pericardium is examined, focusing on the location of the wound, and dissected with a long longitudinal incision (at least 15 cm) parallel to the phrenic nerve and 1.5-2 cm anterior to it. Clots and blood are quickly removed from the cavity. Next, they begin to examine the heart. A myocardial wound is found by a pulsating stream on the anterior or lateral surface, although sometimes when a blood clot forms in a relatively small wound channel, it may not be present. Bleeding is stopped with finger pressure. For a full examination of the myocardium and ease of suturing, the surgeon inserts his left hand into the pericardial cavity so that the heart lies on the palm with its back surface, and the thumb holds it in front.
Interrupted or U-shaped sutures are applied to the wound of the heart using round needles with synthetic threads, covering the entire thickness of the heart wall. The needle is inserted and removed at a distance of 0.6-0.8 cm from the edges of the wound opening. The ligatures are tied tightly, but carefully so as not to cut through the heart muscle.
It is more convenient and reliable to close the same wound of the atrium with a purse-string suture. In this case, both the technique described above and grasping the edges of the atrium wound with a fenestrated clamp or a clamp of the Fedorov and Satinsky type can be used. On top of the tightened and tied purse-string suture, it is good to apply another, unstitched, reinforcing ligature, which reduces the likelihood of bleeding from the injection site.
At the time of suturing the wound, the coronary vessels should be protected in every possible way, since their ligation will cause severe myocardial ischemia. More preferable in these cases are U-shaped sutures passing under the vascular trunks located near the wound.
Revision of the posterior surface of the heart is almost always necessary. To do this, the heart is carefully lifted with the left hand and removed from the pericardial cavity. The wounds found here are also sutured. When cutting sutures or in the case of a significant myocardial defect, plastic surgery is used with a flap taken from the pectoralis major muscle, diaphragm or pericardium. A Teflon gasket can be used for this purpose.
It is necessary to remember the possibility of combined damage to the heart, large pulmonary vessels and vena cava. Therefore, after treating a myocardial wound, it is necessary to carefully examine all suspicious hematomas located on the vascular walls.
It is very important to emphasize that during surgery, severe rhythm disturbances can occur, including cardiac arrest. In such cases, after quickly suturing the myocardial wound, it is necessary to move on to continuous but gentle direct massage, which can only be stopped after making sure that the heart contractions have become strong and stable. Cardiac activity becomes complete only if there is sufficient replenishment of circulating plasma.
After completing the main stage of the intervention, the pericardial cavity is freed from clots and washed with warm saline solution. Next, careful hemostasis must be carried out by electrocoagulation or suturing of bleeding vessels of the pericardium or pericardial tissue. Even small vascular trunks left unligated cause bleeding, requiring rethoracotomy.
The operation is completed by revision of the pleural cavity and suturing of the chest wound, leaving drainage in the pleural sinus for aspiration of air, pleural effusion and rapid expansion of the lung. Sparse silk sutures are placed on the pericardium.
Postoperative treatment. Postoperative management of victims with cardiac injuries, along with general therapeutic measures typical for those who have undergone surgery on the chest organs, has some distinctive features.
In some patients, in the first hours after thoracotomy with suturing of the cardiac wound, acute heart failure develops, associated with the depletion of compensatory mechanisms. Emerging critical situations require timely diagnosis of this condition and emergency resuscitation care. Based on the genesis of hemodynamic disorders, to improve the pumping function of the heart and increase its performance, intensive therapy should be expanded by prescribing additional cardiotropic drugs. When the first signs of weakening cardiac activity appear, it is most beneficial to re-introduce fractional doses of fast-acting cardiac glycosides (strophanthin, korglykon) in combination with drugs that support energy metabolism in the myocardium (potassium drugs, cocarboxylase, vitamins C, B, concentrated glucose solution). For persistent hypotension, steroid hormones (300-400 mg of prednisolone per day) and B-adrenergic agonists (novodrin, dopmin) are administered intravenously. They are canceled only after clear stabilization of hemodynamics.
Intravenous administration of plasma replacement solutions to these patients (subject to adequate replacement of blood volume) should be limited. The use of vasopressors is possible only in cases of severe hypotension to prevent cardiac arrest, when all other medications are ineffective.
The course of traumatic disease in victims with cardiac injuries is determined by the mechanism of injury, the nature and location of the myocardial wound and the intensity of bleeding. Stab wounds of the heart are almost always characterized by a smaller area of myocardial damage and less pronounced blood loss. Gunshot wounds to the heart are characterized by significantly larger wounds and are always accompanied by large blood loss. Around the wound channel in the heart muscle, extensive areas of contusion damage are often found, which play an important role in the course of the traumatic disease. The combination of these factors determines the severity of the condition of such victims and the high mortality rate.
