**C. Level III**


present with clinically significant acute congestive heart failure. Another rare entity is pericardial rupture with cardiac herniation. This requires opening the chest with replacement of the heart in the normal anatomic position and repair of any injured vasculature. Whether you utilize a thoracotomy or sternotomy will depend on the details of the cardiac herniation.

Cardiac Trauma

351

http://dx.doi.org/10.5772/55723

Blunt Cardiac Injury. Schultz JM, Trunkey DD. Critical Care Clin. 20 (2004) 57-70[12]

**Figure 7.** Algorithm for treatment of suspected BCI

Outcomes of emergency department thoracotomy for blunt trauma are universally poor. The salvage rate of patients with or without vital signs on arrival to the emergency department is 1%-2% [14]. This low survival rate mandates that before an emergency department thoracot‐

### *Screening of Blunt Cardiac Injury.* **Pasquale, N K and Clark, J.** s.l. : The Eastern Association for the Surgry of Trauma, 1998.

#### **Figure 6.** EAST guidelines for Blunt Cardiac Injury

due in part to the position of the heart in the chest. The method of repairing the atria is to grasp each side of the atrial wound, place a vascular clamp across the defect, and sew it closed. The method of repair of the ventricle is to place a finger of the non-dominant hand over the injury occluding the wound and stopping the blood loss. Then pledgeted mattress sutures are placed under the finger in order to approximate the wound without tearing through the injured myocardium. Septal rupture requires the patient to be placed on bypass. Coronary artery injury, valve injury and papillary muscle rupture are all very rare. These entities generally

Blunt Cardiac Injury. Schultz JM, Trunkey DD. Critical Care Clin. 20 (2004) 57-70[12]

#### **Figure 7.** Algorithm for treatment of suspected BCI

due in part to the position of the heart in the chest. The method of repairing the atria is to grasp each side of the atrial wound, place a vascular clamp across the defect, and sew it closed. The method of repair of the ventricle is to place a finger of the non-dominant hand over the injury occluding the wound and stopping the blood loss. Then pledgeted mattress sutures are placed under the finger in order to approximate the wound without tearing through the injured myocardium. Septal rupture requires the patient to be placed on bypass. Coronary artery injury, valve injury and papillary muscle rupture are all very rare. These entities generally

1. An admission EKG should be performed on all patients in who there is suspected

1. If the admission EKG is abnormal (arrhythmia, ST changes, ischemia, heart block, unexplained ST), the patient should be admitted for continuous EKG monitoring for 24 to 48 hours. Conversely, if the admission EKG is normal, the risk of having a BCI that requires treatment is insignificant, and the pursuit of diagnosis should be

2. If the patient is hemodynamically unstable, an imaging study (echocardiogram) should be obtained. If an optimal transthoracic echocardiogram cannot be performed, then the patient should have a transesophageal echocardiogram. 3. Nuclear medicine studies add little when compared to echocardiography and, thus,

1. Elderly patients with known cardiac disease, unstable patients, and those with an abnormal admission EKG can be safely operated on provided they are appropriately monitored. Consideration should be given to placement of a

2. The presence of a sternal fracture does not predict the presence of BCI and, thus,

3. Neither creatinine phosphokinase with isoenzyme analysis nor measurement of circulating cardiac troponin T are useful in predicting which patients have or will

does not necessarily indicate that monitoring should be performed.

*Screening of Blunt Cardiac Injury.* **Pasquale, N K and Clark, J.** s.l. : The Eastern

are not useful if an echocardiogram has been performed.

pulmonary artery catheter in such cases.

have complications related to BCI.

Association for the Surgry of Trauma, 1998.

**Figure 6.** EAST guidelines for Blunt Cardiac Injury

EAST guidelines

BCI.

350 Principles and Practice of Cardiothoracic Surgery

terminated.

**A. Level I** 

**B. Level II**

**C. Level III**

present with clinically significant acute congestive heart failure. Another rare entity is pericardial rupture with cardiac herniation. This requires opening the chest with replacement of the heart in the normal anatomic position and repair of any injured vasculature. Whether you utilize a thoracotomy or sternotomy will depend on the details of the cardiac herniation.

Outcomes of emergency department thoracotomy for blunt trauma are universally poor. The salvage rate of patients with or without vital signs on arrival to the emergency department is 1%-2% [14]. This low survival rate mandates that before an emergency department thoracot‐

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504-17.

