Approach Considerations
Penetrating trauma to the chest in an unstable patient is an indication for thoracotomy [17] and possible cardiorrhaphy.
The ventricles are involved in 80% of penetrating cardiac wounds.
Once a cardiac wound is identified, hemostasis should be obtained quickly with a finger or Foley catheter while closure materials are prepared.
Surgical staples may be a faster and safer closure method than the traditional approach using suture with pledgets.
Thoracotomy
Make an incision in either the fourth or fifth intercostal space. In men, this location corresponds to the area inferior to the nipple; in women, the inframammary fold can be used as a landmark. The breast may have to be retracted in women in order to expose this area.
The incision should begin just lateral to the sternum on the left and continue to the midaxillary line. Take care to confine the incision to the inferior border of the intercostal space throughout its course. This ensures wide exposure with the rib spreader through a single intercostal space and decreases the possibility of injuring the neurovascular bundle, which courses over the inferior border of the upper rib. (See the image below.)
The initial incision should be deep enough to cut through the pectoralis major and serratus muscles. The intercostal muscles can be bluntly dissected with the end of the scalpel or scissors. Once the pleura is exposed, make an initial opening with the scalpel. Use the scissors to open the pleura along its length from the scalpel opening, taking care to avoid injury to underlying intrathoracic structures. (See the image below.)
Insert the rib spreader in its closed position through the intercostal incision. Crank the handle to separate the blades and open the chest. Open the chest widely enough to allow easy access to the mediastinum. (See the image below.)
Identify the pericardium, and make a longitudinal opening in the pericardial sac anterior to the phrenic nerve. Avoid the phrenic nerve, which runs vertically along the lateral border. If cardiac tamponade is present, a gush of blood ensues after the initial opening is made. Use the fingers to tear the pericardium longitudinally, opening it along its length. Remove any clots or remaining blood within the pericardium. (See the image below.)
Cardiorrhaphy
Inspect the heart for obvious lacerations, and quickly identify the coronary arteries. Current data suggest that the incidence of chamber laceration in penetrating cardiac injury is as follows: 40% right ventricle (RV), 40% left ventricle (LV), 24% right atrium (RA), and 3% left atrium (LA). [1]
Once the laceration is isolated, several methods exist for temporary hemostasis. If the laceration is small enough, a finger may be placed at the site of the laceration while suture is prepared. Lacerations to the atria can be controlled with Satinsky vascular clamps. Alternatively, if the laceration is large, a Foley catheter may be placed through the wound and the balloon inflated. The catheter should be retracted until resistance is met to seal the wound. Medications may be administered through the Foley catheter into the intracardiac space. (See the image below.)
Once a laceration is found, simple suturing with a monofilament material (eg, 2-0 polypropylene) can be performed in a continuous or interrupted fashion. [1] However, suturing of cardiac wounds over pledgets is the time-honored technique. Because of its time-consuming and complicated nature, however, most authors do not recommend this in the emergency department (ED). [1] To begin the cardiorrhaphy procedure with pledgets, thread nylon suture through the Teflon pledget, and place a horizontal mattress suture across the laceration. (See the image below.)
Thread the suture through another Teflon pledget on the opposite wound edge, and complete the mattress stitch. (See the image below.)
The pledgets prevent further injury to an already friable myocardium. Repeat the suture step until the laceration is sufficiently approximated. Take care to avoid the coronary arteries; a suture placed into or over these arteries can have disastrous consequences. [24, 25, 26] (See the image below.)
In cardiorrhaphy, surgical staples are an excellent alternative to suture with pledgets. They are quicker and equally effective. Animal studies demonstrate that the use of surgical staples reduces time to wound closure and has similar repair integrity. [27, 28] This method also reduces the risk of exposure to contaminated needles in the setting of an ED thoracotomy. These findings have been demonstrated in the clinical setting as well. [29]
Complications
Potential complications of ventricular repair include the following:
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Injury to underlying thoracic structures, including the lung, heart, great vessels, coronary arteries, thoracic duct, esophagus, and phrenic nerve
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Uncontrolled hemorrhage [26]
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Postpericardiectomy syndrome (evidenced by fever, chest pain, pericardial effusion, pericardial rub, and elevated ST segments on electrocardiography [ECG]) [30]
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Dysrhythmias
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Physician and ancillary staff exposure to infectious blood and tissue (eg, HIV, hepatitis B, hepatitis C) [23]
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Serious infection in the setting of ED thoracotomy (uncommon) [23]
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Primary incision in the fourth or fifth intercostal space.
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Open the pleura with scissors.
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Chest opened with rib spreader.
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Initial opening of the pericardium with the scalpel.
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Locate the laceration.
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Suture threading.
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Completed mattress stitch.
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Sufficiently approximated laceration.
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A true pneumothorax line. Note that the visceral pleural line is observed clearly, with the absence of vascular marking beyond the pleural line.
