Heart wounds. Clinic. Diagnostics. Conservative and surgical treatment. Injuries to the pericardium and heart What are the 2 syndromes that accompany a wound to the heart?

A group of injuries to the pericardium, cardiac muscle, valvular, conducting systems as a result of mechanical factors (knife and gunshot wounds, medical manipulations). Manifested by pain, pallor, cyanosis, fainting, falling blood pressure. May be complicated by tamponade, massive blood loss, fatal rhythm disturbances. Diagnosis of pathology is carried out using Echo-KG, ECG, pericardial puncture, radiography. Treatment is only surgical - direct access to the heart with wound suturing, revision of the chest.

ICD-10

S26 Trauma to the heart

General information

Heart injuries are a major public health problem due to the proliferation of weapons, especially firearms. In peacetime, such injuries account for about 10% (of which the effects of bullets, shot - 3%) of all penetrating chest injuries. Injuries to the left ventricle account for 43%, right - 35%, right atrium - 6%, left - 4%. Damage in two or more locations is noted in 11% of cases. Mortality at the prehospital stage ranges from 15 to 40%, at the hospital (during surgery or in the postoperative period) - up to 25%. The variability of indicators is determined by the level of development of the health care system in the region.

Causes

The most frequent etiological factor of traumatic myocardial injury is a direct mechanical effect on the chest area of blunt, sharp objects, shells, fragments, bullets. Also, heart injuries can develop as a result of medical interventions performed on the open heart or endovascular. The main groups of reasons:

Physical factors... Open injuries are found with knife, gunshot wounds. Closed ones are the result of the impact on the chest frame of blunt objects during transport, industrial injuries, natural and man-made disasters, fights, and criminal attacks. They are accompanied by fractures of the sternum, ribs, fragments of which leave blind or through myocardial defects.
Iatrogenic causes... Injuries to cardiac structures can be observed during operations and manipulations in the region of the mediastinum, especially the anterior one: pulmonectomy, pleural, pericardial puncture, valve replacement, organ transplantation. If the procedure is not followed, exposure from the inside is possible, for example, with fragments of probes used in angiography, angioplasty and stenting of coronary vessels, metal conductors, elements of suture material.

Pathogenesis

Heart wounds trigger a complex of pathological reactions, mainly developing as a result of the flow of blood into the pericardial cavity. The outflow of blood into the pericardial bag disrupts the normal functioning of the myocardium, reduces the amplitude and force of contractions up to asystole. At the same time, compression of the coronary vessels occurs, which significantly impairs the supply of oxygen and nutrients to the heart muscle. Prolonged tamponade usually ends with the death of cardiomyocytes, necrotic changes in the tissue. Compression of the vena cava and pulmonary veins reduces the flow of blood into the atria, the aorta and the pulmonary trunk - into the ventricles, which adversely affects circulation in the pulmonary and systemic circulation, reduces ejection, leading to acute or subacute heart failure.

Additional causes of impaired systemic hemodynamics can be blood and air in the pleural cavity, which can displace the mediastinum, cause bending of the vascular bundle. Damage to the interventricular septum provokes non-physiological blood flow inside the heart, which increases the load on the ventricles. Violation of the structural integrity of the conducting system negatively affects the conduction of an exciting impulse, which potentiates atrioventricular blockade of varying degrees, fibrillation. With severe injuries, traumatic, hypovolemic shock often develops due to massive blood loss, tissue hypoxia, excessive irritation of nerve endings in the pleura and pericardium, progressive inhibition of the central nervous system with depression of the respiratory and vasomotor centers.

Classification

The nomenclature of heart injuries is based on the nature of the damage and its consequences for cardiac structures. According to the general systematization of injuries, all lesions are divided into open (with violation of the integrity of the skin) and closed (with preservation of the integrity of the skin). In clinical practice, the following groups of injuries are distinguished:

Isolated heart damage... Include single and multiple non-penetrating, penetrating, through wounds of the organ itself. May be accompanied by hemothorax, hemopericardium, hemopneumothorax. Damage to both the myocardium and coronary vessels, the septum of the heart, the conducting system, and the valve apparatus is possible.
Combined damage. Heart injuries are combined with injuries of other organs, which significantly worsens the prognosis and increases the likelihood of developing multiple organ failure. Together with cardiac structures, organs of the chest cavity (lungs, bronchial tree, esophagus, diaphragm), abdominal cavity (liver, stomach, intestines, kidneys), great vessels, bones, joints, etc. can be affected.