We observed 24 victims with gunshot wounds to the heart. In 15 of them, contusion injuries of the heart muscle around the wound channel of varying severity were discovered during surgery. In this case, the diameter of the contused myocardial zone ranged from 2 to 4.5 cm. During the operation, more than half of these wounded people (11 people) had unstable hemodynamics with various heart rhythm disturbances, which often could not be controlled with medications. On the operating table, 4 out of 11 patients died from progressive cardiovascular failure. In wounded patients with gunshot injuries to the heart without significant myocardial contusion (13 people), hemodynamic parameters during surgery were at the level of 70-80 mm Hg. Art., but were well stabilized by the introduction of plasma-substituting solutions, cardiotropic, vasotonic agents. All of them successfully underwent the intervention. In the postoperative period, a total of 8 out of 24 victims with gunshot wounds of the heart died from progressive cardiovascular failure.
Patients with penetrating stab wounds of the heart (19 people) tolerated the operation better, especially if complete decompression of the pericardium was previously performed. Their hemodynamics remained relatively stable throughout the entire period of surgery. In this group of patients, 2 patients died in the postoperative period from various purulent complications.
Heart wounds and pericardial wounds occur in peacetime in persons hospitalized in hospitals with penetrating chest wounds in 10.8 - 16.1% of cases. In more than half of the observations, this type of injury is accompanied by severe shock and terminal condition. About 2/3 of those wounded in the heart die in the prehospital stage.
Historical information. The possibility of surgical treatment of heart wounds was realized at the end of the 19th century. Until this time, medicine was dominated by the idea of the fatal nature of the injury in question. However, a number still made attempts to save the sick. Thus, in 1649, Riolanus pointed out the possibility of treating heart wounds by aspiration of blood from the pericardial sac. In 1829, Larrey was the first to decompress a wounded heart using , Marks (1893) achieved the recovery of a patient with a heart wound after its packing. The first heart suturing was performed by Cappelen (1895) in Norway, Fariner (1896) in Italy, V. Shakhovsky (1903) in Russia, E. Korchits (1927) in Belarus.
Pathogenesis. Injuries to the pericardium are characterized by the occurrence of a complex of hemocirculatory disorders. Their development is based on the flow of blood into the pericardial cavity, which is accompanied by difficulty in the activity of the heart. At the same time, compression of the coronary vessels occurs and the nutrition of the heart muscle is sharply disrupted. In addition, circulatory disorders in case of cardiac injuries are aggravated by ongoing bleeding, accumulation of air and blood in the pleural cavities, displacement of the mediastinum, bending of the vascular bundle, etc. All of these factors in combination lead to the development of hypovolemic, traumatic and cardiogenic shock.
The volume of hemopericardium depends on the length of the pericardial wound and the location of the cardiac wound. In case of defects in the pericardium of more than 1.5 cm, injuries to the parts of the heart and adjacent vessels with relatively high pressure (aorta, pulmonary artery), blood is not retained in the cavity of the heart sac, but is poured into the surrounding spaces, primarily into the pleural cavity with the formation of hemothorax. In the case of small wounds of the pericardium (up to 1-1.5 cm), blood accumulates in the pericardial cavity, causing the development of cardiac tamponade syndrome in 30 - 50% of cases. Its occurrence is associated with the small volume of the pericardial cavity, which in healthy individuals contains 20 - 50 ml of serous fluid and extremely rarely 80 - 100 ml. A sudden accumulation of more than 150 ml of blood in the heart sac leads to an increase in intrapericardial pressure and compression of the heart. This is accompanied by an increase in atrial pressure, a drop in the pressure gradient between the pulmonary artery and the left atrium. Cardiac activity stops. In persons with rapid accumulation of blood in the pericardial cavity, death from tamponade occurs within 1 to 2 hours from the moment of injury.
Pathological anatomy. Wounds to the heart and pericardium can be stab, stab and gunshot wounds. Knife wounds are usually accompanied by damage to the left side of the heart, which is associated with a more frequent direction of impact from left to right. In other types of injuries, injuries to the right ventricle and atrium predominate due to their direct contact with the anterior chest. Almost 3% of patients have simultaneous injury to the interatrial septum and heart valves. There are cases of damage to the conduction system, coronary arteries, 5 times more often than the left coronary artery. More massive damage to the heart is observed with gunshot wounds. Ruptures of cavities, damage to intracardial structures in 70 - 90% of cases of cardiac injury are accompanied by damage to the upper or lower lobe of the left lung, diaphragm, and large vessels.
Classification of wounds of the heart and pericardium
There are isolated pericardial injuries and pericardial injuries combined with cardiac injuries. The latter are divided into isolated and combined.
Isolated heart injuries are divided into:
I. Non-penetrating:
1: a) single;
b) multiple.
