Factors indicating a heart injury are. Heart wounds

Classification:

1) Wound only the pericardium

2) Wound of the heart:

A) non-penetrating B) penetrating - LV, RV, LP, PP (through, multiple, with damage coronary arteries)

Clinic:

shock, acute blood loss, cardiac tamponade (more than 200 ml in the pericardium)

Symptoms of acute cardiac tamponade:

cyanosis of the skin and mucous membranes, dilation of the superficial veins of the neck, severe shortness of breath, frequent thready pulse, the filling of which falls even more at the time of inspiration, a decrease in the level blood pressure.

Due to acute anemia of the brain, fainting, confused consciousness are not uncommon. Sometimes there is motor excitement.

Physically:

expansion of the boundaries of the heart, the disappearance of the cardiac and apical beat, muffled heart tones. Rg: expansion of the shadow of the heart, (triangular or spherical shape), a sharp weakening of the heart pulsation.

ECG: decrease in voltage of the main teeth, signs of myocardial ischemia.

Diagnosis:

muffled heart sounds; enlargement of the borders of the heart; inflating the jugular veins; a decrease in blood pressure; an increase in heart rate, a weak pulse; there is an external wound. First aid: anti-shock therapy, anesthesia, urgent delivery to the hospital. Unacceptable self-deletion traumatic item.

Treatment:

The choice of access depends on the localization of the external wound.

Most often - left-sided anterolateral thoracotomy in VI-V m\w. When the external wound is located near the sternum, longitudinal sternotomy. Temporarily stop bleeding by closing the wound opening with a finger. The pericardial cavity is freed from blood and clots. The final closure of the wound opening is performed by suturing the wound with knotted or U-shaped sutures from non-absorbable suture material. The suture of the heart - if the wound is small, then p-shaped sutures (thick ligature, silk, nylon, we sew the epi- and myocardium under the endocardium), if the wound is large, then at the beginning in the center is a regular ligature, on both sides of which there are 2 p-shaped seams use pads made of muscle tissue or synthetic strips. The operation is completed with a thorough examination of the heart so as not to leave damage in other places of IT: replenishment of blood loss, correction of disturbed homeostasis. In case of cardiac arrest, heart massage is performed, adrenaline is injected intracardiac. In ventricular fibrillation, defibrillation is performed. All activities are carried out with constant artificial ventilation of the lungs of the seam.

Treatment of cardiac contusion is generally similar to intensive care for acute coronary insufficiency or myocardial infarction. It includes the removal of pain and the appointment of cardiac glycosides, antihistamines, drugs that improve coronary circulation and normalize myocardial metabolism. According to indications, antiarrhythmic and diuretic drugs are prescribed. The necessary infusion therapy is carried out under the control of central venous pressure, and, if possible, intra-aortic through a catheter in femoral artery. In case of cardiac contusion with a tendency to hypotension, wide thoracotomies should be deferred, if possible, until the cardiac activity stabilizes, if indicated, except for emergency operations.

Heart and pericardial injuries are common in peacetime in patients hospitalized with penetrating wounds chest, in 10.8 - 16.1% of cases. In more than half of the cases, this type of injury is accompanied by severe shock and a terminal state. About 2/3 of the wounded in the heart die on prehospital stage.

History reference. The realization of the possibility of surgical treatment of wounds of the heart was approached at the end of the 19th century. Until that time, medicine was dominated by the idea of ​​the fatal nature of the damage in question. However, a number still made attempts to save the sick. So, in 1649, Riolanus pointed out the possibility of treating a heart injury by aspiration of blood from the pericardial sac. In 1829, Larrey for the first time decompressed a wounded heart with the help of Marks (1893) achieved recovery of a patient with a heart wound after its tamponing. The first suturing of the heart was performed by Cappelen (1895) in Norway, Fariner (1896) in Italy, V. Shakhovsky (1903) in Russia, E. Korchits (1927) in Belarus.

Pathogenesis. Pericardial injuries are characterized by the occurrence of a complex of hemocirculatory disorders. Their development is based on the flow of blood into the pericardial cavity, which is accompanied by a difficulty in the activity of the heart. At the same time, compression of the coronary vessels occurs and the nutrition of the heart muscle is sharply disturbed. In addition, circulatory disorders in case of heart injuries are aggravated by ongoing bleeding, accumulation of air and blood in the pleural cavities, mediastinal displacement, kink of the vascular bundle, etc. All of these factors in combination lead to the development of hypovolemic, traumatic and cardiogenic shock.