Symptoms

Patients brought to the hospital with penetrating chest wounds are usually in a serious, often unconscious state and cannot present any complaints. In some cases, mechanical damage to cardiac structures occurs with an erased clinical picture, for a fairly long time, practically nothing, except an external wound, indicates a heart injury. Patients feel satisfactory, are able to move around without assistance with a continuing high risk of developing fatal complications. Massive blood loss is relatively rare.

With closed injuries (consequences of medical manipulations, damage by a bone fragment), the symptoms observed in patients do not allow one to speak unambiguously about the presence or absence of myocardial damage. Blanching and cyanosis of the skin, especially of the distal extremities, cold sweat, impaired consciousness are possible. With preserved consciousness, patients experience a distinct feeling of fear, "near death", complain of severe weakness, dizziness, frequent deep breathing, and coughing. As the tamponade of the heart progresses, the phenomena of respiratory failure intensify, blood pressure drops.

Complications

The most frequent negative consequence of such injuries is tamponade, accompanied by a violation of myocardial contractions, including until the complete cessation of organ activity. Compression of the coronary vessels can lead to heart attack. Damage to the vascular bundle, the descending part of the aorta is complicated by massive blood loss, the development of shock conditions, which significantly worsen the prognosis. The defeat of the conducting system provokes blockade of impulse conduction, disturbances of excitability and contractility of the myocardium up to ventricular fibrillation.

Diagnostics

It is possible to suspect a heart injury by the localization of damage in the "danger zone" - in the projection of the organ onto the chest. In the absence of a wound, pathology is assumed in the general serious condition of the patient, pallor, confusion, swelling of the cervical veins. Progressive disturbances in the activity of the cardiovascular system are noted: a drop in blood pressure, a paradoxical pulse. With auscultation, it is possible to register dull tones, "the noise of a mill wheel". Since heart injuries are life-threatening conditions, often leaving no time for a detailed examination, instrumental methods are used only with stable hemodynamics. Applicable:

Ultrasound procedure... Highly sensitive, highly specific technique for assessing the severity of damage to intracardiac structures, diagnosing tamponade. Allows to identify blood in the pericardial bag, intracardiac hemodynamic disorders, to determine the localization of the wound. With ambiguous results of ultrasound, it is possible to carry out a transesophageal Echo-KG.
Electrocardiography... It is of great diagnostic value at the stage of tamponade detection. When blood is poured into the pericardial sac, there is a decrease in the amplitude of the teeth on the ECG, the monophasic nature of the QRST complex, followed by a decrease in the S-T interval, the appearance of a negative T. A cardiogram is also prescribed to determine the signs of blockade that begins myocardial infarction.
Pericardiocentesis... Puncture of the pericardium is carried out after Echo-KG, is carried out to determine the nature of the fluid in the pericardial cavity, differentiation of blood from hemorrhagic effusion, exudate with pericarditis, rheumatism. The technique helps to reduce pressure and stress on the heart.
Chest X-ray. Can be done to detect tamponade. On radiographs, a dense, enlarged cardiac shadow of a bell-shaped configuration, a reduced pulsation of the chambers is determined. This method has value in clarifying the diagnosis.

In open wounds, the extent of damage to the heart and adjacent organs is established during revision. Differential diagnosis is carried out with a closed nature of the damage, is carried out with diseases accompanied by pain in the cardiac region: angina pectoris, myocardial infarction, dissecting aortic aneurysm. In some cases, a distinction between pathology and pericarditis is required,

Treatment of wounds is only surgical. Opening of the chest, suturing of the myocardial defect with simultaneous elimination of tamponade is performed. Currently, anterolateral thoracotomy in the fourth or fifth intercostal space is considered the most effective. This access provides the necessary conditions for the revision of internal organs. In parallel, measures are taken to restore the volume of circulating blood, eliminate acidosis, and maintain coronary blood flow.

A heart wound is detected by a pulsating stream of blood, and closed with a finger for the time of suturing. For large lesions, an air-filled catheter can be used. At the stage of restoration of anatomical integrity, atraumatic needles are used, sutures are applied without undue tension. In case of cardiac arrest, ventricular fibrillation, direct heart massage is performed, adrenaline is injected intracardiacally, and defibrillation is performed. At the final stage of the operation, a revision of the chest cavity, suturing of other wounds, examination of the diaphragm, and installation of drains are performed.

