How should this situation be handled?

Thrombolytic therapy and anticoagulants are inappropriate. If facilities are available, emergent coronary angiography and angioplasty should be considered.

An unconscious patient is brought to the hospital following a major motor vehicle accident and is found to have deep T-wave inversion in leads Vj, V2, and V3. What has happened?

Again, two scenarios are possible: (1) the ECG changes are the result of myocardial contusion, or (2) more likely, the T-wave inversions are those seen in association with an intracranial process. These ECG changes should prompt an evaluation for head trauma.

What was the first cardiac surgery, and when was it performed?

This subject of this chapter is cardiac trauma, so if you guessed it was repair of a ventricular laceration, you are correct! The procedure was reported by Rehn in 1897.

1If stab wounds to the heart can be survived, what about gunshot wounds?

Yes, such injuries are survivable, but the mortality rate following penetrating cardiac injury from a gunshot is much higher than with stab wounds.

1Is there a role for conservative management of suspected penetrating cardiac wounds?

Not at present. Virtually all patients with suspected penetrating cardiac trauma should undergo emergent thoracotomy.

1Are there any late sequelae of penetrating cardiac injuries?

An amazing variety of fistulae between contiguous cardiac chambers and great vessels following stab or gunshot wounds have been described. Valvular regurgitation from laceration is possible. Myocardial infarction from coronary artery damage may result in left ventricular dysfunction, aneurysms, and mural thrombi. Post-pericardiotomy syndrome may result in pericardial effusion with or without tamponade. Constrictive pericarditis is also possible. Embolization of retained bullets and the like, either to or from the heart, has been described.

How can these complications be diagnosed?

As with nonpenetrating trauma, echocardiography is the most useful tool. Many authors recommend that all patients have an echocardiogram during the initial hospital stay, because many cardiac lesions may go undetected at initial thoracotomy. A follow-up echocardiogram three to six months later should be done.

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