The volume of the hemopericardium depends on the length of the pericardial wound and the localization of the heart wound. With defects in the pericardium of more than 1.5 cm, injuries of the heart and adjacent vessels with relatively high pressure (aorta, pulmonary artery), blood does not linger in the cavity of the heart shirt, but pours out into the surrounding spaces, primarily into the pleural cavity with the formation of hemothorax. In the case of small injuries of the pericardium (up to 1-1.5 cm), blood accumulates in the pericardial cavity, causing the development of cardiac tamponade syndrome in 30-50% of cases. Its occurrence is associated with a small volume of the pericardial cavity, containing in healthy individuals 20-50 ml of serous fluid and rarely 80-100 ml. A sudden accumulation of more than 150 ml of blood in the heart sac leads to an increase in intrapericardial pressure and compression of the heart. This is accompanied by an increase in atrial pressure, a drop in the pressure gradient between the pulmonary artery and the left atrium. Heart activity stops. In individuals with a rapid accumulation of blood in the pericardial cavity, death from tamponade occurs within 1 to 2 hours from the moment of injury.

Pathological anatomy. Wounds of the heart and pericardium can be stab, stab-cut and gunshot. Knife wounds, as a rule, are accompanied by damage to the left parts of the heart, which is associated with a more frequent direction of the blow from left to right. In other types of injuries, injuries of the right ventricle and atrium predominate due to their direct contact with the anterior chest. Almost 3% of patients also have a simultaneous injury to the interatrial septum, heart valves. There are cases of damage to the conduction system, coronary arteries, including 5 times more often than the left coronary artery. More massive destruction of the heart is observed with gunshot wounds. Cavity ruptures, damage to intracardiac structures in 70-90% of cases of heart injury are accompanied by damage to the upper or lower lobe of the left lung, diaphragm, and large vessels.

Classification of wounds of the heart and pericardium

Isolated injuries of the pericardium and injuries of the pericardium, combined with damage to the heart, are distinguished. The latter are divided into isolated and combined.

Isolated wounds of the heart are divided into:

I. Non-penetrating:

1: a) single;

b) multiple.

2: a) with hemopericardium;

b) with hemothorax;

c) with hemopneumothorax;

3: with damage to the coronary vessels;

4: with external and internal bleeding.

II. Penetrating:

one; a) single;

b) multiple;

2: a) through;

b) blind;

3: a) with hemopericardium;

b) with hemothorax;

c) with hemopneumothorax;

d) with mediastinal hematoma;

4: a) with external bleeding;

b) with internal bleeding;

5: a) with damage to the coronary vessels;

b) with damage to the walls of the heart;

c) with damage to the conductive system;

d) with damage to the valve apparatus.

Combined injuries of the heart are divided into:

1) penetrating;

2) non-penetrating;

3) in combination with damage:

a) other organs of the chest (lungs, bronchi, trachea, large vessels, esophagus, diaphragm);

b) abdominal organs (parenchymal organs, hollow organs, large vessels);

c) organs of other localization (bones of the skull, brain, bones and joints, vessels).

Symptoms of injuries of the heart and pericardium

The manifestations of a heart injury are varied. The victims are hospitalized in hospitals in serious condition. At the same time, there are cases of an erased, asymptomatic course of the wound. Patients complain of weakness, dizziness, shortness of breath, in the region of the heart. They are excited, quickly lose strength. In severe shock, there may be no complaints, and in the case of a combined injury, symptoms of damage to adjacent organs often prevail. Patients with severe cardiac tamponade report a feeling of lack of air. Damage to the coronary arteries and multiple wounds are characterized by significant pain in the heart.

There are three clinical options(forms) of heart injuries: with a predominance of cardiogenic, hypovolemic shock and their combinations. Manifestations of these types of shock practically do not differ from those in other diseases.

Diagnosis of wounds of the heart and pericardium. When solving the problems of diagnosis in heart injuries, one should remember the time factor, that the complex of diagnostic measures should be aimed primarily at identifying the most reliable symptoms. In case of shock phenomena, diagnostic measures are carried out in the operating room in parallel with the elements intensive care. About the injury of the heart testify:

The location of the inlet of the wound channel on the chest is mainly in the region of the heart or in the precordial zone. According to I. I. Grekov, the area of ​​​​possible injury to the heart is limited from above by the 2nd rib, from below by the left hypochondrium and epigastric region, on the left by the middle axillary and on the right by the parasternal lines.

Signs of venous hypertension: cyanosis of the face and neck, swelling of the veins of the neck (CVD 140 mm of water column or more). However, in patients with a predominance of blood loss and in severe concomitant trauma, CVP is usually reduced. An increase in CVP in dynamics is a sign of cardiac tamponade.

Shortness of breath (more than 25-30 breaths per 1 minute),
Deafness of heart tones or their absence. If the interventricular septum is damaged, a systolic murmur is determined along the left edge of the sternum with an epicenter in the IV intercostal space. With damage to the mitral and tricuspid valves, a systolic murmur may be heard in lower third sternum, at the Botkin point and at the apex (be aware of the possibility of heart damage in people who previously suffered from heart disease).
Expansion of percussion limits of cardiac dullness.
Tachycardia. In patients in terminal state and in the case of severe cardiac tamponade, bradycardia is noted, paradoxical pulse - a decrease in the pulse wave on inspiration.
Arterial hypotension with reduced systolic and diastolic and reduced pulse pressure. In patients with cardiac tamponade, blood pressure at the onset of hemopericardium may be moderately reduced, but remains stable for some time. In the case of an increase in the phenomena of hemopericardium, blood pressure drops sharply. With extrapericardial bleeding, blood pressure progressively decreases.