The main tasks of the postoperative period are restoration of blood volume, stimulation of erythropoiesis, preservation of the physiological level of systemic and cardiac hemodynamics, restoration of normal peripheral circulation, maintenance of the functions of other organs, prevention of infection. They carry out transfusions of blood and blood substitutes, prescribe infusion therapy, antibiotic therapy, and monitor vital signs. The duration of inpatient treatment depends on the nature and severity of the injury, and can vary from 2 weeks to 2 months.

Forecast and prevention

The survival rate of patients promptly delivered to the clinic with unexpressed or beginning tamponade is about 70%, with significant subpericardial bleeding, the presence of communication with the chest and the external environment - 10%. Injuries to multiple chambers of the heart worsen the prognosis. There is no specific prophylaxis. It is necessary to comply with traffic rules, safety at work, when handling firearms, cold weapons. Invasive medical procedures must be performed by qualified personnel in accordance with established algorithms.

The most common wounds of the heart and pericardium are stab and cut and gunshot

With heart injuries, an external soft tissue wound is usually localized on the left side of the chest in front or on the side. However, in 15-17% of cases, it is located on the chest or abdominal wall outside the projection of the heart. Injuries to the heart and pericardium are often combined with damage to other organs. Especially often, the upper or lower lobe of the left lung is damaged.

Clinic- bleeding, shock, symptoms of cardiac tamponade. The severity of the condition of the wounded is primarily due to acute cardiac tamponade by compression of the heart with blood poured into the pericardial cavity. For the occurrence of cardiac tamponade, the presence of 200-300 ml of blood poured into the pericardial cavity is sufficient.If the amount of blood reaches 500 ml, then there is a threat of cardiac arrest.As a result of tamponade, the normal diastolic filling of the heart is disrupted and a sharp decrease in the stroke and minute volume of the right and left ventricles occurs. this, the central venous pressure rises sharply, and the systemic arterial pressure drops sharply. The main symptoms of acute cardiac tamponade: cyanosis of the skin and mucous membranes, expansion of the superficial veins of the neck, severe shortness of breath, frequent threadlike pulse, the filling of which falls even more at the moment of inhalation, and a decrease in blood pressure. Due to acute anemia of the brain, fainting and confusion are common. Sometimes there is motor excitement. On physical examination, the expansion of the boundaries of the heart, the disappearance of the heart and apical impulse, and muffled heart sounds are determined.

If a lung is injured at the same time, hemopneumothorax appears, as indicated by the presence of subcutaneous emphysema, shortening of the percussion sound and weakening of breathing on the side of the wound. X-ray examination reveals an expansion of the shadow of the heart, which often takes on a triangular or spherical shape, a sharp weakening of the pulsation of the heart. On the electrocardiogram, a decrease in the voltage of the main teeth, signs of myocardial ischemia are recorded Treatment: in case of heart injuries, an immediate operation is required, which is performed under anesthesia The choice of access depends on the localization of the external wound. longitudinal sternotomy The pericardium is opened and the heart is quickly exposed. Temporarily stop bleeding by closing the wound opening with a finger. After that, the pericardial cavity is freed from blood and clots. The final closure of the wound opening is performed by suturing the wound with knotty or U-shaped sutures made of non-absorbable suture material. When the sutures are erupted, pads made of muscle tissue or synthetic strips are used. The operation ends with a thorough examination of the heart so as not to leave damage in other places. During the operation, the necessary intensive therapy is performed, which includes replenishing blood loss, correcting the disturbed homeostasis. In case of cardiac arrest, a heart massage is performed, a tonogen (adrenaline) is injected intracardiacally. With ventricular fibrillation, defibrillation is performed. All activities are carried out with constant artificial ventilation

The main questions of the topic.

History of surgery for heart injuries.
The frequency of heart injury.
Classification of heart injuries.
Clinic for heart wounds.
Diagnostic methods.
Differential diagnosis.
Indications and principles of surgical treatment.

The famous French surgeon Rene Leriche wrote in his book "Memories of my Past Life": "I loved everything that was required in emergency surgery - determination, responsibility and inclusion entirely and completely in action." To the highest degree, these requirements are necessary in the care of victims with heart wounds. Even the fulfillment of all these requirements does not always lead to positive results in case of heart injuries.

