Unstable Penetrating Chest Trauma
Annotation for Point H
If pericardial tamponade is encountered on entering the chest, the pericardium is opened. From the sternotomy approach, ‘‘T-ing’’ the pericardium along the diaphragmatic reﬂections increases exposure. From an anterolateral or posterolateral approach, extending the incision anteriorly to the opposite side and in a craniocaudal manner anterior to the phrenic nerve is optimal. Penetrating injuries affect the ventricles more than the atria and the right more often than the left. Most injuries can be controlled with digital pressure then repaired with sutures (3-0or4-0, surgeon’s choice) often with pledgets (can be pericardial). If signiﬁcant bleeding is encountered, temporizing measures include the use of Foley catheter for tamponade, staples on the left ventricle, and/or caval occlusion.15,19 A Foley catheter can actually lead to more damage, especially if pulled out inadvertently, and should be used primarily for left ventricular injuries if direct pressure is not an option. Staples can be used on the right ventricle, but this thinner walled chamber is more prone to damage and generally has lower pressure, and ﬁnger pressure usually sufﬁces. Caval occlusion is simple and quick and reduces blood loss. If there is evidence of myocardial compromise after repair, insertion of an intra-aortic balloon pump can support the patient.24 Cardiopulmonary bypass has been used rarely to resuscitate patients who have sustained cardiac injury that is repaired and are experiencing severe myocardial compromise or malignant arrhythmias. However, this is only applicable if all the bleeding sources have been controlled.