With heart injuries accompanied by hemopericardium, the ECG shows a low voltage of the ventricular complexes. In persons with severe blood loss, there are signs of myocardial hypoxia, predominantly of a diffuse nature. Damage to large coronary arteries and ventricles is accompanied by ECG changes identical to those in acute stage myocardial infarction. In persons with injuries to the conducting system of the heart, septa and its valves, rhythm and conduction disturbances (blockade of impulse conduction, rhythm dissociation, etc.), signs of overload of the heart departments are noted. However, ECG with injuries of the pericardium and heart does not allow to accurately determine the localization of the wound. This is explained by the fact that stab wounds in themselves do not cause significant changes in the myocardium.

An X-ray examination of the chest organs reveals reliable and probable symptoms of heart injuries. Significant symptoms of heart damage include: pronounced expansion of its boundaries; displacement of the arcs along the right and left contours of the heart; weakening of the pulsation of the contours of the heart (a sign of hemopericardium).

Echocardiography in hemopericardium reveals a gap in echo signals between the walls of the heart and the pericardium. The exact dimensions of the hemopericardium are determined by ultrasonography.

Based on a comprehensive examination of patients with heart injuries, the Beck triad is distinguished - a sharp decrease in blood pressure, a rapid and significant increase in CVP, and the absence of heart pulsation during fluoroscopy.

Treatment of wounds of the heart and pericardium

Suspicion of injury to the heart and pericardium is an absolute indication for surgery. Preparation for the operation includes the most necessary diagnostic, laboratory and instrumental manipulations, preural cavities in case of tension pneumothorax, catheterization of the central veins.

When choosing an access, the localization of the inlet of the wound channel and its approximate direction are taken into account. The most common is an anterolateral thoracotomy. If the wound is localized in the lower parts of the chest, it is advisable to perform a left-sided anterolateral thoracotomy in the 5th intercostal space, and in the upper parts - in the 4th intercostal space. Expansion of the wound or opening of the pleural cavities through the wound channel is not recommended. When the main vessels are injured - ascending aorta, trunk pulmonary artery- Bilateral thoracotomy with transection of the sternum is performed. A number of surgeons perform a longitudinal median sternotomy for heart injuries.

After opening the chest, the pericardium is dissected longitudinally in front of the phrenic nerve. At the time of its opening from the pericardial cavity, a large number of blood and clots. Blood flows from the wound of the heart. For penetrating wounds of the left parts of the heart, the flow of scarlet blood is characteristic. Bleeding from the ventricles is sometimes pulsatile. To temporarily stop bleeding, the wound of the heart is covered with a finger. The defect in the wall of the heart is sutured with non-absorbable suture material.

Ventricular wounds are most often sutured with conventional interrupted or U-shaped sutures on synthetic pads. Punctures are made through the entire thickness of the myocardium, retreating from the edges of the wound by 0.5 - 0.8 cm.

When the wound is located near the coronary vessels, U-shaped sutures are used with their placement under the vascular bundles. Large ventricular wall wounds are sutured with the initial application of wide U-shaped sutures, bringing together the edges of the wound. Wounds of thin-walled atria are sutured with interrupted U-shaped sutures on synthetic pads, an atraumatic needle, purse-string sutures on pads, and a continuous suture after lateral squeezing of the atrial wall with a clamp. Wounds of the ascending aorta less than 1 cm long are sutured by applying two purse-string sutures to the adventitia of the aorta. The internal purse-string suture runs no closer than 8-12 mm from the edge of the wound; The pericardium is sutured with rare sutures.

In case of sudden cardiac arrest or fibrillation during the operation, a direct heart is made, 0.1 ml of adrenaline is injected intracardiacly and defibrillation is performed.

AT postoperative period complex therapy is carried out and, if necessary, topical diagnostics of the pathology that has arisen as a result of heart injury.

Patients with severe cardiac tamponade at the prehospital stage and in the hospital with an extremely severe or atonal condition, if it is impossible to perform an emergency thoracotomy, a pericardial puncture from known points is indicated. It is expedient to carry out a puncture of a pericardium under control or an ECG. In this case, the appearance of extrasystoles on the ECG or rhythm disturbance indicates contact with the myocardium, and an increase in the voltage of ventricular complexes indicates the effectiveness of cardiac decompression. After aspiration of the contents from the pericardial cavity, an increase in blood pressure, a decrease in CVP, and a decrease in tachycardia are observed. The next operation is performed.

