Khaladj N, Knobloch K, Winterhalter M, Shrestha M, Hildebrand F, Gerich T, Krettek C, Haverich A, Hagl C
Klinik für Herz-, Thorax-, Transplantations- und Gefässchirurgie, Medizinische Hochschule, Carl-Neuberg-Strasse 1, 30625 Hannover, Deutschland.
Unfallchirurg. 2008 Feb;111(2):107-11. doi: 10.1007/s00113-007-1305-8.
Penetrating chest trauma involving the heart is usually known with a high mortality rate. Neither the absence of hemodynamic depression nor ECG changes exclude a potential fatal injury to the heart. We report on the diagnosis and definitive treatment of a stab wound injury with transected coronary artery, concomittant ventricular penetration, and pulmonary injury.A 37-year-old female was admitted to our emergency room with multiple left-sided gashes (cheek, neck, upper extremity) and a single stab wound in the left thorax. At the scene of the accident the patient's hemodynamic condition was stable with no signs of shock or shortness of breath. Auscultation revealed regular respiratory sound on both lung sides. Hospital transfer by ground was uneventful. Chest X-ray showed left pleural effusion with no signs of pneumothorax. ECG demonstrated regular sinus rhythm without repolarization changes or low voltage. Transthoracic echocardiography revealed pericardial effusion with a swinging heart. The patient was electively intubated in the emergency room and transferred to the operating room for pericardial paracentesis. Median sternotomy was necessary due to extensive bleeding in the drain. Examination of the heart showed a laceration of the left coronary artery (LAD), left ventricle, and upper lobe of the left lung. Cardiopulmonary bypass was instituted and the LAD was ligated proximal to the penetration. The left internal thoracic artery was used for coronary revascularization of the LAD. Postoperative ECG and creatine kinase evaluations excluded myocardial ischemia. The patient was discharged from hospital at POD 10 fully recovered. Transthoracic echocardiography in the emergency room is the diagnostic tool of choice to exclude/confirm a potential cardiac injury. In the case of pericardial effusion, paracentesis sometimes followed by thoracotomy should be performed. The importance of rapid diagnosis and intervention should be emphasized to reduce mortality due to cardiac tamponade or acute myocardial infarction as illustrated by this case.
穿透性胸部创伤累及心脏通常死亡率很高。血流动力学无抑制以及心电图无变化均不能排除心脏潜在的致命损伤。我们报告一例刺伤导致冠状动脉横断、合并心室贯通伤和肺损伤的诊断及确定性治疗。一名37岁女性因左侧多处裂伤（脸颊、颈部、上肢）及左胸一处刺伤被送入我院急诊室。在事故现场，患者血流动力学状况稳定，无休克或呼吸急促迹象。听诊双肺呼吸音正常。经地面转运至医院过程顺利。胸部X线显示左侧胸腔积液，无气胸迹象。心电图显示窦性心律正常，无复极改变或低电压。经胸超声心动图显示心包积液及心脏摆动。患者在急诊室被选择性插管，然后转至手术室进行心包穿刺。由于引流管大量出血，需行正中胸骨切开术。检查发现左冠状动脉（前降支）、左心室及左肺上叶有裂伤。建立体外循环，在前降支穿透处近端结扎。采用左胸廓内动脉对前降支进行冠状动脉血运重建。术后心电图及肌酸激酶评估排除心肌缺血。患者术后第10天出院，完全康复。急诊室经胸超声心动图是排除/确认潜在心脏损伤的首选诊断工具。对于心包积液，有时应先进行穿刺，随后行开胸手术。应强调快速诊断和干预的重要性，以降低本例所示的心包填塞或急性心肌梗死导致的死亡率。
