1. Stable patients with hemopericardium after penetrating trauma can be safely treated with pericardial drainage and wash-out, rather than sternotomy and cardiac repair.
2. Compared to patients managed with sternotomy, patients managed with pericardial drainage had less severe complications, shorter ICU stays, and shorter total hospital stay.
Evidence Rating Level: 1 (Excellent)
Study Rundown: It is currently acceptable to manage a patient with hemodynamically stable penetrating cardiac injury with immediate sternotomy and cardiac exploration. However, previous studies have suggested that many of these procedures may be unnecessary, as often there was no cardiac injury, only tangential injury, or the injury had sealed. This study demonstrated that patients managed with pericardial drainage and wash-out had similar survival to discharge compared to patients managed with sternotomy and cardiac repair. Moreover, the drainage group had less severe complications and significantly shorter ICU and total hospital stays than the sternotomy group.
This study is limited by the fact that the cohort of patients selected to be randomized was very specific. Moreover, the primary endpoint was survival to discharge, rather than long term survival. The follow-up interval was inconsistent, ranging from 2 weeks to 5.5 years after discharge, with several patients lost to follow-up. The study only reported follow-up data from the drainage group, omitting comparison of long term outcomes with the sternotomy group.
Relevant Reading: Does hemopericardium after chest trauma mandate sternotomy?
In-Depth [randomized controlled trial]: This study included 111 adult patients who sustained penetrating chest trauma and were hemodynamically stable. Screening for hemopericardium was performed by subxiphoid pericardial window (SPW) on ultrasound. Patients with active bleeding at SPW were converted to medial sternotomy and were not included in the trial. Patients with positive SPW and no active bleeding were randomized to receive either sternotomy (56 patients) or drainage (55 patients). There was no reported crossover between groups. The two groups had similar proportions of stab wounds to gunshot wounds, and similar baseline characteristics.
There were no postoperative deaths in the drainage group, and one postoperative death in the sternotomy group (iatrogenic). While there were a similar number of complications between groups, the complications in the sternotomy group were of higher grade on the Clavien-Dindo classification scale, including spontaneous cardiac arrest and sternal sepsis. 71% of patients in the sternotomy group were managed in the ICU postoperatively, compared to 16% of patients in the drainage group. Mean ICU stay was 1.8 days longer in the sternotomy group (95% CI: 0.8-2.7). Mean hospital stay in the sternotomy group was significantly longer (6.5 days vs 4.1 days, P<0.001).
By James Jiang and Allen Ho
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