The first mentions of the fatal consequences of wounds of the heart are described by the Greek poet Homer in the 13th book of the Iliad (950 BC).

Galen's observation makes a special impression: “When one of the heart's ventricles is perforated, gladiators die immediately on the spot from blood loss, especially if the left ventricle is damaged. If the sword does not penetrate into the cavity of the heart, but stops in the heart muscle, then some of the wounded survive for the whole day, and also, despite the wound, and the following night; but then they die of inflammation. "

At the end of the 19th century, when the survival rate for heart injuries was about 10%, authoritative surgeons, in particular T. Billroth, argued that inexperienced surgeons without a solid reputation were trying to deal with surgical treatment of heart injuries.

For the first time, Cappelen put a suture on a stab wound in the heart in Oslo on September 5, 1895, but the wounded man died 2 days later from pericarditis. In March 1896, Farina in Rome stitched a wound in the right ventricle, but six days later the wounded man died of pneumonia.

The first successful operation of this kind was performed on September 9, 1896 by L. Rehn, who demonstrated the patient at the 26th Congress of German Surgeons in Berlin (J.W.Blatford, R.W. Anderson, 1985). In 1897, the Russian surgeon A.G. The undercut has successfully closed a gunshot wound to the heart for the first time in the world. In 1902 L.L. Hill was the first in the United States to successfully stitch a 13-year-old boy's heart stab wound (on the kitchen table under the light of two kerosene lamps). However, with the accumulation of experience, the romantic coloring of this section of emergency surgery began to disappear, and already in 1926 K. Beck in his classic monograph, which has not lost its significance until our time, wrote: "Successful suturing of a heart wound is not a special surgical feat."

Classification.

Heart wounds are divided into non-fire (knife, etc.) and gunshot: penetrating into the cavity of the heart and non-penetrating. Penetrating, in turn, - on the blind and through. This is the localization of injuries in relation to the chambers of the heart: injuries to the left ventricle (45-50%), right ventricle (36-45%), left atrium (10-20%) and right atrium (6-12%). They, in turn, are damaged and without damage to the intracardiac structures.

Currently, heart wounds account for 5 to 7% of all penetrating chest wounds, including no more than 0.5-1% among gunshot wounds. With stab wounds of the heart and pericardium, isolated damage to the pericardium is 10-20%. By themselves, injuries to the pericardium do not pose a threat to the victim's life, however, bleeding from the transected pericardial vessels can lead to cardiac tamponade.

Cardiac tamponade is a condition in which blood penetrating into the pericardial cavity, as it were, “strangles” the heart.

Acute cardiac tamponade occurs in 53-70% of all heart injuries. The degree of tamponade is determined by the size of the heart wound, the rate of bleeding from the heart into the cavity of the cardiac shirt, as well as the size of the pericardial wound. Small stab wounds of the pericardium are quickly closed with a clot of blood or adherent fat, and cardiac tamponade quickly sets in. The accumulation of more than 100-150 ml of blood in the cavity of the cardiac shirt leads to compression of the heart, a decrease in the contractility of the myocardium. Left ventricular filling and stroke volume fall rapidly, and deep systemic hypotension occurs. Myocardial ischemia is aggravated by compression of the coronary arteries. In the presence of 300-500 ml, cardiac arrest occurs in most cases. It should be remembered that an extensive wound of the pericardium prevents the occurrence of tamponade, because blood flows freely into the pleural cavity or outside.

According to S. Tavares (1984), mortality in cardiac injuries is associated with the nature, size, location of the heart wound, as well as concomitant injuries and the length of time from the moment of injury to the start of resuscitation and treatment. In recent years, there has been an increase in mortality, which is primarily due to the severity of heart damage.

Rhythm disturbance also affects the prognosis. So, for example, with a sinus rhythm, the survival rate is 77.8%. According to J.P. Binet (1985), only 1/3 of victims with heart injury are admitted to the hospital, and the rest die at the scene or on the way to the hospital. The alleged causes of death at the prehospital stage, according to the observations of V.N. Wolf (1986), the following: 32.8% die from massive blood loss, 26.4% - a combination of massive blood loss and cardiac tamponade, 12.7% - isolated cardiac tamponade. In addition, the mortality rate is influenced by factors such as the duration of acute cardiac tamponade, the degree of blood loss, and the presence of damage to the coronary arteries and intracardiac structures.