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[2] Thourani, V.H., et al., Penetrating cardiac trauma at an urban trauma center: a 22-

[3] Velmahos, G.C., et al., Penetrating trauma to the heart: a relatively innocent injury.

[4] Plummer, D., et al., Emergency department echocardiography improves outcome in

[5] Karrel, R., M.A. Shaffer, and J.B. Franaszek, Emergency diagnosis, resuscitation, and treatment of acute penetrating cardiac trauma. Ann Emerg Med, 1982. 11(9): p.

[6] Asensio, J.A., et al., Penetrating cardiac injuries: a prospective study of variables pre‐

[8] Evans, J., et al., Principles for the management of penetrating cardiac wounds. An‐

[9] Kang, N., et al., Penetrating cardiac injury: overcoming the limits set by Nature. In‐

[10] Hancock Friesen, C., J.G. Howlett, and D.B. Ross, Traumatic coronary artery fistula

[11] Lowe, J.E., et al., The natural history and recommended management of patients with traumatic coronary artery fistulas. Ann Thorac Surg, 1983. 36(3): p. 295-305. [12] Schultz, J.M. and D.D. Trunkey, Blunt cardiac injury. Crit Care Clin, 2004. 20(1): p.

[13] Sutherland, G.R., et al., Anatomic and cardiopulmonary responses to trauma with as‐

[14] Cothren, C.C. and E.E. Moore, Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World J Emerg Surg, 2006. 1:

[7] Symbas, P.N., Cardiothoracic trauma. Curr Probl Surg, 1991. 28(11): p. 741-97.

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jury, 2009. 40(9): p. 919-27.

**Figure 8.** Schematic Representation of right atrial repair

omy is undertaken both the mechanism of injury and the length or presence of CPR be taken into consideration.

#### **Author details**

Daniel Eiferman\* , R. Nathan Cotterman and Michael Firstenberg

Ohio State University Medical Center, Department of Surgery, Division of Trauma, Critical Care, and Burn, Columbus, OH, USA

### **References**

omy is undertaken both the mechanism of injury and the length or presence of CPR be taken

Ohio State University Medical Center, Department of Surgery, Division of Trauma, Critical

, R. Nathan Cotterman and Michael Firstenberg

into consideration.

**Author details**

Daniel Eiferman\*

Care, and Burn, Columbus, OH, USA

**Figure 8.** Schematic Representation of right atrial repair

352 Principles and Practice of Cardiothoracic Surgery


**Chapter 14**

**Gastrointestinal Complications in**

Hooman Khabiri and Stanislaw P. A. Stawicki

Additional information is available at the end of the chapter

III and IV heart failure, and hepatic insufficiency [8].

**2. Risk factors for GIC-CTS**

Gastrointestinal complications (GIC) in cardio-thoracic surgery (GIC-CTS) constitute a het‐ erogenous group of non-cardiac/thoracic complications. Although relatively infrequent, these complications are associated with significant mortality and severe clinical sequelae. It is also well recognized that GIC-CTS are often difficult to identify clinically [1], and the pre‐ sentation of each specific complication may differ from the presentation of said complication in non-CTS patient populations. The incidence of gastrointestinal complications following CTS ranges from <1% to 4.1% patients [2-4], and is associated with mortality rates between 13.9% and 63% [5-7]. Commonly reported GIC-CTS include gastrointestinal hemorrhage, esophagitis/gastritis, perforated ulcer, acute cholecystitis, acute pancreatitis, and mesenteric ischemia [5]. Predominant factors associated with increased mortality following a gastroin‐ testinal complication after cardiac surgery include patient age, COPD, smoking, NYHA class

Numerous studies report on specific risk factors for GIC-CTS. Although some of the factors seem to be universally present across different studies, some others are likely unique to spe‐ cific study populations. A comprehensive list of commonly cited risk factors compiled from the literature includes: (a) decreased left ventricular ejection fraction (<40%) including post‐ operative low cardiac output; (b) advanced patient age; (c) pre-existing conditions such as diabetes, renal failure, peripheral vascular disease; (d) valvular surgery or combined coro‐

and reproduction in any medium, provided the original work is properly cited.

© 2013 Schwartz et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

Jennifer Schwartz, David E. Lindsey,

http://dx.doi.org/10.5772/54348

**1. Introduction**

**Cardiothoracic Surgery: A Synopsis**

**Chapter 14**
