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Cardiac injuries can be obvious and catastrophic to patient outcome. Instances arise, however, when detection of cardiac injury is subtle, relying on several modalities to make the diagnosis. Cardiac injury may account for approximately 10% of deaths from gunshot wounds, and three fourths of patients with penetrating cardiac injury die before receiving any medical care.1

The diagnosis of cardiac injury and great vessel injury should be suspected in a patient with chest, lower neck, epigastric, or precordial injury. Observe such patients closely for evidence of hemodynamic instability, loss of circulating blood volume, electrocardiographic changes, cardiac tamponade, and hemothorax.

This chapter discusses blunt, penetrating, and iatrogenic injury2 to the heart and pericardium.

Penetrating Cardiac Injury

Penetrating trauma is the most common cause of significant cardiac injury, with most injuries occurring from guns and knives.3 Usually, the injury involves only the free cardiac wall, but other structures can be injured, such as cardiac valves, chordae tendineae, papillary muscles, atrial or ventricular septum, coronary arteries, and the conduction system (Table 259-1).

Table 259-1 Penetrating Wounds of the Heart

Anatomy of Injury

Pericardial injury can result in acute tamponade. The ventricles are at greatest risk for penetrating cardiac trauma due to their anterior anatomic location. Involvement of cardiac structures due to penetrating injuries involves the right ventricle, left ventricle, right atrium, and left atrium at frequencies of 40%, 35%, 20%, and 5%, respectively.4,5 The right ventricle is at greatest risk due to its large anterior exposure. The right and left atria are less frequently involved due to their smaller surface area. Single or multiple penetrating agents can injure multiple structures. Knives tend to frequently involve a single chamber, producing a single slit-like defect. Gunshot wounds can cause a spectrum of injury from multiple-chamber perforation to gaping defects depending on the caliber and velocity of the missile. Patients with stab wounds to the heart are 17 times more likely to survive than gunshot wounds.6

The anatomic “cardiac box” is the chest area bounded by the sternal notch superiorly, the xiphoid process inferiorly, and the nipples laterally. Most stab wounds injuring the heart enter through this ...

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