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Penetrating Cardiothoracic War Wounds
Penetrating Cardiothoracic War Wounds
Penetrating Cardiothoracic War Wounds
Bojan Bioc' inaa,*, Z& eljko Sutlića, Ino Husedz' inovića, Igor Rudez' a, Ranko Ugljena,
Dalibor Leticaa, Zoran Slobodnjakb, Jerolim Karadz' a b, Vojtjeh Bridac,
Tomislav Vladović-Reljab, Ivan Jelića
Abstract
Objecti6e: Penetrating cardiothoracic war wounds are very common among war casualties. Those injuries require prompt and
specific treatment in an aim to decrease mortality and late morbidity. There are a few controversies about the best modality of
treatment for such injuries, and there are not many large series of such patients in recent literature. Methods: We analysed a group
of 259 patients with penetrating cardiothoracic war wounds admitted to our institutions between May 1991 and October 1992.
Results: There were 235 (90.7%) patients with thoracic wounds, 14 (5.4%) patients with cardiac wounds and in 10 (3.7%) patients
both heart and lungs were injured. The cause of injury was shrapnel in 174 patients (67%), bullets in 25 patients (9.7%), cluster
bomb particles in 45 patients (17.3%) and other (blast etc.) in 15 patients (6%). Patients, 69, had concomitant injuries of various
organs. The initial treatment in 164 operated patients was chest drainage in 76 (46.3%) patients, thoracotomy and suture of the
lung in 71 (43.2%) patients, lobectomy in 12 (7.3%) patients and pneumonectomy in 5 (3%) patients. Complications include pleural
empyema and/or lung abscess in 20 patients (8.4%), incomplete reexpansion of the lung in 10 patients (4.2%), osteomyelitis of the
rib in 5 patients (2.1%) and bronchopleural fistula in 1 patient (0.4%). Secondary procedures were decortication in 12 patients, rib
resection in 5 patients, lobectomy in 2 patients, pneumonectomy in 4 patients, reconstruction of the chest wall in 2 patients and
closure of the bronchopleural fistula in 1 patient. The cardiac chamber involved was right ventricle in 12 patients, left ventricular
in 6 patients, right atrium in 7 patients, left atrium in 3 patients, ascending aorta in 2 patients and in 1 patient which involved
descending aorta, right ventricle and coronary artery (left anterior descending) and inferior vena cava, respectively. The primary
procedure was suture in 17 patients (in 10 patients with the additional suture of the lung), suture + extraction of the foreign body
in 4 patients, 2 of them with cardiopulmonary bypass. Complications were pericardial effusion in 6 patients, arrhythmia in 2
patients, myocardial infraction in 1 patient and migration of the foreign body in 1 patient. Patients, 7, died, five of the group with
concomitant injuries, two of thoracic and one of cardiac injuries (5, 1.2 and 4.2%, respectively). Conclusions: Penetrating
cardiothoracic wounds are among the most serious injuries in war, either in combat or among civilians. In spite of their nature,
they can be treated successfully with relatively low mortality and morbidity. © 1997 Elsevier Science B.V.
Table 3 Table 5
Symptoms and signs Treatment
Fig. 1. Diagnosis of a retained shrapnel using fluoroscopy (a) and CXR (b).
complications in patients who received only CCD, al- patients with cardiac injury and late (more than 1
though it was not statistically significant (Tables 6 and month after injury) arrhythmias in 2 (8.4%) patients.
7). (Table 6) Both patients had retained shrapnel within
Late pericardial effusion was present in 6 (25%) the heart. In one patient rhythm disturbance was
B. Bioc' ina et al. / European Journal of Cardio-thoracic Surgery 11 (1997) 399–405 403
Table 6 Table 8
Complications Secondary procedures
contributed to the lower incidence of burns than re- sternotomy was successfully used for bilateral lung
ported elsewhere [15]. In a typical urban war series repair, as shown elsewhere.
[17] 43% of injuries are caused by bullets, while in In the group of patients with cardiac wounds, a
newer reports from the Middle East conflicts up to small number of patients does not allow for reliable
14% of bullet injuries were reported, in spite of very conclusions. Cardiac arrest in 21% of patients and
good armour protection [15]. apparent pericardial tamponade in 42% of patients
In our series thoracotomy was used as a primary indicated emergency operation in most of them. In our
method of surgical treatment in 88 (53.6%) patients, experience, left anterior thoracotomy with a possibility
much more frequently than in civilian reports [9,6] as of transsternal extension is a method of choice, as it
well as many war trauma reports [10,14]. The ratio of has been shown in many previous reports [11,4]. We
thoracotomy to CCD in our report is close to the did not observe any difference in survival between
results of those authors who recommend an aggressive patients with cardiac arrest and those without it, but
surgical approach and who claim better results using it it may be due to a long evacuation time and by the
[17,13,5]. We believe that in a military setting thoraco- fact that only survivors were evacuated from field
tomy combined with early extubation has a number of hospitals.
[11] Mitchel ME, Muakkassa FF, Poole GV, Rhodes RS, Griswold Zacharia had successful results from high thoracotomy rates in the
JA. Surgical approach of choice for penetrating cardiac wounds. Lebanon, Fischer showed how the earlier conservative management
J Trauma 1993;34(1):17–20 of the Vietnam war was replaced by more active treatment. From the
[12] NATO Hanbook. Emergency War Surgery. Government Print- first world war famous surgeons in all three main armies began to
ing Office, Washington, D.C., 1975:105. carry out thoracotomies to avoid an unacceptably high mortality. As
[13] Placak B. Radical approach to pulmonary gunshot injuries. Int with previous generations it seems to take a war to remind us that
Surg 1967;48:536–9. skilled surgeons with high thoracotomy rates get the best results in
[14] Roostar L. Indications for surgery in penetrating chest injuries. major chest trauma.
Ann Chir Gynaecol 1993;82(3):177–81. Dr Bioc' ina: We thought that thoracotomy was the method of
[15] Rosenblatt M, Lemer J, Best LA, Peleget H. Thoracic wounds in choice, first, because of high incidence of death with improperly
Israeli battle casualties during the 1982 evacuation of wounded placed chest drains and another thing was that we didn’t have enough
from Lebanon. J Trauma 1985;25:350–4. nursing staff to maintain drains patent. In that case we thought it was
[16] Symbas PN, Picone Al, Hatcher CR Jr., Hale SE. Cardiac better to open the patient to repair lungs properly, to control bleeding
missiles; a review of literature and personal experience. Ann Surg point and to put two big and properly placed chest drains and that
1990;211(5):639–48. reduced our incidence of tension pneumothorax dramatically.
[17] Zakharia AT. Cardiovascular and thoracic batttle injuries in the Another thing we showed in our own series, there is still a trend,
Lebanon war. J Thorac Cardiovasc Surg 1985;89:723 – 33. but we got another set of data, at the moment we have more than 350
patients, which were not presented here, that patients with chest