2: a) with hemopericardium;
b) with hemothorax;
c) with hemopneumothorax;
3: with damage to the coronary vessels;
4: with external and internal bleeding.
II. Penetrating:
1; a) single;
b) multiple;
2: a) end-to-end;
b) not through;
3: a) with hemopericardium;
b) with hemothorax;
c) with hemopneumothorax;
d) with mediastinal hematoma;
4: a) with external bleeding;
b) with internal bleeding;
5: a) with damage to the coronary vessels;
b) with damage to the septum of the heart;
c) with damage to the conduction system;
d) with damage to the valve apparatus.
Combined cardiac injuries are divided into:
1) penetrating;
2) non-penetrating;
3) in combination with damage:
a) other organs of the chest (lungs, bronchi, trachea, large vessels, esophagus, diaphragm);
b) abdominal organs (parenchymal organs, hollow organs, large vessels);
c) organs of other localization (bones of the skull, brain, bones and joints, blood vessels).
Symptoms of wounds of the heart and pericardium
Manifestations of heart injury are varied. The victims are hospitalized in medical institutions in serious condition. At the same time, there are cases of erased, asymptomatic wounds. Patients complain of weakness, dizziness, shortness of breath in the heart area. They are excited and quickly lose strength. In severe shock, there may be no complaints, but in the case of combined trauma, symptoms of damage to adjacent organs often prevail. Patients with severe cardiac tamponade report a feeling of lack of air. Damage to the coronary arteries and multiple wounds are characterized by significant pain in the heart.
There are three clinical variants (forms) of cardiac injuries: with a predominance of cardiogenic, hypovolemic shock and their combinations. The manifestations of these types of shock are practically no different from those in other diseases.
Diagnosis of wounds of the heart and pericardium. When solving diagnostic issues for cardiac injuries, one should remember the time factor, and that a set of diagnostic measures should be aimed primarily at identifying the most reliable symptoms. In cases of shock, diagnostic measures are carried out in the operating room in parallel with elements of intensive care. A heart injury is indicated by:
The location of the wound channel entrance on the chest is predominantly in the heart area or in the precordial zone. According to I.I. Grekov, the area of possible injury to the heart is limited above by the 2nd rib, below by the left hypochondrium and epigastric region, on the left by the middle axillary and on the right by the parasternal lines.
Signs of venous hypertension: cyanosis of the face and neck, swelling of the neck veins (CVP 140 mmH2O or more). However, in patients with predominant blood loss and severe concomitant trauma, CVP is usually reduced. An increase in central venous pressure over time is a sign of cardiac tamponade.
Shortness of breath (more than 25-30 breaths per minute),
Deafness of heart sounds or their absence. If the interventricular septum is damaged, a systolic murmur is detected along the left edge of the sternum with the epicenter in the fourth intercostal space. If the mitral and tricuspid valves are damaged, a systolic murmur may be heard in the lower third of the sternum, at Botkin's point and at the apex (one should remember the possibility of heart damage in people who have previously suffered from heart disease).
Expansion of the percussion boundaries of cardiac dullness.
Tachycardia. In terminal patients and in cases of severe cardiac tamponade, bradycardia and paradoxical pulsus are observed - a decrease in the pulse wave during inspiration.
Arterial hypotension with reduced systolic and diastolic and reduced pulse pressure. In patients with cardiac tamponade, blood pressure at the onset of hemopericardium may be moderately reduced, but remains stable for some time. If hemopericardial symptoms increase, blood pressure drops sharply. With extrapericardial bleeding, blood pressure progressively decreases.
In case of cardiac injuries accompanied by hemopericardium, low voltage of the ventricular complexes is observed on the ECG. In persons with severe blood loss, signs of myocardial hypoxia are observed, mainly of a diffuse nature. Damage to the large coronary arteries and ventricles is accompanied by ECG changes identical to those in the acute stage of myocardial infarction. In persons with injuries to the conduction system of the heart, septa and its valves, rhythm and conduction disturbances (blockade of impulse conduction, rhythm dissociation, etc.) and signs of overload of the heart parts are observed. However, an ECG for wounds of the pericardium and heart does not accurately determine the location of the wound. This is explained by the fact that stab wounds themselves do not cause significant changes in the myocardium.
An x-ray examination of the chest organs reveals reliable and probable symptoms of heart injuries. Reliable symptoms of heart damage include: pronounced expansion of its boundaries; displacement of the arches along the right and left contours of the heart; weakening of the pulsation of the heart contours (a sign of hemopericardium).
Echocardiographically, with hemopericardium, a gap in the echo signals between the walls of the heart and the pericardium is detected. The exact dimensions of the hemopericardium are determined by ultrasonography.