In patients with extremely severe comorbidities admitted 12-24 hours after injury and stable hemodynamic parameters, pericardial puncture with blood removal may be the final treatment.

The main questions of the topic.

1. History of surgery for cardiac injuries.
2. Frequency of heart injuries.
3. Classification of wounds of the heart.
4. Clinic of heart injuries.
5. Diagnostic methods.
6. Differential diagnosis.
7. Indications and principles surgical treatment.

The famous French surgeon René Leriche, in his book “Memories of a Past Life,” wrote: “I loved everything that was required in emergency surgery - determination, responsibility and inclusion completely and completely in action.” In the highest degree, these requirements are necessary in providing assistance to victims with heart injuries. Even the fulfillment of all these requirements does not always lead to positive results with heart injuries.

The first mention of the fatal consequences of wounding the heart is described by the Greek poet Homer in the 13th book of the Iliad (950 BC).

The observation of Galen makes a special impression: “When one of the ventricles of the heart is perforated, the gladiators die immediately on the spot from blood loss, especially fast when the left ventricle is damaged. If the sword does not penetrate into the cavity of the heart, but stops in the heart muscle, then some of the wounded survive for a whole day, and also, despite the wound, the following night; but then they die of inflammation.”

At the end of the 19th century, when the survival rate for heart injuries was approximately 10%, reputable surgeons, in particular, T. Billroth, argued that inexperienced surgeons without a solid reputation were trying to deal with surgical treatment of heart injuries.

For the first time, a suture on a stab-cut wound of the heart was imposed by Cappelen in Oslo on September 5, 1895, but the wounded man died 2 days later from pericarditis. In March 1896, Farina in Rome put stitches on the wound of the right ventricle, but six days later the wounded man died of pneumonia.

The first successful operation of this kind was performed on September 9, 1896 by L. Rehn, who demonstrated the patient at the 26th Congress of German Surgeons in Berlin (J.W. Blatford, R.W. Anderson, 1985). In 1897, the Russian surgeon A.G. The undercut was the first in the world to successfully close a gunshot wound of the heart. In 1902 L.L. Hill was the first in the United States to successfully suture a stab wound to the heart of a 13-year-old boy (on a kitchen table by the light of two kerosene lamps). However, with the accumulation of experience, the romantic coloring of this section of emergency surgery began to disappear, and already in 1926, K. Beck in his classic monograph, which has not lost its significance to this day, wrote: “Successful suturing of a heart wound is not a special surgical feat.”

Classification.

Wounds of the heart are divided into non-gunshot (knife, etc.) and gunshot: penetrating into the cavity of the heart and non-penetrating. Penetrating, in turn, - on the blind and through. This is the localization of injuries in relation to the chambers of the heart: injuries to the left ventricle (45-50%), right ventricle (36-45%), left atrium (10-20%) and right atrium (6-12%). They, in turn, with and without damage to intracardiac structures.

Currently, heart injuries account for 5 to 7% of all penetrating chest injuries, including gunshot wounds - no more than 0.5-1%. With stab wounds of the heart and pericardium, isolated damage to the pericardium is 10-20%. By themselves, pericardial wounds do not pose a danger to the life of the victim, however, bleeding from transected pericardial vessels can lead to cardiac tamponade.

Cardiac tamponade is a condition in which blood entering the pericardial cavity, as it were, “suffocates” the heart.

Acute cardiac tamponade occurs in 53-70% of all cardiac injuries. The degree of tamponade is determined by the size of the heart wound, the rate of bleeding from the heart into the cavity of the heart shirt, and the size of the pericardial wound. Small knife wounds of the pericardium quickly close with a clot of blood or adjacent fat, and cardiac tamponade quickly sets in. The accumulation of more than 100-150 ml of blood in the cavity of the heart shirt leads to compression of the heart, a decrease in myocardial contractility. The filling of the left ventricle and the stroke volume are rapidly falling, there is a deep systemic hypotension. Myocardial ischemia is exacerbated by compression of the coronary arteries. In the presence of 300-500 ml in most cases, cardiac arrest occurs. It should be remembered that an extensive pericardial wound prevents the occurrence of tamponade, because. blood flows freely into the pleural cavity or out.

According to S.Tavares (1984), lethality in heart injuries is associated with the nature, size, localization of the heart wound, as well as concomitant injuries and the length of time from the moment of injury to the start of resuscitation and treatment. In recent years, there has been an increase in mortality, which is primarily due to the severity of heart damage.

The prognosis is also affected by rhythm disturbance. So, for example, with sinus rhythm, the survival rate is 77.8%. According to J. P. Binet (1985), only 1/3 of victims with a heart injury are admitted to the hospital, and the rest die at the scene or on the way to the hospital. Estimated causes of death at the prehospital stage, according to the observations of V.N. Wolf (1986), the following: 32.8% die from massive blood loss, 26.4% - a combination of massive blood loss and cardiac tamponade, 12.7% - isolated cardiac tamponade. In addition, factors such as the duration of acute cardiac tamponade, the degree of blood loss, and the presence of damage to the coronary arteries and intracardiac structures influence the mortality rate.

