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Objective: Demonstrate capabilities of a level II trauma center
Design: Case report
Setting: A rural level II trauma center
Patients: 58 year old male presented with a gunshot wound to the left flank. Injuries included tension pneumothorax, a bullet lodged against the right ventricle with hemopericardium, and a grade IV splenic laceration.
Interventions: Bilateral chest tubes were placed on arrival. A perforating injury to the right ventricle was identified and repaired via median sternotomy while on cardiopulmonary bypass. A midline laparotomy was performed with emergent splenectomy and repair of the diaphragm.
Main Outcome Measure: Survival
Results: The patient recovered well and was subsequently discharged at his baseline status five days postoperatively.
Conclusion: Approximately 75% of patients with penetrating cardiac injury die prior to, or on arrival, to the emergency room. Survival depends on prompt recognition and treatment. Clinical signs of tamponade are helpful but often absent. Suspicion must remain high with injuries outside of the cardiac “box,” as injuries can be missed. Focused Assessment with Sonography in Trauma (FAST) exam, and CT angiography are the tests of choice. The presence of solid organ or head injuries increases the risk of mortality as well as the rate of neurologic disability in survivors.
Proper treatment requires surgical intervention. Studies show limited survival benefit from emergency room thoracotomy. Intraoperative adjuncts such as temporary inflow occlusion, Foley catheters, and cardiopulmonary bypass can help control bleeding and/or stabilize the patient to allow for definitive repair. We demonstrate that treatment of such injuries can be performed at non-level 1 trauma centers if appropriate surgical and ancillary resources are available.