Based on a comprehensive examination of patients with cardiac injuries, Beck's triad is distinguished - a sharp decrease in blood pressure, a rapid and significant increase in central venous pressure, and the absence of cardiac pulsation during fluoroscopy.
Treatment of wounds of the heart and pericardium
Suspicion of injury to the heart and pericardium is an absolute indication for surgery. Preparation for surgery includes the most necessary diagnostic, laboratory and instrumental manipulations, preural cavities for tension pneumothorax, and catheterization of the central veins.
When choosing an access, the location of the wound canal inlet and its approximate direction are taken into account. The most common procedure is an anterolateral thoracotomy. If the wound is localized in the lower parts of the chest, it is advisable to perform a left-sided anterolateral thoracotomy in the 5th intercostal space, and in the upper parts - in the 4th intercostal space. Expansion of the wound or opening of the pleural cavities through the wound channel is not recommended. If the main vessels are injured - the ascending aorta, the trunk of the pulmonary artery - a bilateral thoracotomy is performed with intersection of the sternum. A number of surgeons perform longitudinal median sternotomy for cardiac injuries.
After opening the chest, the pericardium is dissected longitudinally in front of the phrenic nerve. At the time of its opening, a large amount of blood and clots are released from the pericardial cavity. Blood pours out from a wound in the heart. Penetrating wounds of the left side of the heart are characterized by the flow of scarlet blood. Bleeding from the ventricles is sometimes pulsating. To temporarily stop bleeding, the heart wound is covered with a finger. The defect in the heart wall is closed with non-absorbable suture material.
Ventricular wounds are most often sutured with conventional interrupted or U-shaped sutures on synthetic pads. Punctures are made through the entire thickness of the myocardium, retreating from the edges of the wound by 0.5 - 0.8 cm.
When the wound is located near the coronary vessels, U-shaped sutures are used with their placement under the vascular bundles. Large wounds of the ventricular wall are sutured with the initial application of wide U-shaped sutures bringing the edges of the wound closer together. Wounds of thin-walled atria are sutured with interrupted U-shaped sutures on synthetic pads, an atraumatic needle, purse-string sutures on pads, and a continuous suture after lateral pressing of the atrium wall with a clamp. Wounds of the ascending aorta less than 1 cm in length are sutured by placing two purse-string sutures on the adventitia of the aorta. The internal purse string suture runs no closer than 8 - 12 mm from the edge of the wound; The pericardium is sutured with rare sutures.
If cardiac arrest or fibrillation suddenly occurs during surgery, the heart is rectified, 0.1 ml of adrenaline is injected intracardially and defibrillation is performed.
In the postoperative period, complex therapy and, if necessary, topical diagnosis of the pathology resulting from a heart injury are carried out.
For patients with severe cardiac tamponade at the prehospital stage and in the hospital with an extremely severe or atonal condition, if it is impossible to perform an emergency thoracotomy, pericardial puncture from known points is recommended. It is advisable to perform pericardial puncture under the control of an ECG. In this case, the appearance of extrasystoles on the ECG or a rhythm disturbance indicates contact with the myocardium, and an increase in the voltage of the ventricular complexes indicates the effectiveness of cardiac decompression. After aspiration of contents from the pericardial cavity, an increase in blood pressure, a decrease in central venous pressure, and a decrease in tachycardia are observed. The operation is then performed.
In patients with extremely severe concomitant pathology, admitted 12 to 24 hours after injury, and stable hemodynamic parameters, pericardial puncture with blood removal may be the definitive treatment.
The article was prepared and edited by: surgeonHistory of cardiac surgery
The famous French surgeon Rene Leriche wrote in his book “Memories of My Past Life”: “I loved everything that was required in emergency surgery - determination, responsibility and inclusion entirely in the action.” These requirements are extremely necessary when providing assistance to victims with heart injuries. Even fulfilling all these requirements does not always lead to positive results in cardiac injuries.
The first mention of the fatal consequences of a heart injury was described by the Greek poet Homer in the 13th book of the Iliad (950 BC).
Galen’s observation is especially impressive: “When one of the ventricles of the heart is perforated, the gladiators die immediately on the spot from blood loss, especially quickly if the left ventricle is damaged. If the sword does not penetrate the cavity of the heart, but stops in the heart muscle, then some of the wounded survive for the whole day, and also, despite the wound, the subsequent night; but then they die from inflammation.”
At the end of the 19th century, when the survival rate for heart wounds was approximately 10%, authoritative surgeons, in particular T. Billroth, argued that inexperienced surgeons without a solid reputation were trying to treat heart wounds surgically.
For the first time, a suture was applied to a stab wound of the heart by Cappelen in Oslo on September 5, 1895, but the wounded man died 2 days later from pericarditis. In March 1896, Farina in Rome stitched the wound to the right ventricle, but six days later the wounded man died of pneumonia.
