Asensio J A, Berne J D, Demetriades D, Chan L, Murray J, Falabella A, Gomez H, Chahwan S, Velmahos G, Cornwell E E, Belzberg H, Shoemaker W, Berne T V
Department of Surgery, University of Southern California, and the Los Angeles County/University of Southern California Medical Center, Los Angeles 90033-4525, USA.
J Trauma. 1998 Jun;44(6):1073-82. doi: 10.1097/00005373-199806000-00022.
To analyze the parameters measured in the field, during transport, and upon arrival of the physiologic condition of patients sustaining penetrating cardiac injuries, along with the Cardiovascular Respiratory Score (CVRS) component of the Trauma Score, the mechanism and anatomical site of injury, operative characteristics, and cardiac rhythm as predictors of outcome. We also set out to identify a set of patient characteristics that best predict mortality outcome and to correlate cardiac injury grade as determined by the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) with mortality.
This report was a prospective study at American College of Surgeons Level I urban trauma center. Interventions included thoracotomy, sternotomy, or both, for resuscitation and definitive repair of cardiac injury. The main outcome measures used were those parameters measuring physiologic condition of patients, CVRS, mechanism and anatomical site of injury, mortality, and grade of injury.
A total of 105 patients sustained penetrating cardiac injuries: 68 injuries (65%) were gunshot wounds and 37 injuries (35%) were stab wounds. The mean Injury Severity Score was 36. Of the 105 wounds, 23 wounds (22%) involved multiple-chamber injuries. The overall survival was 35 of 105 patients (33%): survival of gunshot wound victims was 11 of 68 patients (16%); survival of stab wound victims was 24 of 37 patients (65%). Emergency department thoracotomy was performed in 71 of the 105 patients (68%) with 10 survivors (14%). CVRS: 94% mortality (50 of 53) when CVRS = 0, 89% mortality (57 of 64) when CVRS = 0 to 3, and 31% mortality (12 of 39) when CVRS 4 to 11 (p < 0.001). The presence of sinus rhythm when pericardium was opened predicted survival (p < 0.001). Anatomical site of injury (injured chamber) and the presence of tamponade did not predict survival. Stepwise logistic regression analysis identified gunshot wound, exsanguination, and restoration of blood pressure as most predictive variables of mortality. AAST-OIS injury grade and mortality: grade I, 0 of 1 (0%); grade II, 1 of 2 (50%); grade III, 2 of 3 (66%); grade IV, 28 of 50 (56%); grade V, 29 of 38 (76%); grade VI, 10 of 11 (91%). Overall incidence: grades IV-VI, 99 of 105 (94%).
Parameters measuring physiologic condition, CVRS, and mechanism of injury are significant predictors of outcome in penetrating cardiac injuries. AAST-OIS injury grades I-III are rare in penetrating cardiac trauma. AAST-OIS Injury grades IV-VI are common in penetrating cardiac trauma and accurately predict outcome.
分析穿透性心脏损伤患者在现场、转运途中及到达时所测量的参数，以及创伤评分中的心血管呼吸评分（CVRS）、损伤机制和解剖部位、手术特点及心律作为预后预测指标。我们还旨在确定一组最能预测死亡结局的患者特征，并将美国创伤外科协会器官损伤评分（AAST - OIS）所确定的心脏损伤分级与死亡率相关联。
本报告是在美国外科医师学会一级城市创伤中心进行的一项前瞻性研究。干预措施包括开胸手术、胸骨切开术或两者同时进行，用于心脏损伤的复苏和确定性修复。主要结局指标包括测量患者生理状况的参数、CVRS、损伤机制和解剖部位、死亡率及损伤分级。
共有105例患者发生穿透性心脏损伤：68例损伤（65%）为枪伤，37例损伤（35%）为刺伤。平均损伤严重程度评分为36分。在105处伤口中，23处伤口（22%）涉及多腔室损伤。105例患者中总体生存率为35例（33%）：枪伤受害者生存率为68例中的11例（16%）；刺伤受害者生存率为37例中的24例（65%）。105例患者中有71例（68%）进行了急诊开胸手术，其中10例存活（14%）。CVRS：CVRS = 0时死亡率为94%（53例中的50例），CVRS = 0至3时死亡率为89%（64例中的57例），CVRS为4至11时死亡率为31%（39例中的12例）（p < 0.001）。打开心包时窦性心律的存在可预测生存（p < 0.001）。损伤的解剖部位（受伤腔室）和心包填塞的存在不能预测生存。逐步逻辑回归分析确定枪伤、失血和血压恢复是死亡率最具预测性的变量。AAST - OIS损伤分级与死亡率：I级，1例中的0例（0%）；II级，2例中的1例（50%）；III级，3例中的2例（66%）；IV级，50例中的28例（56%）；V级，38例中的29例（76%）；VI级，11例中的10例（91%）。总体发生率：IV - VI级，105例中的99例（94%）。
测量生理状况、CVRS和损伤机制的参数是穿透性心脏损伤预后的重要预测指标。AAST - OIS损伤分级I - III级在穿透性心脏创伤中罕见。AAST - OIS损伤分级IV - VI级在穿透性心脏创伤中常见且能准确预测预后。
