In the past 15 years, our hospital has admitted many patients with cardiac rupture, some of whom were already dead when they came to the hospital, and some died quickly. The successful surgical treatment of 28 patients with cardiac rupture without extracorporeal circulation in our department has given us a lot of experience, which provides a little reference for the successful emergency treatment of patients with critical cardiac injury in primary care hospitals.
Patients admitted to our department are basically stab wounds with parasternal, precordial, and bilateral thoracic cavities. The appropriate staging of cardiac rupture can help to further identify the condition. Different measures according to the typing have certain significance to improve the success rate of resuscitation.
(1) Acute hemorrhagic shock type.
(2) Acute pericardial tamponade type.
(3) Subacute pericardial filling type.
1. Acute hemorrhagic shock type.
Most because of the wound is large, the heart and pericardial fissure can not be blocked for blood clot, a large amount of blood outflow to the chest and abdominal cavity or outside the body, causing hemorrhagic shock, this type of patients are mostly at the time of injury, most died within minutes or in transit. Patients who cannot be corrected by transfusion or blood transfusion or who are too late to be corrected die rapidly. This type of patients basically can not be corrected, admitted to the hospital to tell the family of the condition, too late to save treatment.
2, acute pericardial filling type.
Pericardial injury wound is not large, can be a blood clot or pericardial lax tissue hematoma compression pericardial rupture, heart wound is large, pericardial accumulation of blood more, resulting in patients with acute pericardial filling manifestations: there is a progressive drop in blood pressure, pale face, sweating, wet and cold, increased heart rate, distant heart sound, jugular vein anger, mental agitation. Due to the large amount of pericardial fluid or rapidly growing small amount of fluid, ventricular diastole is blocked and cardiac blood output is reduced. The systolic pressure does not rise and the diastolic elevation is increased after rehydration. Patients in this category require rapid emergency open-heart surgery to relieve pericardial tamponade, which can be life-saving. This type of patients need emergency physicians, the patient’s family to be active, rapid open chest, emergency operating room open chest, may save the patient’s life. But physicians have to take a lot of risk, because the patient died at any time, and now the medical environment is not good, it is not good enough to set fire to the body.
3. Subacute pericardial tamponade type.
Pericardial, heart injury wound is not large, can be a blood clot or pericardial lax tissue hematoma compression pericardial rupture, bleeding suspended, pericardial blood accumulation is not much, resulting in patients with acute pericardial filling is not heavy, performance: there is a progressive drop in blood pressure can be corrected, but there is again lower, increased heart rate, distant heart sound, jugular vein anger, mental agitation. Such patients are relatively uneventful and have the opportunity of ultrasound, chest X-ray and CT examination. All patients treated in our department are of this type.
Surgical approach:
Regardless of the right or left side of the chest wound, the chest is entered along the stab wound incision, with an anterolateral incision and an “L-shaped” Nike mark-like incision. Cut the upper and lower edges of the stab wound with 2 ribs cartilage, which helps to fully expose the injury site, do not rush to open the pericardium, expand the open chest incision, fully reveal the pericardial fissure, finger through the pericardial fissure deep into the pericardium, find the heart fissure, because the heart fissure is not too far from the pericardial fissure, fingertip blocking the heart fissure, which helps to stop the heart from bleeding rapidly and continue to bleed, avoid a long time can not find the heart fissure This will help to stop the heart from bleeding rapidly and continuing to bleed, avoiding the inability to find the heart wound for a long time, and causing excessive bleeding, causing a rapid decrease in the amount of circulating blood and crisis of life.
At this point, the assistant then expands the pericardial wound, aspirates the blood in the pericardium, reveals the heart wound, timely suturing and rapid hemostasis. We sutured the heart wound with a 7-gauge silk thread. The patient had no short-term significant special discomfort after the operation and no special long-term follow-up. After removal of the blood accumulation in the pericardium, the pericardial wound was opened and adequately drained. This facilitated the elimination of intrapericardial fluid and reduced the occurrence of re-formation of pericardial tamponade.
After the operation, the patient had no obvious special discomfort. One of the patients showed intermittent tachycardia, the fastest being 126 times, which started to occur three days after the operation with a maximum of 13 times per day repeatedly, lasting about 3-10 minutes. No special treatment was given. The episodes of tachycardia gradually decreased, and the duration was shortened. The tachycardia returned to normal after half a month. In this case, the wound was in the right ventricle near the junction of the right and left ventricles, and when it was sutured, there might be part of the conduction bundle and vascular suture, and the electrocardiogram suggested ischemic changes in the lower wall. It gradually returned to normal after half a month.
Summary:The characteristics of heart repair surgery without extracorporeal circulation conditions are: “fast, accurate and stable”
Fast, rapid judgment of the condition, clear diagnosis, and rapid organization of surgery. Rapid intraoperative opening of the chest and opening of the pericardium. Two purposes, conducive to pericardial decompression; conducive to reducing bleeding. Quickly find the bleeding site, quickly control the bleeding and save lives.
Accurate, after accurate judgment of the injury, the correct surgical approach is half of the success of the operation. Accurate surgical approach is conducive to the exposure of the heart wound, which provides a reliable guarantee for timely and effective hemostasis of the operation.
Stability, as the operator, cardiac hemorrhage, at any time life-threatening, in the face of danger, active and effective organization, calm and comfortable to carry out each step of the operation, stabilize the family, assistants and other medical workers is very important psychologically. It is very important to stabilize the family, assistants and other medical workers. It can make the family emotionally stable and not to affect the rescue work. For other medical staff to work carefully with a calm mind, to ensure error-free and improve the success rate of surgery. With 120 heartbeats per minute, heart repair is not an easy task. It is necessary to achieve a steady heart and steady hands to achieve rapid suture wound closure and reduce the occurrence of cardiac side injuries.
When resuscitating patients for rapid correction of shock, blood transfusion is not necessarily immediate, but blood must be actively prepared, first with crystals and then with colloids, to be fully prepared during surgery. It must be consistent with the principles of rescue of patients in shock. However, blood pressure is not required to necessarily rise to normal, nor can it reach normal. These cases of patients from injury to surgery are in 3-5 hours, indicating that patients with cardiac rupture are not certain to die, and we should establish the psychological preparation and positive action for active rescue and life-saving treatment.