The highest lethality is observed with gunshot wounds.

Diagnostics.

According to the literature, in the diagnosis of heart injuries, the localization of the chest wound in the projection of the heart and the degree of blood loss are decisive. An important and reliable sign of a heart injury is the localization of an external wound in the projection of the heart, which, according to V.V. Chalenko et al., (1992) - met in 96%, M.V. Grineva, A.L. Bolshakov, (1986) - in 26.5% of cases.

Difficulties in diagnosis arise in the absence of typical clinical signs. According to D.P. Chukhrienko et al., (1989), cardiac tamponade occurs in 25.5% of cases of heart injuries. V.N. Wolfe (1986) distinguishes two stages of cardiac tamponade: the first - blood pressure at the level of 100-80 mm Hg. Art., while the hemopericardium does not exceed 250 ml; the second, when blood pressure is less than 80 mm Hg. Art., which corresponds to a hemopericardium of more than 250 ml. J.H. Vasiliev (1989) believes that a sudden accumulation of 200 ml of fluid in the pericardial cavity causes a clinical picture of cardiac compression, an accumulation of about 500 ml leads to cardiac arrest.

Cardiac tamponade can also be caused by pneumopericardium.

Beck's triad, according to A.K. Benyan et al. (1992), was observed in 73% of cases, according to the conclusion of D. Demetriades (1986) - in 65%, according to M. McFariane et al. (1990) - 33%.

X-ray examinations in case of heart injury are carried out in 25% and 31.5%. On the basis of radiographs, one can judge the volume of blood in the pericardial cavity - the volume of blood from 30 ml to 85 ml is not detected; in the presence of 100 ml, there are signs of weakening of the pulsation; with a blood volume of more than 150 ml, there is an increase in the borders of the heart with a smoothing of the "arcs".

For the diagnosis of heart injury, additional research methods are used - ultrasound, pericardiocentesis [Chukhrienko D.P. et al., 1989; Demetriades D., 1984; Hehriein F. W. 1986; McFariane M. et al., 1990], pericardiotomy [Vasiliev Zh.Kh., 1989; Grewal N. et al., 1995].

It should be emphasized that when performing puncture of the pericardium, false-negative results were obtained in 33% [Chalenko V.V. et al., 1992] and in 80% of cases.

ECG is performed quite often: in 60%. At the same time, such signs of heart injury as large-focal lesions with changes in the T wave, a decrease in the RST interval were found in 41.1%, rhythm disturbances - in 52%.

The diagnosis of cardiac injury before surgery was established in 75.3%.

According to the authors, progress in diagnostics is obvious, but mainly due to the "classical" clinical approach. This opinion is also shared by K.K. Nagy et al., (1995), they attribute clinical signs of damage and active surgical intervention to the most reliable diagnostic methods.

The following triad of symptoms should be considered as characteristic signs of a heart injury:

localization of the wound in the projection of the heart;
signs of acute blood loss;
signs of acute cardiac tamponade.

When the wound is located within the following boundaries: above - the level of the second rib, below - the epigastric region, on the left - the anterior axillary line and on the right - the parasternal line, there is always a real danger of injury to the heart. This localization of wounds was found in 76.8% of our victims.

With the localization of the wound in the epigastric region and the direction of the blow from the bottom up, the wound canal, penetrating into the abdominal cavity, goes further through the tendon center of the diagram into the cavity of the cardiac shirt and reaches the apex of the heart.

The classical clinical picture of cardiac tamponade was described by K. Beck (1926): deafness of heart sounds; low blood pressure with a low, rapid pulse (and low pulse pressure); high venous pressure with swelling of the neck veins.

If the patient's condition is stable, the diagnosis of a heart injury can be confirmed by X-ray examination.

Currently, the most accurate and fastest method of non-invasive diagnostics is the echocardiography method. In this case, within 2-3 minutes, the discrepancy of the pericardial sheets (more than 4 mm), the presence of fluid and echo-negative formations (blood clots) in the cavity of the cardiac shirt, zones of akinesia in the area of the myocardial wound, as well as a decrease in the contractility of the myocardium are clearly revealed.

