Penetrating Cardiac Injuries: “Damage Control” and ERAS Ways of Thinking

Abstract

Background. Penetrating stab wounds to the heart are potentially survivable injuries, with reported mortality ranging from 9.7 % to 35 % among patients who arrive at the hospital with signs of life. Management remains challenging and depends on rapid diagnosis, timely surgical intervention, coordinated anesthesiological resuscitation, and streamlined perioperative algorithms.

Aim. To describe the variability of clinical presentation, to analyze and optimize diagnostic, surgical, anesthetic, and postoperative approaches, and to identify management errors based on 23 years of institutional experience.

Materials and Methods. This retrospective cohort study covered a 23-year period and included 67 adult patients who met the inclusion criteria. Patients were stratified into four clinical categories on admission: benign condition, cardiac tamponade, critically unstable, and patients with signs of life or in cardiac arrest. All patients underwent anterolateral thoracotomy (Spangaro incision) for tamponade release, cardiac repair, and management of associated injuries. Anesthetic management consisted of general intravenous anesthesia, with rapid sequence intubation performed in 100 % of cases.

Results. Among the 67 patients, 61 (91.05 %) had isolated cardiac injuries and 6 (8.95 %) had multiple-chamber wounds. Overall survival was 91.05 %. Emergency department thoracotomy (EDT) was performed in 8 patients (11.94 %), with a 50 % survival rate. The distribution of isolated injuries was as follows: LV 29 (47.54 %), RV 24 (39.36 %), RA 4 (6.55 %), and LA 4 (6.55 %). Associated injuries occurred in 15 patients (22.38 %). Mortality was 8.95 %; deaths resulted from cardiac tamponade (4 patients, 66.7 %), exsanguination (1 patient, 16.65 %), and injury to the left anterior descending artery (1 patient, 16.65 %). Postoperative complications occurred in 5 patients (7.46 %).

Patients were subsequently divided into two groups: Standard (n=35) and ERAS-based management (n=32). Implementation of ERAS principles led to a significant reduction in ICU stay (2.2 → 1.6 days, p<0.05) and hospital LOS (9.3 → 6.5 days, p<0.05) without an increase in complications or mortality.

Conclusion. Survival after penetrating cardiac injury can be improved through the implementation of a simple, rational, and scientifically grounded management strategy that integrates damage-control principles and ERAS-based perioperative optimization.