Abstract 2061: High Velocity Penetrating Thoracic Trauma with Suspected Cardiac Involvement in Combat During Operation Iraqi Freedom

Introduction: The most common cardiac injuries in the U.S. are either blunt trauma from motor vehicle accidents, or low-velocity injuries from stabbings. High-velocity injury is less common, and survival to presentation is rare. During military conflict, high-velocity injury, including gunshot wounds (GSW) and fragment injury from improvised explosive devices (IED) are relatively more common. Methods: Retrospective review of cases with high-velocity penetrating injury and suspected myocardial involvement. We sought to describe the role of varying diagnostic modalities during a 6 month period in Baghdad, Iraq at a U.S. Army hospital during Operation Iraqi Freedom. Results: There were 11 cases who survived to admission (GSW in 5, IED in 6). The mean age of the all male cohort was 27 years (range 3 to 54). Eight of the eleven patients (73%) were victims of polytrauma. The entrance involved the right ventricle (n=3), right atrium (n=2), left ventricle (n=1) or mediastinum and pericardial reflections (n=5). Echocardiography was performed in all eleven patients. All patients had preserved or hyperdynamic myocardial contractility. In seven patients, no foreign body was identifiable, in two patients the foreign body was identified as being within the pericardial fat pad. Three patients were identified as having a suspected ventricular septal defect, ranging in size from 2 to 8 mm. The most common ECG abnormality was conduction delay, both atrioventricular block and right bundle branch block. Plain film radiography and CT scanning were routinely performed, but definitive localization was frequently limited by metallic streak artifact. In four patients, the management of the chest injury was non-surgical, and in one patient the treatment was a chest tube only. Four of the patients underwent median sternotomy, one underwent emergent lateral thoracotomy, and one underwent an infra-diaphragmatic approach. Conclusions: While this case series is too small to draw definitive conclusions, it does demonstrate that a multidisciplinary approach to high-velocity injuries with potential for cardiac involvement augments pre-operative assessment for myocardial injury and may allow selective non-operative management.