The highest mortality is observed in gunshot wounds.

Diagnostics.

According to the literature, in the diagnosis of heart injuries, the determining factor is the localization of the chest wound in the projection of the heart and the degree of blood loss. An important and reliable sign of a heart injury is the localization of an external wound in the projection of the heart, which, according to the observations of V.V. Chalenko et al., (1992) - met in 96%, M.V. Grineva, A.L. Bolshakova, (1986) - in 26.5% of cases.

Difficulties in diagnosis arise in the absence of typical clinical signs. According to D.P. Chukhrienko et al., (1989), cardiac tamponade occurs in 25.5% of cases of cardiac injuries. V.N. Wolf (1986) distinguishes two stages of cardiac tamponade: the first - blood pressure at the level of 100-80 mm Hg. Art., while the hemopericardium does not exceed 250 ml; the second, when blood pressure is less than 80 mm Hg. Art., which corresponds to a hemopericardium of more than 250 ml. J.Kh. Vasiliev (1989) believes that a sudden accumulation of 200 ml of fluid in the pericardial cavity causes clinical picture compression of the heart, accumulation of about 500 ml leads to cardiac arrest.

The pneumopericardium may also be the cause of cardiac tamponade.

Beck's triad, according to A.K. Benyan et al. (1992), was observed in 73% of cases, according to D. Demetriades (1986) - in 65%, according to M. McFariane et al. (1990) - in 33%.

X-ray examinations in case of injury to the heart are carried out in 25% and 31.5%. On the basis of radiographs, one can judge the volume of blood in the pericardial cavity - the volume of blood from 30 ml to 85 ml is not detected; in the presence of 100 ml - there are signs of a weakening of the pulsation; with a blood volume of more than 150 ml, an increase in the boundaries of the heart with smoothing of the "arcs" is noted.

Used to diagnose cardiac injury additional methods research - ultrasound, pericardiocentesis [Chukhrienko D.P. et al., 1989; Demetriades D., 1984; Hehriein F.W., 1986; McFariane M. et al., 1990], pericardiotomy [Vasiliev Zh.Kh., 1989; Grewal H. et al., 1995].

It should be emphasized that when performing a puncture of the pericardium, false negative results were obtained in 33% [Chalenko V.V. et al., 1992] and in 80% of cases.

ECG is performed quite often: in 60%. At the same time, such signs of heart injury as large-focal lesions with changes in the T wave, a decrease in the RST interval were detected in 41.1%, rhythm disturbances - in 52%.

The diagnosis of heart injury before surgery was established in 75.3%.

According to the authors, progress in diagnostics is obvious, but mainly due to the "classical" clinical approach. This opinion is also shared by K.K. Nagy et al., (1995), they refer to clinical signs of damage and active surgical intervention to the most reliable diagnostic methods.

The following triad of symptoms should be considered as characteristic signs of heart injury:

1. localization of the wound in the projection of the heart;
2. signs of acute blood loss;
3. signs of acute cardiac tamponade.

When the wound is located within the following boundaries: above - the level of the second rib, below - the epigastric region, on the left - the anterior axillary line and on the right - the parasternal line, there is always a real danger of injuring the heart. 76.8% of our victims had such localization of wounds.

With the localization of the wound in the epigastric region and the direction of the blow from the bottom up, the wound channel, penetrating into abdominal cavity, goes further through the tendon center of the diagram into the cavity of the heart shirt and reaches the apex of the heart.

The classic clinical picture of cardiac tamponade was described by K. Beck (1926): deafness of heart sounds; low blood pressure with a small rapid pulse (and low pulse pressure); high venous pressure with swelling of the jugular veins.

If the patient's condition is stable, the diagnosis of heart injury can be confirmed by X-ray examination.

Currently, the most accurate and fastest method of non-invasive diagnostics is the method of echocardiography. At the same time, within 2-3 minutes, the divergence of the pericardial sheets (more than 4 mm), the presence of fluid and echo-negative formations (blood clots), akinesia zones in the area of ​​the myocardial wound, and a decrease in myocardial contractility in the cavity of the heart shirt are clearly detected.

Recently, surgeons have sometimes begun to use such a minimally invasive method as thoracoscopy to diagnose a heart injury. It should be noted that indications for this method occur quite rarely, for example, in clinically unclear cases, when it is impossible to diagnose a heart injury with echocardiography, when, on the one hand, it is dangerous to continue monitoring and examination in dynamics, and on the other hand, it is dangerous to perform a classic thoracotomy (for example, in patients with decompensated diabetes mellitus).

Treatment.

