penetrating cardiac trauma
Introduction
Introduction to penetrating cardiac trauma Penetrating heart trauma is caused by a strong, high-speed, sharp foreign body penetrating the chest wall or entering the heart. A few cases are caused by violent displacement of the sternum or rib fracture. The heart penetrating wound has pericardial damage. Sometimes there are many heart wounds, which are especially common in stab wounds and gunshot wounds. basic knowledge The proportion of the disease: the probability of the population is 0.013% Susceptible people: no specific people Mode of infection: non-infectious Complications: constrictive pericarditis, hemorrhagic shock, ascites
Cause
Penetrating heart trauma
The causes of this disease are as follows:
1. High-speed foreign body damage caused by high-speed foreign bodies usually refers to bullets, shrapnel, sharp knives and other high-speed sharp foreign objects penetrate the chest wall injury and pericardium, caused by the heart, which is especially common in wartime, usually also common, such damage often Coexisting with the chest and abdominal trauma is the most common cause of penetrating heart injury.
2. The rupture of the sternum or rib fracture is severely inward. The damage caused by penetrating the heart is mostly caused by traffic accidents or industrial accidents.
3. Penetrating heart injury caused by other causes Cardiac catheterization, interventional cardiac therapy, pericardial puncture and esophageal foreign body can cause heart penetrating injury, and occasionally the rib fixed steel needle displacement causes heart damage.
Heart penetrating injuries are difficult to estimate accurately. Many critically ill patients have died before the visit. Only about half of the stab wounds and 15% to 20% of gunshot wounds can reach medical institutions.
Prevention
Penetrating heart trauma prevention
Factors affecting the prognosis of penetrating cardiac trauma include: anatomical and physiological factors after injury, clinical type and staging effects, and medical interventions. Therefore, comprehensive consideration should be given to the treatment of this disease, and efforts should be made to make the most suitable treatment plan for patients in a timely manner.
Complication
Penetrating cardiac trauma complications Complications, constrictive pericarditis, hemorrhagic shock, ascites
In penetrating cardiac trauma, repeated and incomplete puncture and suction, easy to concurrent infection or residual traumatic constrictive pericarditis, most patients died early due to hemorrhagic shock or acute pericardial tamponade due to lack of timely treatment.
1. Constrictive pericarditis
Constrictive pericarditis is caused by chronic pericardial inflammation, pericardial thickening, adhesions and even calcification, dilatation of the heart, limited contraction, decreased heart function, diseases causing systemic blood circulation disorders, generally thickened pericardium bound the heart, all The organ is bruised, and there are signs of jugular vein engorgement, hepatomegaly, ascites, and pleural effusion.
2, hemorrhagic shock
The rapid loss of blood due to trauma, if not treated in time, will lead to a rapid decline in blood volume leading to shock.
3, acute pericardial tamponade
Traumatic heart rupture or pericardial vascular injury causes blood accumulation in the pericardial cavity. Due to the limited elastic force of the pericardium, acute pericardial hemorrhage up to 150ml can limit blood back to heart and heart beat, causing acute circulatory failure, which leads to cardiac arrest. Once the bloody pericardium appears, it must be scrambled for rescue treatment. When the sharp-breasted chest wall wound is crushed in the precordial area or chest, there is progressive blood pressure drop, pale face, heart rate increase, heart sound distant, jugular vein engorgement When you are upset and uneasy, you should first consider the existence of blood pericardium. You should urgently do pericardial puncture, discharge blood and decompression, relieve tamponade, temporarily improve hemodynamics, fight for rescue time, and correct saline hemorrhage with saline and blood. Prepare for emergency thoracotomy, strict anesthesia management, prevent cardiac arrest, supplement enough blood, remove pericardial hemorrhage during operation, restore normal contraction and diastolic function of the heart, repair the heart damage accurately and accurately, and carefully monitor the heart after operation Functional and rational application of cardiovascular active drugs.
Symptom
Penetrating heart trauma symptoms Common symptoms Internal bleeding cold sweat shock Heart stiffness Myocardial ischemia Blood pressure Drops Pericardial damage Pericardial hemorrhage Low blood pressure Qimai
The site of cardiac permeation is most common in the right ventricle (about 47%), followed by the left ventricle (34%), right atrium (14%) and left atrium (10%). The pathological changes of cardiac penetrating injury depend on The location of the injury and the size of the rupture, and the degree of pericardial rupture, the pericardial hemorrhage and functional damage caused by the rupture of the left ventricle are obviously more serious than the right ventricle, and the worse, according to the size and patency of the pericardial wound, There are three different pathophysiological changes and clinical manifestations:
1. The heart has a large wound, the pericardial wound is small or the blood clot is blocked around the wound. The acute pericardial hemorrhage can increase the pressure in the pericardial cavity by 100-200ml, which affects the normal relaxation of the heart and produces acute pericardial tamponade. The first pressure is the vena cava and atrium, causing an increase in central venous pressure and end-diastolic pressure, and gradually increase the venous pressure of the whole body. At first, due to the reflexive contraction of peripheral blood vessels, the blood pressure is normal or slightly high, and the diastolic heart is severely restricted. At the same time, the blood volume per stroke is significantly reduced, the arterial pressure will drop rapidly, and the pressure in the pericardial cavity rises to 17cmH2O, so that the heart beats without blood, unless the rapid rehydration increases the venous pressure, otherwise the patient quickly enters the shock symptoms.