Recently, surgeons sometimes began to use such a minimally invasive method as thoracoscopy to diagnose heart injuries. It should be noted that indications for this method are rare enough, for example, in clinically unclear cases when it is impossible to diagnose a heart injury with echocardiography, when, on the one hand, it is dangerous to continue observation and examination in dynamics, and on the other hand, it is dangerous to perform classical thoracotomy (for example, in patients with decompensated diabetes mellitus).

Treatment.

When the heart or pericardium is injured after opening the pleural cavity, it is clearly visible how blood shines through the walls of the tense pericardium. Further manipulations of the surgeon and his assistants, the entire team on duty, including the anesthesiologist, must be clearly coordinated. The surgeon puts two retaining threads on the pericardium, opens it wide parallel and in front of the phrenic nerve.

The holder assistant widely spreads the pericardial wound and, at the same time, frees the pericardial cavity from liquid blood and convolutions, and the surgeon, guided by the pulsating blood stream, immediately tampons a small heart wound with the second finger of his left hand, or, if the wound exceeds 1 cm, with the first finger, bringing the palm under the back wall of the heart.

For more extensive wounds, a Foley catheter can be used to achieve temporary hemostasis. Inserting the catheter into the heart chamber and inflating the balloon with gentle tension temporarily stops the bleeding. This task can also be accomplished by inserting a finger into the myocardial wound. The last technique was successfully used by us in four observations. When suturing a heart wound, exclusively non-absorbable suture material is used, preferably on an atraumatic needle. It should be remembered that thin threads cut easily when suturing a flabby wall, especially in the atrium.

In these cases, it is better to use thicker threads and put patches under them, cut in the form of strips from the pericardium. In cases of injury to the ear of the heart, instead of suturing, it is better to simply bandage the ear at the base, having previously applied a fenestrated Luer clamp on it.

In order to avoid myocardial infarction with dangerous proximity to the wound of the branches of the coronary arteries, vertical interrupted sutures should be applied bypassing the coronary artery.

Of no small importance for the postoperative course is thorough sanitation and proper drainage of the cavity of the cardiac shirt. If this is not done, then postoperative pericarditis will inevitably develop, leading to an increase in the duration of inpatient treatment, and, in some cases, to a decrease in the patient's ability to work.

Therefore, the cavity of the heart shirt is thoroughly washed with warm isotonic solution, in the posterior wall of the pericardium an area of about 2-2.5 cm in diameter is excised, making the so-called "window" that opens into the free pleural cavity, and rare interrupted sutures are applied to the anterior wall of the pericardium for prevention of dislocation of the heart and "infringement" of it in a wide wound of the pericardium.

In cases of abdomino-thoracic wounds with damage to the heart from the bottom up, it is more convenient to suture the heart wound with a transphrenic-pericardial approach, without performing a lateral thoracotomy.

Noteworthy is the proposed by Trinkle J.K. (1979) subxiphoid fenestration of the pericardium. It consists in the dissection of soft tissues in the region of the xiphoid process, resection of the latter, reaching the pericardium, placing holders on it, opening and evacuating blood clots in an open way. This operation can be performed under local anesthesia and is life-saving in cases where it is necessary to gain time, but it is not possible to perform a thoracotomy.

History of heart injury surgery

The famous French surgeon Rene Lerish wrote in his book "Memories of My Past Life": "I loved everything that was required in emergency surgery - determination, responsibility and inclusion entirely and completely in action." To the highest degree, these requirements are necessary in the care of victims with heart wounds. Even the fulfillment of all these requirements does not always lead to positive results in case of heart injuries.

The first mentions of the fatal consequences of wounds of the heart are described by the Greek poet Homer in the 13th book of the Iliad (950 BC).

For the first time, Cappelen put a suture on a stab wound in the heart in Oslo on September 5, 1895, but the wounded man died 2 days later from pericarditis. In March 1896, Farina in Rome stitched a wound in his right ventricle, but six days later the wounded man died of pneumonia.

The first successful operation of this kind was performed on September 9, 1896 by L. Rehn, who demonstrated the patient at the 26th Congress of German Surgeons in Berlin (J.W.Blatford, R.W. Anderson, 1985). In 1897, the Russian surgeon A.G. The undercut has successfully closed a gunshot wound to the heart for the first time in the world. In 1902 L.L. Hill was the first in the United States to successfully stitch a 13-year-old boy's heart stab wound (on the kitchen table under the light of two kerosene lamps). However, with the accumulation of experience, the romantic coloring of this section of emergency surgery began to disappear, and already in 1926 K. Beck, in his classic monograph, which has not lost its significance until our time, wrote: "Successful suturing of a heart wound is not a special surgical feat." ...