When the heart or pericardium is injured, after opening the pleural cavity, it is clearly visible how blood shines through the walls of the tense pericardium. Further manipulations of the surgeon and his assistants, the entire team on duty, including the anesthesiologist, must be clearly coordinated. The surgeon puts two threads-holders on the pericardium, widely opens it parallel and in front of the phrenic nerve.

The assistant spreads the pericardial wound wide by the handles, and at the same time frees the pericardial cavity from liquid blood and clots, and the surgeon, guided by the pulsating blood stream, immediately plugs a small wound of the heart with the second finger of the left hand, or, if the size of the wound exceeds 1 cm, with the first finger, bringing the palm under the back wall of the heart.

In cases of more extensive wounds, a Foley catheter can be used to achieve temporary hemostasis. Inserting a catheter into the heart chamber and inflating the balloon with gentle tension temporarily stops bleeding. This task can also be accomplished by inserting a finger into the myocardial wound. The latter technique was successfully used by us in four observations. When suturing a heart wound, only non-absorbable suture material is used, preferably with an atraumatic needle. It should be remembered that thin threads are easily cut through when suturing a flabby wall, especially in the atrial region.

In these cases, it is better to use thicker threads and put under them patches cut in the form of strips from the pericardium. In cases of injury to the auricle of the heart, instead of suturing, it is better to simply bandage the ear at the base, after placing a fenestrated Luer clamp on it.

In order to avoid myocardial infarction when the branches of the coronary arteries are dangerously close to the wound, vertical interrupted sutures should be applied with a bypass of the coronary artery.

Of no small importance for the postoperative course is a thorough sanitation and proper drainage of the cavity of the heart shirt. If this is not done, then postoperative pericarditis inevitably develops, leading to an increase in the duration of inpatient treatment, and, in some cases, to a decrease in the patient's ability to work.

Therefore, the cavity of the heart shirt is thoroughly washed with a warm isotonic solution, a section of about 2-2.5 cm in diameter is excised in the posterior wall of the pericardium, making the so-called “window” that opens into the free pleural cavity, and rare interrupted sutures are placed on the anterior wall of the pericardium for prevention of dislocation of the heart and "infringement" of it in a wide wound of the pericardium.

In cases of abdomino-thoracic injuries with damage to the heart from the bottom up, it is more convenient to suture the wound of the heart through a transdiaphragmatic-pericardial approach, without performing a lateral thoracotomy.

Noteworthy is the proposed Trinkle J.K. (1979) Subxiphoidal fenestration of the pericardium. It consists in dissection of soft tissues in the region of the xiphoid process, resection of the latter, reaching the pericardium, applying holders to it, opening and evacuating blood clots in an open way. This operation can be performed under local anesthesia and is saving in cases where it is necessary to gain time, and it is not possible to perform a thoracotomy.

The frequency of damage to the heart and pericardium with penetrating chest injuries is 10-12%.

The clinical picture, features of surgical tactics and treatment outcomes depend on the location, size and depth of the wound. There are small (up to 1 cm) and large (more than 1 cm) wounds of the heart. How more wound the more dangerous it is for the victim. The results of treatment worsen when the wound penetrates into the cavity of the heart, damage to the coronary vessels, intracardiac structures, through the nature of the injury. The intensity and volume of blood loss is higher, and the immediate results of treatment are worse when the left heart is injured than the right. The most reliable signs of injury to the heart and pericardium are the localization of the wound in the projection of the heart (I.I. Grekov), the expansion of the boundaries of cardiac dullness, the dullness of the heart tones, the decrease in blood pressure, the paradoxical nature of the pulse, the development of symptoms of venous stasis on the face, neck, upper body due to cardiac tamponade. Intensive internal bleeding can also be manifested by massive hemothorax, significant suffocation. Gushing external bleeding is rarely observed in the emergency room.

A possible injury to the heart should be considered if the inlet wound opening is located in a zone bounded from above - by the II rib, from below - by the left hypochondrium and epigastric region, on the right - by the right parasternal line, on the left - by the middle axillary line. Although, exceptions to this rule are not uncommon - atypical localization of entry wounds on the back, abdomen, etc., especially with a gunshot wound. General state in most of the victims, severe and extremely severe, sometimes terminal, progressively turning into clinical death during transportation. But there are also options for treating the victim "on their own feet."

Developing acute cardiac tamponade causes a forced sitting or semi-sitting position of the victim, accelerated, shallow breathing with the participation of auxiliary muscles, pale cyanotic color skin, puffiness of the face, increased venous pattern on the neck. The pulse is small, frequent, weak filling, sometimes disappears on inspiration (paradoxical). The disappearance of the apex beat, physical and radiographically detectable enlargement of the boundaries of the heart, smoothness of the left contours of the heart, the absence of heart pulsation during fluoroscopy supplement the results of electrocardiography (decrease in voltage ECG waves, infarct-like changes). Prolonged ischemia of the brain, liver, kidneys aggravates and diversifies the clinical picture, can lead to acute multiple organ failure, convulsive and other additional symptoms, and death of the victim.

