During the wars in Iraq and Afghanistan , thoracic injuries accounted for 10% of combat casualties with truncal hemorrhage reported as the main cause of preventable death in 47–67% of cases. The mechanisms for cardiac injury in the civilian trauma environment are typically from stab wounds and low-velocity gunshot wounds. These also exist in the combat environment, along with the additional threat from improvised explosive devices (IEDs ) and high-velocity weapons. Recent terrorist attacks in Paris and the United States show that these injuries are possible on large scale in the civilian environment. These patients present on a spectrum from benign in appearance to lifeless, occasionally with rapid progression. Evaluation for these injuries must be rapid and diligent, with immediate treatment before the development of pericardial tamponade.

Patients presenting with penetrating injuries of the neck, trunk, or upper abdomen should be suspected of having a PCI until proven otherwise. There should seldom be a diagnostic dilemma in the evaluation of a suspected PCI. For the hemodynamically unstable or arrested patient, the EDT is both diagnostic and therapeutic.

Patients who present hemodynamically stable must be exposed, rolled, and examined for other areas of injury. An AP chest radiograph may increase the suspicion for PCI with widening of the mediastinum or the presence of fragments over the cardiac silhouette (Fig. 16.1).

The Extended Focused Assessment with Sonography for Trauma (eFAST ) exam is a rapid and sensitive method to identify intrapericardial fluid. During the Paris attacks of November 2015, FAST was utilized as an initial screen for unstable casualties. In patients with a negative FAST, a CT scan can be performed for further evaluation after normalization of hemodynamics with resuscitation. However, a CT scan is unnecessary for confirmation of a positive FAST, and a patient with a suspected PCI does not belong in the Department of Radiology.

The presence of pericardial fluid on FAST or CT scan must be explored with subxiphoid pericardial window or transdiaphragmatic pericardial window during laparotomy. In these cases, it is imperative for the surgeon to be ready in the operating room during the induction of anesthesia. The initiation of positive pressure ventilation along with the loss of sympathetic tone can lead to cardiac arrest. As the situation allows, the chest should be prepared, and the surgeon should be gowned and gloved.

Patients who lose vital signs en route and present without signs of life should undergo immediate intubation and a left anterolateral thoracotomy (resuscitative thoracotomy) (Fig. 16.2). This left side is the first side of chest entry regardless of the side of injury. The incision is carried from just below and medial to the nipple down the table. The chest is entered in the fifth intercostal space, and the inferior pulmonary ligament is released. The goals of a resuscitative thoracotomy are (1) release of left-sided tension pneumothorax, (2) opening of the pericardium for release of tamponade, (3) cross clamping of the descending aorta, and (4) identification and treatment of injuries. If pericardial tamponade is identified, a clamshell thoracotomy should always be performed to facilitate repair (Fig. 16.3).

Unstable patients, with a positive pericardial FAST who respond or have a transient response to blood product resuscitation, can be taken immediately to the operating room for definitive management with median sternotomy. Incisions can be extended from the sternotomy as needed once the tamponade has been released and the injury repaired. Again, nonresponders should undergo a resuscitative thoracotomy in the trauma bay.

In cases with penetrating chest trauma where tamponade physiology is evident clinically or by ultrasound examination, the patient should proceed immediately to median sternotomy for cardiac repair (Figs. 16.4, 16.5, and 16.6), again keeping in mind the risk of cardiac arrest on induction of general anesthesia.

For situations in which there is a suspected PCI in the setting of abdominal hemorrhage, a transdiaphragmatic pericardial window can be performed. Standard indications include (1) the presence of pericardial fluid on FAST exam, (2) missiles or fragments in the vicinity of the heart on X-ray or CT scan, (3) suspicious trajectory (i.e., trans-mediastinal), and (4) sudden hemodynamic deterioration without another obvious cause. The diaphragm is easy to repair; never hesitate to open it if there is suspicion of intrathoracic pathology.

Patients who presented hemodynamically stable with positive pericardial fluid represent a high-risk group. The benefit of additional diagnostic imaging studies such as CT scan or plain films must be weighed against the real threat of cardiovascular collapse from tamponade. There should be a low threshold to perform a pericardial window to rule out PCI. When in doubt, be aggressive and vigilant.

These techniques should be employed in the operating room under general anesthesia with the patient prepped and draped from above the chin to below the knees bilaterally. The operative field created provides you access for pericardial window, median sternotomy, laparotomy, neck and thoracic inlet exploration, and exposure of the femoral vessels and saphenous vein as needed.

A pericardial window is a diagnostic procedure to confirm the presence of hemopericardium. The setup for the procedure should include a sternal saw or Lebsche knife and a full trauma prep. A midline incision is created centered over the xiphoid process for 2–3 cm in either direction. The incision is carried either sharply or with electrocautery down to the linea alba which is incised inferiorly to expose the xiphoid process. The xiphoid process is then dissected inferiorly and laterally, grasped with a Kocher clamp, and divided with a curved Mayo scissor. A finger can then be passed bluntly substernally through the foramen of Morgagni. The pericardium can then be palpated deep to the sternum and cleared bluntly with a lap sponge. The pericardium is then grasped with two Allis clamps and opened sharply with Mayo scissors with the incision carried inferiorly. Take care not to open the pericardium initially with cautery to avoid conducting on the heart. Cautery can be used once the pericardium is opened for hemostasis along the pericardial edges. Any pericardial fluid is evacuated along with residual clot. The presence of hemopericardium mandates a median sternotomy. Serous fluid can be managed with a small JP or Blake drain (7 Fr or 10 Fr) in the pericardial space through a separate stab incision through the rectus abdominis fascia and skin. The fascial defect and skin are closed with suture of your choice. Secure the drain to the skin with a nylon or silk suture 2-0 or larger and place the drain to bulb suction. Even in cases of a negative pericardial window, a pericardial drain should be placed in case there is bleeding along the pericardial edge.