The first successful operation of this kind was performed on September 9, 1896 by L. Rehn, who demonstrated the patient at the 26th Congress of German Surgeons in Berlin (J.W.Blatford, R.W.Anderson, 1985). In 1897, Russian surgeon A.G. Undercut was the first in the world to successfully suture a gunshot wound to the heart. In 1902 L.L. Hill was the first in the United States to successfully stitch a stab wound to the heart of a 13-year-old boy (on a kitchen table under the light of two kerosene lamps). However, as experience accumulated, the romantic connotation of this section of emergency surgery began to disappear, and already in 1926, K. Beck, in his classic monograph, which has not lost its significance to this day, wrote: “Successful suturing of a heart wound is not a special surgical feat.” .
Classification.
Heart wounds are divided into non-gunshot (knife, etc.) and gunshot: into those penetrating into the cavities of the heart and non-penetrating. Penetrating ones, in turn, are divided into blind and through ones. This is the localization of injuries in relation to the chambers of the heart: injuries to the left ventricle (45-50%), right ventricle (36-45%), left atrium (10-20%) and right atrium (6-12%). They, in turn, with and without damage to intracardiac structures.
Currently, cardiac injuries account for 5 to 7% of all penetrating chest wounds, including gunshot wounds - no more than 0.5-1%. In case of stab wounds of the heart and pericardium, isolated pericardial injuries account for 10-20%. Pericardial injuries themselves do not pose a threat to the life of the victim, however, bleeding from the crossed pericardial vessels can lead to cardiac tamponade.
Cardiac tamponade is a condition in which blood entering the pericardial cavity “strangles” the heart.
Acute cardiac tamponade occurs in 53-70% of all cardiac injuries. The degree of tamponade is determined by the size of the heart wound, the rate of bleeding from the heart into the cavity of the cardiac membrane, as well as the size of the pericardial wound. Small stab wounds to the pericardium are quickly closed by a blood clot or adjacent fat, and cardiac tamponade quickly ensues. The accumulation of more than 100-150 ml of blood in the cavity of the cardiac membrane leads to compression of the heart and a decrease in myocardial contractility. Left ventricular filling and stroke volume rapidly decrease, and profound systemic hypotension occurs. Myocardial ischemia is aggravated due to compression of the coronary arteries. If there is 300-500 ml, cardiac arrest occurs in most cases. It should be remembered that an extensive pericardial wound prevents the occurrence of tamponade, because blood flows freely into the pleural cavity or out.
According to S. Tavares (1984), mortality from cardiac injuries is associated with the nature, size, location of the cardiac wound, as well as associated injuries and the length of time from the moment of injury to the start of resuscitation and treatment. In recent years, there has been an increase in mortality, which is primarily due to the severity of heart damage.
The prognosis is also affected by rhythm disturbances. For example, with sinus rhythm, survival rate is 77.8%. According to J. P. Binet (1985), only 1/3 of victims with heart injuries are admitted to the hospital, and the rest die at the scene or on the way to the hospital. Supposed causes of death at the prehospital stage, according to the observations of V.N. Wolf (1986), the following: 32.8% die from massive blood loss, 26.4% from a combination of massive blood loss and cardiac tamponade, 12.7% from isolated cardiac tamponade. In addition, the mortality rate is influenced by such factors as the duration of acute cardiac tamponade, the degree of blood loss, as well as the presence of damage to the coronary arteries and intracardiac structures.
The highest mortality rate is observed with gunshot wounds.
Diagnostics.
According to the literature, the determining factors in diagnosing heart wounds are the localization of the chest wound in the projection of the heart and the degree of blood loss. An important and reliable sign of a heart injury is the localization of the external wound in the projection of the heart, which, according to the observations of V.V. Chalenko et al., (1992) - met in 96%, M.V. Grineva, A.L. Bolshakova, (1986) - in 26.5% of cases.
Difficulties in diagnosis arise in the absence of typical clinical signs. According to D.P. Chukhrienko et al., (1989), cardiac tamponade occurs in 25.5% of cases of cardiac injuries. V.N. Wolf (1986) distinguishes two stages of cardiac tamponade: the first - blood pressure at the level of 100-80 mm Hg. Art., while the hemopericardium does not exceed 250 ml; the second, when blood pressure is less than 80 mm Hg. Art., which corresponds to a hemopericardium of more than 250 ml. J.H. Vasiliev (1989) believes that a sudden accumulation of 200 ml of fluid in the pericardial cavity causes a clinical picture of cardiac compression; an accumulation of about 500 ml leads to cardiac arrest.
Cardiac tamponade can also be caused by pneumopericardium.