Diagnostic in unclear cases, and with developed tamponade - an effective first aid is a pericardial puncture, most often performed according to Marfan or Larrey, less often - according to Pirogov-Delorme or Kurshman.

Marfan's method: in a half-sitting or reclining position on a couch with a padded roller, the patient under local infiltration anesthesia with a 0.25% solution of novocaine is punctured with a medium needle strictly along the midline immediately under the xiphoid process. The needle is directed from bottom to top, from front to back and penetrate into the pericardial cavity. With the Larrey method, the needle is injected into the angle between the base of the xiphoid process of the sternum and the attachment of the VII left costal cartilage to a depth of 1.5-2 cm, and then advanced upward and medially parallel to the chest wall for another 2-3 cm, getting into the pericardial cavity.

For general surgeons, reliable signs of injury to the heart and pericardium, as well as a reasonable suspicion of injury to the heart, are an indication for emergency hospitalization and emergency thoracotomy to stop bleeding, eliminate cardiac tamponade, and suture the wound of the heart. The extremely serious condition of the victim excludes various diagnostic measures and speeds up surgical intervention. Able clinical death only immediate thoracotomy combined with resuscitation on the operating table can give a chance to save the life of the victim.

In unclear diagnostic situations and in the condition of the wounded, which allows to deepen diagnostic measures, the above studies (ECG, radiography, fluoroscopy, echocardioscopy, measurement of CVP) can be used to identify hemopneumopericardium, measure heart pulsation, concomitant signs of intrapleural bleeding and disorders of position and mobility diaphragm.

In some difficult diagnostic cases, repeated X-ray examination of the victim for a comparative analysis of changes becomes important. Established cardiac tamponade is an indication for pericardial puncture followed by intravenous infusion of fluids to replenish BCC during surgery. Until the elimination of tamponade, jet intravenous infusions of fluids are contraindicated, because. they aggravate disturbances of the central hemodynamics.

Thoracotomy is performed under intubation anesthesia in the IV or V intercostal space in the position on the right side - from the left edge of the sternum to the posterior axillary line. The pericardium is opened with a longitudinal incision up to 8-12 cm parallel to the phrenic nerve, retreating from it ventrally or dorsally 1.5-2 cm. The left palm is inserted into the pericardial cavity so that the heart lies on the palm with the back surface, and thumb lay on its front surface and could, if necessary, temporarily stop the bleeding from the wound of the heart by pressing. The wound of the heart is sutured with a round needle, nodal or mattress, more often nylon sutures, passing through all layers on the atria, on the ventricles of the heart through the thickness of the myocardium, without penetrating into the heart cavity. When cutting sutures on the myocardium, a piece of the pectoralis major muscle with fascia or a pericardial flap can be used as a lining, damage to the coronary vessels should be avoided. There is no need to rush to remove blood clots plugging the heart wound before a reliable suture is applied. It is useful to apply temporary holders to the edges of the wound of the heart to reduce blood loss (in order to temporarily bring the edges of the wound closer together). Be sure to make an audit of the heart for a possible penetrating injury. To improve the outflow of fluid from the pericardium in the postoperative period and prevent pericarditis, a window is cut out in the posterior inferior wall of the pericardium with a diameter of 2.5-3 cm, and the pericardial wound is sutured with rare (2-2.5 cm) single sutures. If necessary, a thoracotomy wound can be supplemented by transection of the sternum or even a contralateral thoracotomy. Access should be convenient for suturing the wound of the heart and saving the life of the victim. Fears of developing osteomyelitis of the sternum, etc. recede into the background. During the operation, the spilled pleural and donor blood is used for reinfusion, significantly reducing the need for donor blood. In many ways, the final results of the treatment of victims depend on the timeliness of delivery to the hospital and the speed of surgical intervention. With penetrating wounds of the heart with damage to intracardiac structures, patients need subsequent treatment by a cardiac surgeon.

The classification is described above. Consider the clinic of penetrating wounds of the heart.

The symptom complex of a heart injury consists of: 1. the presence of a wound in the projection of the heart; 2. symptoms of intrapleural bleeding; 3. signs of cardiac tamponade.

The anatomical region dangerous for heart damage is limited (Grekov's zone): above - 2 ribs, below - the left hypochondrium and epigastric region, on the right - the parasternal line, on the left - the middle axillary line. Wounds located in the anatomical projection of the heart are especially dangerous.

The amount of intrapleural bleeding depends on the size of the heart wound and, especially, on the size of the pericardial wound. With very small pericardial wounds, bleeding into the pleural cavity will be negligible. In this situation, the picture of cardiac tamponade will prevail.