On the one hand, acute cardiac tamponade reduces the amount of cardiac output, affects the blood supply to the coronary arteries, leads to myocardial hypoxia, sudden decompensation of heart function, and failure. On the other hand, pericardial tamponade can delay fatal bleeding in the early stage. Or temporarily stop the bleeding of the myocardial rupture, providing valuable time for the rescue of the patient's life.
Acute pericardial tamponade symptoms include cold sweating around the body, cyanosis of the face, shortness of breath, shallow venous stenosis of the neck, decreased blood pressure, fine pulse rate and odd pulse. Typical Beck triad: distant heart sound, decreased systolic blood pressure and venous pressure In the presence of high, it is helpful for the diagnosis of acute pericardial tamponade, but generally only 35% to 40% of patients have all typical symptoms. In fact, the increase of venous pressure is the earliest, and the decrease of arterial pressure occurs in the late stage because the heart wears The pericardial tamponade caused by osmotic injury is less in the pericardium, and in the supine position, the blood accumulates in the pericardial cavity of the posterior part of the heart, so the heart sound is far less common, but the odd pulse is more common.
2. Pericardium and heart wounds are kept open, heart bleeding can be spilled smoothly, from the chest wall wound or into the chest, mediastinum or abdominal cavity, and there is no large blood accumulation in the pericardium, clinical hemorrhagic shock is the main performance, showing cold sweat Thirst, thirst, rapid pulse, weak breathing, decreased blood pressure, irritability and other shock symptoms, major bleeding usually leads to the death of the wounded.
3. The heart is small, especially the oblique stab wound of the myocardium, which can be closed by itself, the bleeding stops, and the condition tends to be stable; but after several days or weeks, the blood clots dissolve or fall off and re-bleed, causing delay. Pericardial tamponade, sudden pericardial tamponade in a few days or weeks after injury, pericardial puncture to extract non-coagulant, should be suspected of this disease.
Examine
Penetrating heart trauma examination
1. Determination of venous pressure: The measurement of venous pressure is very helpful in the identification of pericardial tamponade and acute blood loss. The increase of central venous pressure is one of the early signs of pericardial tamponade. If it is massive intrapulmonary hemorrhage, blood volume is not corrected. The venous pressure rises, the jugular vein engorgement and the odd pulse are not. It is obvious that even if there is complete circulatory failure, the central venous pressure can still be normal. After the blood volume is quickly replenished, the central venous pressure can be abnormally increased. When it is greater than 15cmH2O, there is Diagnostic value, the central venous pressure needs to be measured repeatedly, and at the same time: 1 adjust the measurement zero point; 2 the water column in the tube should fluctuate with the breathing; 3 should be measured in the patient's quiet state.
2. Echocardiography is helpful for the diagnosis of pericardial tamponade, cardiac foreign body, blood pericardium, heart valve and interventricular perforation. It can also estimate the amount of pericardial blood, but when the blood in the pericardium has solidified, the rate of misdiagnosis is higher. high.
3, pericardial puncture has great value in the diagnosis and treatment of pericardial tamponade, but when the blood in the pericardial cavity is coagulated, false negatives may occur, which is worth noting.
4, X-ray examination is not helpful for the diagnosis of acute heart injury, but chest X-ray can show the presence of hemothorax, pneumothorax, metal foreign body or other organs, such as chest radiograph showing a liquid level in the pericardium is diagnostic. Under the chest, the pericardial tamponade is weakened.
5, ECG examination is generally not typical, does not help the diagnosis, if there is voltage reduction, ST segment changes, can help diagnose.
Diagnosis
Diagnosis and diagnosis of penetrating cardiac trauma
The diagnosis of this disease is not difficult. According to the symptoms of chest trauma and the symptoms of pericardial tamponade, it can be diagnosed without identification. There are two main characteristics of this disease:
1 The main cause of hemorrhagic shock is that the pericardial wound is large enough, and the blood flowing out of the heart flows into the chest cavity.
2 The main manifestations of pericardial tamponade, the typical Beck triple sign, that is, elevated venous pressure, arterial pressure decreased, heart sounds distant, if the condition allows, you can do B-ultrasound and chest X-ray examination, you can also consider pericardial puncture, Pericardial puncture can be diagnosed and decompressed, but whether or not to perform pericardial puncture for diagnosis or decompression before surgery, the literature has different opinions, because sometimes due to blood coagulation can occur false negative, but also can damage the heart, in addition, pericardial tamponade Although it affects the amount of blood returning to the heart, it increases the pressure of the pericardial cavity, which can reduce the bleeding of the heart wound to support the patient's chance of obtaining a definitive rescue operation. In addition, for patients with penetrating cardiac trauma, it is necessary to identify the pericardial tamponade in time. With acute blood loss, this treatment of the disease is extremely important, therefore, the central venous pressure needs to be measured in order to make a correct diagnosis and treatment.