Beck's triad, according to A.K. Benyan et al. (1992), was observed in 73% of cases, according to the conclusion of D. Demetriades (1986) - in 65%, according to M. McFariane et al. (1990) - in 33%.
X-ray examinations of cardiac injuries are carried out in 25% and 31.5%. Based on radiographs, one can judge the volume of blood in the pericardial cavity - a blood volume from 30 ml to 85 ml is not detected; if 100 ml is present, signs of weakening pulsation are observed; when the blood volume is more than 150 ml, there is an increase in the boundaries of the heart with smoothing of the “arcs”.
To diagnose cardiac injury, additional research methods are used - ultrasound, pericardiocentesis [Chukhrienko D.P. et al., 1989; Demetriades D., 1984; Hehriein F.W., 1986; McFariane M. et al., 1990], pericardiotomy [Vasiliev Zh.Kh., 1989; Grewal N. et al., 1995].
It should be emphasized that when performing pericardial puncture, false negative results were obtained in 33% [Chalenko V.V. et al., 1992] and in 80% of cases.
ECG is performed quite often: in 60%. At the same time, signs of cardiac injury such as large-focal injuries with changes in the T wave, a decrease in the RST interval were detected in 41.1%, rhythm disturbances - in 52%.
The diagnosis of cardiac injury before surgery was established in 75.3%.
According to the authors, progress in diagnosis is obvious, but mainly due to the “classical” clinical approach. This opinion is also shared by K.K.Nagy et al., (1995), they classify clinical signs of damage and active surgical intervention as the most reliable diagnostic methods.
The following triad of symptoms should be considered characteristic signs of heart injury:
1) localization of the wound in the projection of the heart;
2) signs of acute blood loss;
3) signs of acute cardiac tamponade.
When the wound is located within the following boundaries: above - the level of the second rib, below - the epigastric region, on the left - the anterior submuscular line and on the right - the parasternal line, there is always a real danger of injury to the heart.
When the wound is localized in the epigastric region and the blow is directed from bottom to top, the wound canal, penetrating into the abdominal cavity, goes further through the tendon center of the diagram into the cavity of the cardiac sac and reaches the apex of the heart.
The classic clinical picture of cardiac tamponade was described by K. Beck (1926): dullness of heart sounds; low blood pressure with a low rapid pulse (and low pulse pressure); high venous pressure with swelling of the neck veins.
If the patient's condition is stable, the diagnosis of cardiac injury can be confirmed by X-ray examination.
Currently, the most accurate and fastest non-invasive diagnostic method is echocardiography. In this case, within 2-3 minutes, the divergence of the pericardial layers (by more than 4 mm), the presence of fluid and echo-negative formations (blood clots) in the cavity of the heart lining, zones of akinesia in the area of the myocardial wound, as well as a decrease in myocardial contractility are clearly revealed.
Recently, surgeons have sometimes begun to use a minimally invasive method such as thoracoscopy to diagnose cardiac injuries. It is worth noting that indications for this method arise quite rarely, for example, in clinically unclear cases when it is impossible to diagnose a heart injury with echocardiography, when, on the one hand, it is dangerous to continue observation and examination over time, and on the other hand, it is dangerous to perform classical thoracotomy (for example, in patients with decompensated diabetes mellitus).
When the heart or pericardium is injured, after opening the pleural cavity, it is clearly visible how blood shines through the walls of the tense pericardium. Further manipulations of the surgeon and his assistants, the entire team on duty, including the anesthesiologist, must be clearly coordinated. The surgeon places two suture holders on the pericardium and opens it wide, parallel and in front of the phrenic nerve.
The holding assistant widely spreads the pericardial wound, and, at the same time, frees the pericardial cavity from liquid blood and clots, and the surgeon, guided by the pulsating stream of blood, immediately plugs a small heart wound with the second finger of his left hand, or, if the wound size exceeds 1 cm, with the first finger, bringing your palm under the back wall of the heart.
In cases of more extensive wounds, a Foley catheter can be used to achieve temporary hemostasis. Inserting a catheter into the heart chamber and inflating the balloon with gentle tension can temporarily stop bleeding. This task can also be accomplished by inserting a finger into the myocardial wound. We successfully used the last technique in four observations. When suturing a heart wound, exclusively non-absorbable suture material is used, preferably with an atraumatic needle. It should be remembered that thin threads are easily cut through when sutures are placed on a flabby wall, especially in the area of the atria.
In these cases, it is better to use thicker threads and place patches under them, cut in the form of strips from the pericardium. In cases of injury to the appendage of the heart, instead of applying sutures, it is better to simply bandage the appendage at the base, after first applying a windowed Luer clamp to it.
