急诊开胸手术治疗心脏和大血管穿透伤：来自两个城市创伤中心的283例连续病例评估

Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers.

作者信息

Seamon Mark J, Shiroff Adam M, Franco Michael, Stawicki S Peter, Molina Ezequiel J, Gaughan John P, Reilly Patrick M, Schwab C William, Pryor John P, Goldberg Amy J

机构信息

Division of Trauma and Surgical Critical Care, Department of Surgery, Temple University School of Medicine, Philadelphia, PA 19104, USA.

出版信息

J Trauma. 2009 Dec;67(6):1250-7; discussion 1257-8. doi: 10.1097/TA.0b013e3181c3fef9.

DOI:10.1097/TA.0b013e3181c3fef9

PMID:20009674

Abstract

BACKGROUND

Historically, patients with penetrating cardiac injuries have enjoyed the best survival after emergency department thoracotomy (EDT), but further examination of these series reveals a preponderance of cardiac stab wound (SW) survivors with only sporadic cardiac gunshot wound (GSW) survivors. Our primary study objective was to determine which patients requiring EDT for penetrating cardiac or great vessel (CGV) injury are salvageable.

METHODS

All patients who underwent EDT for penetrating CGV injuries in two urban, level I trauma centers during 2000 to 2007 were retrospectively reviewed. Demographics, injury (mechanism, anatomic injury), prehospital care, and physiology (signs of life [SOL], vital signs, and cardiac rhythm) were analyzed with respect to hospital survival.

RESULTS

The study population (n = 283) comprised young (mean age, 27.1 years +/- 10.1 years) men (96.1%) injured by gunshot (GSW, 88.3%) or SWs (11.7%). Patients were compared by injury mechanism and number of CGV wounds with respect to survival (SW, 24.2%; GSW, 2.8%; p < 0.001; single, 9.5%; multiple, 1.4%; p = 0.003). Three predictors-injury mechanism, ED SOL, and number of CGV wounds-were then analyzed alone and in combination with respect to hospital survival. Only one patient (0.8%) with multiple CGV GSW survived EDT.

CONCLUSION

When the cumulative impact of penetrating injury mechanism, ED SOL, and number of CGV wounds was analyzed together, we established that those sustaining multiple CGV GSWs (regardless of ED SOL) were nearly unsalvageable. These results indicate that when multiple CGV GSWs are encountered after EDT, further resuscitative efforts may be terminated without limiting the opportunity for survival.

摘要

背景

从历史上看，穿透性心脏损伤患者在急诊室开胸手术（EDT）后存活率最高，但对这些病例系列的进一步研究发现，心脏刺伤（SW）幸存者占多数，心脏枪伤（GSW）幸存者仅为零星病例。我们的主要研究目标是确定哪些因穿透性心脏或大血管（CGV）损伤而需要进行EDT的患者是可挽救的。

方法

对2000年至2007年期间在两个城市的一级创伤中心因穿透性CGV损伤接受EDT的所有患者进行回顾性研究。分析了人口统计学、损伤情况（机制、解剖损伤）、院前护理和生理学指标（生命体征[SOL]、生命体征和心律）与医院存活率的关系。

结果

研究人群（n = 283）包括年轻男性（平均年龄27.1岁±10.1岁），占96.1%，受伤原因包括枪伤（GSW，88.3%）或刺伤（SW，11.7%）。根据损伤机制和CGV伤口数量对患者的存活率进行比较（SW，24.2%；GSW，2.8%；p < 0.001；单发，9.5%；多发，1.4%；p = 0.003）。然后单独分析并综合分析三个预测因素——损伤机制、急诊室生命体征和CGV伤口数量——与医院存活率的关系。只有1例（0.8%）多发CGV枪伤患者在EDT后存活。