heart, Penetrating Cardiac Trauma Index, (PCH) and other thoracic organs has been .... Since cardiac tamponade produces a sudden andpro- found physiologic ...
Penetrating
Cardiac Trauma Quantifying the Severity ofAnatomic and Physiologic Injury
RAO R. IVATURY, M.D., F.A.C.S.
MANOHAR N. NALLATHAMBI, M.D., F.A.C.S. MICHAEL ROHMAN, M.D., F.A.C.S.
A method of quantifying the anatomic extent of injury to the heart, Penetrating Cardiac Trauma Index, (PCH) and other thoracic organs has been proposed. The total extent of thoracic injury, Penetrating Thoracic Trauma Index (PTTI), was measured. When associated abdominal injury was present, it was assessed by the Penetrating Abdominal Trauma Index (PATI) of Moore et al."1 The severity of total injury sustained by the patient, represented by the Penetrating Trauma Index (PTI), was determined by the sum total of these scores. The extent of physiologic abnormality induced by cardiac penetration, (Physiologic Index or PI), was graded on a scale of increasing severity from 5-20 based on the vital signs of patients on admission. Analysis of 112 patients with penetrating cardiac injuries (19731983) revealed that the indices, PCII and PI, showed an excellent correlation with survival (R2 = 0.827 and 0.928, respectively) as did the total extent of trauma (PTI). A composite prognostic score of the sum of PI and PTI demonstrated a significant separation of survivors from nonsurvivors (p < 0.001). It is concluded that these anatomic (PMTI and PTI) and physiologic (PI) indices are valid and, with additional confirmation, may provide an objective method of evaluating penetrating cardiac injuries.
WILLIAM M. STAHL, M.D., F.A.C.S.
From the Department of Surgery, New York Medical College, and Lincoln Medical and Mental Health Center, Bronx, New York
There is difficulty in evaluating and comparing different series of penetrating cardiac injuries, since survival depends on such variables as the nature of prehospital support, the clinical status of patients on admission, the nature and extent of the trauma, the mode of injury, and the efficacy of treatment. Trinkle'0 recently pointed out the inherent patient self-selection in clinical studies of penetrating cardiac trauma that complicates valid comparison of results. It may be beneficial, therefore, to have a well-defined, easily reproducible method of reporting the extent of cardiac trauma and associated organ injuries sustained by the patient along with the physiologic disruption that results from trauma. Unfortunately, none of the current indices is applicable to cardiac trauma. We propose an index for quantifying penetrating cardiac injuries and their physiologic consequences. The index is designed to supplement the Penetrating Abdominal Trauma Index (PATI) described by Moore et al."
URVIVAL AFTER PENETRATING cardiac trauma has > improved in recent years concurrent with advances LJ in prehospital care, rapid transport of injured victims to trauma centers, and the evolution of resuscitative thoracotomy for patients in extremis.' We previously reported the survival of one third of patients who arrived moribund in the emergency center after cardiac injuries.57 However, the overall survival rate in 228 patients with penetrating cardiac trauma (1963-1983) was only 47.4% because more than half of these 228 patients were in extremis on admission.8 In contrast, Tavares et al.9 recently reported a survival rate of 70% among 64 patients with cardiac injuries, but only 13 of these patients (20.3%) were "lifeless" on arrival to the hospital.
Materials and Methods One hundred and twelve consecutive patients with penetrating cardiac injuries (1973-1983) were reviewed retrospectively. Seventy-nine patients had stab wounds and 33 patients had gunshot wounds. There were 105 men and seven women aged 4-60 years. Our approach to the management of penetrating cardiac injuries has been previously described in detail.5-8 It consists of emergency room thoracotomy for patients in extremis and for those who do not respond promptly to rapid volume expansion. After successful resuscitation and control of the cardiac wound, patients are transferred to the operating
Reprint requests and correspondence: Rao R. Ivatury, M.D., Department of Surgery, Lincoln Medical and Mental Health Center, 234 East 149th Street, Bronx, NY 10451. Submitted for publication: July 11, 1986.
