Technical Section: Technical tutorial, notes and tips

BackgroundWith an increasing incidence of penetrating wounds in the UK, there is a need for all surgeons to be familiar with the management of penetrating cardiac injuries (PCIs). 1 PCIs are amongst the most lethal of injuries; typically < 10% of patients with PCI arrive at hospital alive. 2 Nevertheless, rapid diagnosis and operation can salvage patients who would otherwise be lost. 3,4All general surgeons should be capable of recognising these injuries and intervening if a cardiothoracic surgeon is not immediately available. DiagnosisPatients with PCI can be classified into five groups: lifeless, critically unstable, cardiac tamponade, thoraco-abdominal injury and those with a benign presentation. 5Rapid clinical diagnosis of unstable patients is based on the site of penetration together with signs of shock, cardiac tamponade or exsanguination.Compensating, stable patients may be agitated and unwilling to lie supine. 6ltrasound can rapidly diagnose the presence of pericardial blood with high levels of accuracy. 7,8However, small myocardial wounds may seal off and the patient respond to resuscitation; hence, the assessment of a stable patient can be difficult.Occult cardiac injuries do occur and ultrasound may occasionally be falsely negative; a high index of suspicion is required and repeat ultrasound studies should be obtained. 9Pericardiocentesis and subxiphoid window are not always helpful in establishing the diagnosis; 9 if diagnostic uncertainty persists, videothoracoscopy enables direct pericardial inspection and window. 10 Surgical techniqueIf the penetrating implement remains in situ, it should not be removed until the chest is open.Every effort is made to convey the injured patient to an operating theatre, though lifeless or critically unstable patients must be opened in the resuscitation area. Median sternotomyMedian sternotomy is preferable in most stable patients in whom the diagnosis of PCI is reasonably certain and the presence of another lesion is not suspected. 11Median sternotomy gives access to the heart and great vessels, to other structures in the mediastinum and to both pleural cavities.