Classification.

Heart wounds are divided into non-fire (knife, etc.) and gunshot: penetrating into the cavity of the heart and non-penetrating. Penetrating, in turn, - on the blind and through. This is the localization of injuries in relation to the chambers of the heart: injuries to the left ventricle (45-50%), right ventricle (36-45%), left atrium (10-20%) and right atrium (6-12%). They, in turn - with damage and without damage to the intracardiac structures.

Cardiac tamponade is a condition in which blood penetrating into the pericardial cavity, as it were, “strangles” the heart.

Acute cardiac tamponade occurs in 53-70% of all heart injuries. The degree of tamponade is determined by the size of the heart wound, the rate of bleeding from the heart into the cavity of the cardiac shirt, as well as the size of the pericardial wound. Small stab wounds of the pericardium are quickly closed with a clot of blood or adherent fat, and cardiac tamponade quickly sets in. The accumulation of more than 100-150 ml of blood in the cavity of the cardiac shirt leads to compression of the heart, a decrease in the contractility of the myocardium. The filling of the left ventricle and the stroke volume fall rapidly, and deep systemic hypotension occurs. Myocardial ischemia is aggravated by compression of the coronary arteries. In the presence of 300-500 ml, cardiac arrest occurs in most observations. It should be remembered that an extensive wound of the pericardium prevents the occurrence of tamponade, because blood flows freely into the pleural cavity or outside.

Rhythm disturbance also affects the prognosis. So, for example, with a sinus rhythm, the survival rate is 77.8%. According to J.P. Binet (1985), only 1/3 of victims with heart injury are admitted to the hospital, and the rest die at the scene or on the way to the hospital. The alleged causes of death at the prehospital stage, according to the observations of V.N. Wolf (1986), the following: 32.8% die from massive blood loss, 26.4% - a combination of massive blood loss and cardiac tamponade, 12.7% - isolated cardiac tamponade. In addition, the mortality rate is influenced by such factors as the duration of acute cardiac tamponade, the degree of blood loss, as well as the presence of damage to the coronary arteries and intracardiac structures.

The highest lethality is observed with gunshot wounds.

Diagnostics.

Cardiac tamponade can also be caused by pneumopericardium.

Beck's triad, according to A.K. Benyan et al. (1992), was observed in 73% of cases, according to the conclusion of D. Demetriades (1986) - in 65%, according to M. McFariane et al. (1990) - 33%.

It should be emphasized that when performing puncture of the pericardium, false-negative results were obtained in 33% [Chalenko V.V. et al., 1992] and in 80% of cases.

ECG is performed quite often: in 60%. At the same time, such signs of heart injury as large-focal lesions with changes in the T wave, a decrease in the RST interval were detected in 41.1%, rhythm disturbances - in 52%.

The diagnosis of cardiac injury before surgery was established in 75.3%.

The following triad of symptoms should be considered as characteristic signs of heart injury:

1) localization of the wound in the projection of the heart;

2) signs of acute blood loss;

3) signs of acute cardiac tamponade.

When the wound is located within the following boundaries: above - the level of the second rib, below - the epigastric region, on the left - the anterior submuscular line and on the right - the parasternal line, there is always a real danger of heart injury.

With the localization of the wound in the epigastric region and the direction of the blow from the bottom up, the wound channel, penetrating into the abdominal cavity, goes further through the tendon center of the diagram into the cavity of the cardiac shirt and reaches the apex of the heart.

If the patient's condition is stable, the diagnosis of a heart injury can be confirmed by X-ray examination.

Currently, the most accurate and fastest method of non-invasive diagnostics is the echocardiography method. At the same time, within 2-3 minutes, the discrepancy of the pericardial leaves (more than 4 mm), the presence of fluid and echo-negative formations (blood clots) in the cavity of the cardiac shirt, zones of akinesia in the area of the myocardial wound, as well as a decrease in the contractility of the myocardium are clearly detected.

The holder assistant widely spreads the pericardial wound, and, at the same time, frees the pericardial cavity from liquid blood and convolutions, and the surgeon, guided by the pulsating blood stream, immediately tampons a small heart wound with the second finger of his left hand, or, if the wound exceeds 1 cm, with the first finger, bringing the palm under the back wall of the heart.