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IVATURY AND OTHERS
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Ann. Surg. * January 1987
TABLE 1. Injury Severity Index (PTTI) Organ Risk Factor
Organ Heart
5
Major vascular
5
Lung
4
Esophagus
4
Injury Severity Estimate (Injuries and Management) 1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 1. 2. 3. 4. 5.
Tangential, involving pericardium or wall up to endocardium Single right-sided chamber Comminuted tears of a single chamber Multiple chambers, isolated left atrium, or left ventricle Coronary injury, major intracardiac defects Intercostal vessel ligation Internal mammary artery ligation Primary repair of major vessels End-to-end anastomosis, patch graft Interposition grafting or bypass Minor injury, thoracostomy tube alone Minor debridement, suturing Segmental resection/significant contusion Lobectomy Major tracheobronchial disruption, pulmonary hilum injury, pneumonectomy 25% circumferential laceration 25-50% circumferential laceration Greater than 50% circumferential laceration Delayed diagnosis, more than 12 hours Delayed diagnosis, more than 24 hours PTTI = sum of organ injury scores.
Organ injury score = organ risk factor X injury severity estimate.
room, situated on another floor, for definitive cardiorrhaphy and management of associated injuries. The thoracic and cardiac injuries sustained by the patient are quantified by a method similar to that proposed by Moore et al. for abdominal trauma." The method consists of assigning a risk factor for each thoracic organ (Table I), based on the reported mortality and morbidity rates from injury to that organ. For instance, the heart and the major vessels of the thorax receive a score of 5, whereas the lung is given a risk factor of 4. The extent of injury to each organ is graded on a scale of 1-5, 1 being minor and 5 being the most severe. The product of the risk factor and the estimate of the severity ofinjury equals the organ injury score. The sum of the thoracic organ injury scores in a given patient constitutes the Penetrating Thoracic Trauma Index (PTTI). For example, consider a patient with a gunshot wound of the lung (treated by thoracostomy) and the coronary vessels of the heart. The Heart TABLE 2. Clinical Status on Admission and PI
Clinical Status
Unconscious No vital signs No respiratory effort No physical activity, but some sign of life in transit to hospital Semiconscious Thready pulse
PI
20
15
Gasping respiration No measurable BP
Systolic BP of 80 mmHg or less Conscious Stable
10 5
Injury Score or the Penetrating Cardiac Trauma Index (PCTI) is organ risk factor (5) X injury severity estimate (5) = 25. The Lung Injury Score is organ risk factor (4) X injury severity estimate (1) = 4. The Penetrating Thoracic Trauma Index (PTTI) equals 25 + 4, or 29. In patients with combined thoracoabdominal injuries, the total extent of trauma, represented by the Penetrating Trauma Index (PTI), can be expressed by the sum of the thoracic and abdominal indices (PTTI + PATI). PATI is measured by the method of Moore et al." These formulations are summarized as follows: Organ risk factor X injury severity estimate = organ injury score. Sum of organ injury scores = PTI. Also, PTI = PTTI + PATI. Since cardiac tamponade produces a sudden and profound physiologic aberration that may be out of proportion to the extent of the cardiac injury, an analysis of survival from cardiac penetration would be incomplete without consideration of the patient's clinical status on admission. For this purpose a graded Physiologic Index (PI) of increasing severity, from 5-20, is formulated (as summarized in Table 2) and represents a numerical expression of the classification we have previously described.68 Results Stab wounds had a mean PTI of 18.2, whereas gunshot wounds had a higher index of 31.5 (p < 0.001). The mean PI in these two groups, however, was comparable (13 and 14.8, respectively). Sixty of the 112 patients with penetrating cardiac trauma survived. All the various trauma indices (PI, PCTI, PTI) had statistically significant differences between survivors and nonsurvivors (Table 3).
Vol. 205 * No. I
QUANTIFYING CARDIAC TRAUMA
TABLE 3. Anatomic (PCTI, PTI) and Physiologic (PI) Indices of Survivors and Nonsurvivors Survivors N = 60
Nonsurvivors N = 52
pValue
11.3 12.1 19.2
16.3 17.1 26.2