In order to avoid myocardial infarction when the branches of the coronary arteries are dangerously close to the wound, vertical interrupted sutures should be applied, bypassing the coronary artery.
Of no small importance for the postoperative course is careful sanitation and proper drainage of the cavity of the cardiac membrane. If this is not done, then postoperative pericarditis inevitably develops, leading to an increase in the duration of hospital treatment, and, in some cases, to a decrease in the patient’s ability to work.
Therefore, the cavity of the cardiac membrane is thoroughly washed with a warm isotonic solution, a section of about 2-2.5 cm in diameter is excised in the posterior wall of the pericardium, making a so-called “window” that opens into the free pleural cavity, and rare interrupted sutures are placed on the anterior wall of the pericardium to preventing dislocation of the heart and “strangulation” of it in a wide wound of the pericardium.
In cases of abdominal-thoracic wounds with damage to the heart from bottom to top, it is more convenient to suture the heart wound through the diaphragmatic-pericardial approach, without performing a lateral thoracotomy.
Noteworthy is the proposed Trinkle J.K. (1979) subxiphoid fenestration of the pericardium. It consists of dissecting the soft tissue in the area of the xiphoid process, resection of the latter, reaching the pericardium, applying holders to it, opening and evacuating blood clots in an open manner. This operation can be performed under local anesthesia and is life-saving in cases where it is necessary to gain time, but it is not possible to perform a thoracotomy.
We studied the results of using subxiphoid partial pericardiectomy in 10 patients with cardiac injury. The operation ended with the installation of a silicone drainage tube with a diameter of 5 mm into the cavity of the cardiac membrane. To improve the outflow from the pericardial cavity, the distal end of the drainage was connected to the aspiration system.
So, depending on the conditions of care, there may be different solutions to tactical problems for cardiac injuries.
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Damage to the pericardium and heart during penetrating chest wounds is a fairly common occurrence. W. S. Shoemaker and J. Carey (1970) out of 800 victims with penetrating chest wounds operated on 80 people for heart wounds. B. D. Komarov et al. (1972) report on 170 patients operated on over 16 years in the surgical clinics of the Research Institute named after. N.V. Sklifosovsky, which amounted to 12% of people with penetrating chest wounds.
We have experience in treating 108 victims with damage to the heart and pericardium - 11% of the total number of patients with penetrating chest wounds. According to the generalized data of E. Derra (1955), with wounds of the heart, damage to the pleura is present in 70-95%, lungs - in 17-42%, diaphragm - in 5-10% of cases; injuries to the liver, stomach, intestines, spleen, kidneys, spinal cord total 5%.
Of our 108 patients, 39 had injuries to the left ventricle, 27 to the right, 16 to the right atrium, and 9 to the left. Isolated pericardial injuries were observed in 17 people.
The clinical picture and features of surgical tactics are related to the location, size and depth of the wound.
In practical terms, the classification proposed by W. Schmitt and I. Garten (1961) is convenient. The authors distinguish isolated non-penetrating wounds of the heart, wounds of the coronary vessels (isolated and with myocardial wounds), penetrating wounds of the heart, damage to internal structures (valve, septum), multiple wounds of the heart, wounds of the heart with needles. L. A. Brewer and R. C. Carter (1968) distinguish between small (1 cm in size) and large (more than 1 cm) heart wounds. According to these authors, the former do not pose a threat to life and can be cured by aspiration of blood from the heart sac; wounds larger than 1 cm are accompanied by massive blood loss and require urgent suturing.
H. S. Anishin et al. (1973) were able to diagnose cardiac injury in 39 out of 48 cases before surgery. They consider the most reliable diagnostic signs to be the location of the wound in the projection of the heart, the expansion of the boundaries of cardiac dullness, dullness of tones, shortness of breath, hemothorax, and sometimes gushing bleeding from the wound of the chest wall, and a decrease in blood pressure. Valuable diagnostic indicators were also a feeling of suffocation, pallor and cyanosis. With small wounds, the clinical picture of cardiac tamponade usually develops, with large wounds - heavy internal bleeding.
The following circumstances should suggest a heart injury:
I. Location of the wound. Even I.I. Grekov defined the area of possible heart injury within the following boundaries: above - the 2nd rib, below - the left hypochondrium and epigastric region, on the left - the middle axillary line and on the right - the parasternal line. Wounds were usually located within these same boundaries in our observations (Fig. 24).
Rice. 24. Location of entrance holes for cardiac injuries.
Of course, there are cases of atypical location of the inlet holes: in the epigastric region, on the back, etc., but still, the closer the inlet hole is to its projection on the anterior chest wall, the greater the possibility of injury to the heart.