With large pericardial wounds, on the contrary, the clinic of tamponade will not be expressed, but the clinic of profuse intrapleural bleeding and acute blood loss prevails.

Signs of intrapleural bleeding: decrease in blood pressure, tachycardia, pulse of weak filling, pallor of the skin, shortness of breath, dullness of percussion sound on the side of the injury, weakening of breathing on the side of the injury. With a pleural puncture, we obtain blood.

The clinic of cardiac tamponade has a leading role in the diagnosis of heart injury.

The cause of cardiac tamponade is bleeding from the cavities of the heart, bleeding from the coronary vessels and the vessels of the pericardium. The severity of cardiac tamponade depends on the size of the pericardial wound. Clinically, cardiac tamponade is manifested by Beck's triad: 1. A significant decrease in blood pressure in combination with a paradoxical pulse. 2. A sharp increase in central venous pressure. 3. Deafness of heart tones and absence of heart pulsation during fluoroscopy. The condition of the victim is very serious. Sometimes the patient is in clinical death. The skin is pale cyanotic. Swollen neck veins are visible. BP below 60. Percussion borders of the heart are expanded. Heart sounds are muffled or completely absent.

With ECG - signs of damage to the myocardium, pericardium: a decrease in the QRST interval, ST, a negative T wave.

Direct radiographic symptoms of a heart injury include: expansion of the boundaries of the heart, smoothness of the cardiac arches, an increase in the intensity of the shadow of the heart, the disappearance of the heart pulsation, signs of pneumopericardium.

According to the clinical course, 4 groups of victims with heart injuries are distinguished:

1. Victims with a cardiac tamponade clinic. 2. Victims with a clinic of profuse intrapleural bleeding. 3. Victims with a combination of signs of tamponade and bleeding. 4. Absence of symptoms of tamponade and bleeding.

Pericardial puncture is used to detect blood in the pericardial cavity. Pericardial puncture methods:

Diagnostics heart injury is based on the presence of a wound in the projection of the heart and signs of damage to the heart. In most cases, the diagnosis is made only on the basis of examination of the patient. The main task of the surgeon is to establish the diagnosis of a heart injury in a very limited time and to operate on the patient as soon as possible. The success of the treatment of heart injuries depends on:

1. The time elapsed since the injury and the speed of delivery to the hospital. 2. The speed of diagnosis and the timeliness of the operation. 3. Adequacy of resuscitation measures.

When transporting a victim with a suspected heart injury, the ambulance dispatcher is obliged to inform the hospital that this patient is being taken to them. After such a call, the operating sister prepares for a thoracotomy, and the surgeon and resuscitator are waiting for the victim in the emergency room. If there are several surgeons in the team, then one of them is preparing for the operation together with the operating sister. Such actions will be justified even if the SP doctor made a mistake in the diagnosis and the victim does not require urgent surgical intervention.

Without such training, the team will not have enough time to save the victim in a state of clinical death.

When delivering a victim with a suspected heart injury without prior notification to the emergency room: if the diagnosis is confirmed during examination by the surgeon, the victim is immediately sent to the operating room. Resuscitation measures are carried out simultaneously with diagnostic ones, and continue on the operating table.

Any suspicion of injury to the heart is an indication for thoracotomy. This should be the rule of thumb for thoracic trauma surgeons. If the doctor makes a mistake, this tactic will be justified.

The main access is anterolateral thoracotomy in the 4th-5th intercostal space. The pericardium is opened in front of the phrenic nerve, having previously taken it on a holder. Then proceed to the examination of the heart. When bleeding from a wound, it is closed with the finger of the left hand. Heart wounds are sutured with non-absorbable suture material: silk, lavsan, nylon. When suturing the wound of the heart, it is necessary not to damage the coronary vessels. A purse-string suture can be applied to thin-walled atria. To prevent the eruption of myocardial sutures, the following are used: pericardial area, pericardial fat, pectoral muscle area, diaphragm flap. A revision of the posterior wall of the heart is mandatory. For this, the heart is lifted and removed from the pericardial cavity. This may lead to cardiac arrest. If the wound is located near the coronary vessels, it is sutured with U-shaped sutures. Especially sharp
Wounds near the conduction pathways may need to be treated. If during the operation a cardiac arrest occurs, direct massage is performed, defibrillation until its work is restored. At the end of the operation, the pericardial cavity is freed from blood and clots. Rare sutures are applied to the pericardial wound.

The pleural cavity is drained, its revision is carried out. Drainage is installed according to Bulau.

The next postoperative period the patient is in the intensive care unit. In a normal postoperative course, the patient can get up for 3 days. ECG monitoring is constantly carried out. The patient after the operation is carried out together with the therapist or cardiologist. If post-traumatic heart defects are detected, the patient is sent to the cardiosurgical department.

Complications: 1. Pneumonia. 2. Pleurisy 3. Pericarditis. 4. Violations of the heart rhythm. 5. Suppuration of the wound.