For more extensive wounds, a Foley catheter can be used to achieve temporary hemostasis. Inserting the catheter into the heart chamber and inflating the balloon with gentle tension temporarily stops the bleeding. This task can also be accomplished by inserting a finger into the myocardial wound. The last technique was successfully used by us in four observations. When suturing a heart wound, exclusively non-absorbable suture material is used, preferably on an atraumatic needle. It should be remembered that thin threads are easily cut through when suturing a flabby wall, especially in the atrium.

In order to avoid myocardial infarction with dangerous proximity to the wound of the branches of the coronary arteries, vertical interrupted sutures should be applied bypassing the coronary artery.

Noteworthy is the proposed by Trinkle J.K. (1979) subxiphoid fenestration of the pericardium. It consists in dissection of soft tissues in the region of the xiphoid process, resection of the latter, reaching the pericardium, placing holders on it, opening and evacuating blood clots in an open way. This operation can be performed under local anesthesia and is life-saving in cases where it is necessary to gain time, but it is not possible to perform a thoracotomy.

We studied the results of subxiphoid partial pericardiectomy in 10 patients with heart injury. The operation ended with the installation of a silicone drainage tube 5 mm in diameter into the cavity of the heart shirt. To improve the outflow from the pericardial cavity, the distal end of the drain was connected to the aspiration system.

So, depending on the conditions for the provision of assistance, there may be various solutions to tactical problems in case of heart injuries.

Classification:

1) Injury only to the pericardium

2) Injury to the heart:

A) non-penetrating B) penetrating - LV, RV, LA, PP (through, multiple, with damage to the coronary arteries)

Clinic:

shock, acute blood loss, cardiac tamponade (more than 200 ml in the pericardium)

Symptoms of acute cardiac tamponade:

cyanosis of the skin and mucous membranes, expansion of the superficial veins of the neck, severe shortness of breath, frequent threadlike pulse, the filling of which falls even more at the moment of inhalation, a decrease in the level of blood pressure.

Due to acute anemia of the brain, fainting and confusion are common. Sometimes there is motor excitement.

Physically:

expansion of the borders of the heart, the disappearance of the heart and apical impulse, dull heart sounds. Rg: expansion of the shadow of the heart, (triangular or spherical), a sharp weakening of the pulsation of the heart.

ECG: decreased voltage of the main teeth, signs of myocardial ischemia.

Diagnosis:

muffled heart sounds; enlargement of the borders of the heart; inflating of the jugular veins; lowering blood pressure; increased heart rate, weak pulse; there is an external wound First aid: anti-shock therapy, anesthesia, urgent delivery to the hospital. Self-removal of a traumatic object is unacceptable.

Treatment:

The choice of access depends on the location of the external wound.

Most often - left-sided anterolateral thoracotomy in VI-V m / f When an external wound is located next to the sternum, a longitudinal sternotomy Temporarily stop bleeding by closing the wound opening with a finger. The pericardial cavity is freed from blood and clots. The final closure of the wound hole is performed by suturing the wound with knotted or U-shaped sutures made of non-absorbable suture material. Heart suture - if the wound is small, then U-shaped sutures (thick ligature, silk, nylon we stitch the epi- and myocardium under the endocardium), if the wound is large, then in the beginning there is a regular ligature in the center, on both sides of which there are 2 U-shaped sutures. sutures use pads made of muscle tissue or synthetic strips The operation ends with a thorough examination of the heart so as not to leave damage in other places of the IT: replenishment of blood loss, correction of impaired homeostasis. In cardiac arrest, cardiac massage is performed, adrenaline is injected intracardiacally; in ventricular fibrillation, defibrillation is performed. All measures are carried out with constant artificial ventilation of the lungs of the suture.

Treatment of cardiac contusion is generally similar to intensive care for acute coronary insufficiency or myocardial infarction. It includes the removal of pain and the appointment of cardiac glycosides, antihistamines, drugs that improve coronary circulation and normalize myocardial metabolism. According to indications, antiarrhythmic and diuretic drugs are prescribed. The necessary infusion therapy is carried out under the control of central venous pressure, and, if possible, intra-aortic through a catheter in the femoral artery. In case of heart contusion with a tendency to hypotension, according to indications, wide thoracotomies, with the exception of urgent operations, should be delayed as far as possible until cardiac activity stabilizes.