2. General condition. When the wound is located in the area of possible heart injury, you should pay close attention to the patient’s condition. If he has a confused look, a pale face covered with cold sweat, a wandering, absent or glassy look - be on your guard! Fainting or semi-fainting should be even more alarming. According to B. D. Komarov et al. (1972), among victims brought to the clinic with a heart injury, a serious condition was noted in 48%, terminal in 18, and 17% of those admitted were in a state of clinical death.
3. Bleeding. With wounds of the heart, bleeding is often intrapleural, reaching 2-2.5 liters or more. From an external wound, blood usually flows out continuously in a thin stream or the hole becomes covered with bloody foam. Only sometimes external bleeding is so violent that it itself evokes the idea of a heart injury.
Patient B., 29 years old, was wounded in the chest with a knife. 30 minutes later he was admitted to the surgical department. He briefly lost consciousness. There is gushing bleeding from the wound, which he tries to press with his hand. The first aid physician inserted a gauze pad into the wound to stop the intense external bleeding.
The patient is pale, lips are cyanotic. Pulse 110 per minute, soft, blood pressure 95/40 mm Hg. Art. The wound is located in the fourth intercostal space, 3 cm from the left parasternal line. The right border of the heart is normal, the left border is not determined due to a boxy sound during percussion.
The patient refused the operation. Not giving in to persuasion, he got up from the operating table. The pallor intensified, the face became covered with large drops of sweat, pronounced pulsation of the vessels of the neck appeared, the pulse became arrhythmic. The patient began to choke and, trying to ease his breathing, tried to pull the tampon out of the wound, but completely weakened and was laid on the operating table.
A thoracotomy was performed in the fourth intercostal space on the left. There are 2400 ml of blood in the pleural cavity. The pericardium is stretched and tense. Blood spurts out from the slit wound. The pericardium is dissected, in its cavity there is about 400 ml of blood, a large flat clot enveloping the heart mainly at the base. Heart contractions are sluggish. A wound 1.5 cm long penetrates into the cavity of the right ventricle. Four interrupted silk sutures were applied. The stomach became full and the heart contractions became stronger. The pericardium is sutured with rare sutures. 2 liters of blood were reinfused. Recovery followed.
4. Cardiac tamponade. With the rapid accumulation of blood in the pericardial cavity, the right atrium and thin-walled vena cava are first compressed. Normal pressure in the systole phase in the right atrium is 31-33 mm H2O. Art. with fluctuations from 27 to 81 mm water. Art. R. N. Cooley et al. (1955) in experiments on dogs found that with intrapericardial installation of an isotonic sodium chloride solution at a pressure of 27 mm of water. Art. the heart loses its pumping function and blood circulation stops.
Clinical observations indicate that with rapid accumulation of blood in the heart sac, even 200 ml can have a fatal effect, but with slow filling of the pericardial cavity without the development of tamponade, 400-500 ml of blood can accumulate.
Acute cardiac tamponade is manifested by Beck's triad, which includes a sharp decrease in blood pressure, sometimes with paradoxical pulsus; rapid and significant increase in central venous pressure; sharp weakening of heart sounds and absence of pulsation of the heart shadow during fluoroscopy. On radiographs, the shadow of the heart is expanded and has the shape of a trapezoid or ball.
Patients often complain of anginal heart pain, the face acquires a pale cyanotic or pale gray color, breathing becomes accelerated, shallow with short respiratory impulses, the pulse is small, frequent, sometimes disappears on inspiration (paradoxical pulse), stagnant veins in the neck are visible. In the absence of hemopneumothorax, percussion is easy to establish the expansion of the borders of the heart; the apex beat is usually not detected.
The presence of hemopericardium leads to a decrease in the voltage of the ECG waves.
Injury to the ventricle is indicated by infarct-like changes in the ECG - the monophasic nature of the QRST complex with a subsequent decrease in the S-T interval to the isoline and the appearance of a negative T wave; less commonly, deep Q waves, jaggedness and widening of the QRS complex are observed, indicating a violation of intraventricular conduction.
In some cases, the ECG can also be used to judge the location of the damage. Moreover, an ECG performed during surgery and during the postoperative period gives an idea of the anatomical and functional changes in the wounded heart.
Depletion of the arterial system with blood causes ischemia of the brain, liver, and kidneys, which can be a direct cause of death.
Cardiac tamponade is not always associated with a penetrating injury to one of its cavities or piercing the heart through. The source of bleeding can be damaged vessels of the base of the heart, coronary and even small muscle branches. In cases of injury to the superficial muscle layers or with isolated damage to the pericardium, the pattern of tamponade develops more slowly.
Injury to the heart's own blood vessels poses a serious danger, as it entails severe disturbances in the nutrition of the heart muscle. In addition, due to injury from these damages to highly sensitive receptor zones, disturbances in cardiac activity, including cardiac arrest, are possible.
E.A. Wagner
