Could someone with sound medical knowledge and vocabulary translate this into basic English?
I am mostly interested in cardiac injuries due to shrapnel and what a survivor may face in the years to come. Like, is there ever a case where it would be too dangerous to remove the shrapnel?
Traumatic cardiac penetration is highly lethal, with case fatality rates of 70-80%. The degree of anatomic injury and occurrence of cardiac standstill, both related to the mechanism of injury, determine survival probability. Patients who reach the hospital before cardiac arrest occurs usually survive. Those patients surviving penetrating injury to the heart without coronary or valvular injury can be expected to regain normal cardiac function on long-term follow up.
Ventricular injuries are more common than atrial injuries, and the right side is involved more often than the left side. In 1997, Brown and Grover noted the following distribution of penetrating cardiac injuries:
Right ventricle - 43%
Left ventricle - 34%
Right atrium - 16%
Left atrium - 7%
The Beck triad (ie, high venous pressure, low arterial pressure, muffled heart sounds) is documented in only 10-30% of patients who have proven tamponade.
Pericardiocentesis can be both diagnostic and therapeutic, although some centers report a false-negative rate of 80% and a false-positive rate of 33%. This procedure is reserved for patients with significant hemodynamic compromise without another likely etiology.
Echocardiography is a rapid, noninvasive, and accurate test for pericardial fluid. It has a sensitivity of at least 95% and is now incorporated into the Focused Assessment with Sonography for Trauma protocol. Once again, the management algorithm is based on the patient's hemodynamic status, with patients who are in extremis or who are profoundly unstable benefiting from emergency thoracotomy with ongoing aggressive resuscitation. In patients with GSWs from high-caliber missiles, the absence of an organized cardiac rhythm portends a grave prognosis. For patients with stab wounds or GSWs from low-caliber missiles who are apparently lifeless upon arrival, resuscitative thoracotomy is justified.
Stable patients with cardiac wounds may be diagnosed using a subxiphoid pericardial window. Bleeding must be rapidly controlled using finger occlusion, sutures, or staples. Inflow occlusion and cardiopulmonary bypass are rarely necessary. Distal coronary injuries are usually ligated, whereas proximal injuries may require bypass grafts. Intracardiac shunts or valvular injuries in patients who survive are usually minor and do not require emergent repair. Foreign bodies in the left cardiac chambers must be removed.
Postoperative deterioration may be due to bleeding or postischemic cardiac myocardial dysfunction. Residual and delayed sequelae include postpericardiotomy syndrome, intracardiac shunts, valvular dysfunction, ventricular aneurysms, and pseudoaneurysms. Wall et al, in a classic 1997 paper, described in detail the management of 60 complex cardiac injuries.
Embolization to the pulmonary arteries is usually treated with surgical removal or interventional techniques. A chest radiograph taken immediately preceding incision or intraoperative fluoroscopy is mandatory in order to detect more distal embolization that may occur during positioning. Asymptomatic patients with small distal fragments may be treated expectantly. Occasionally, missile emboli may migrate through a patent foramen ovale or from central parenchymal or vascular injuries to gain access to the left side of the heart and then to the systemic circulation.
Most cardiovascular arterial-to-venous fistulae occur following stab wounds. Virtually all manifest as a machinery murmur after approximately 1 week. Innominate artery-to-vein fistulae are the most common. Patients with coronary artery fistulae, usually to the right ventricle, present with ischemia, cardiomyopathy, pulmonary hypertension, or bacterial endocarditis. Aortocardiac, aortopulmonary, and aortoesophageal fistula are quite rare because the probability of survival from the acute injury is slim. While requiring open repair in the past, interventional techniques may be used in a large number of these patients.
- Janet PierceLv 77 years agoFavorite Answer
Nobody is going to sit here and dumb down all that.
Shrapnel is left in place many times when removal is far too risky. In most cases involving the heart it's a moot issue as the patient won't make it to medical care anyway.
- Anonymous6 years ago
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