title: Thinking outside the box: re-evaluating the approach to penetrating cardiac injuries.
abstract: BACKGROUND
  Penetrating cardiac injuries are infrequent but highly lethal. To address these injuries, cardiopulmonary bypass and cardiothoracic surgery availability are required for Level I trauma center verification. However, acute care surgeons are more readily available for this time-sensitive injury. The purpose of this study was to review an acute care surgery-based experience with penetrating cardiac trauma at an urban Level 1 trauma center. Our hypothesis was that care provided solely by acute care surgeons was both safe and effective for this patient population.
  
  
  METHODS
  All patients with injuries to the 'cardiac box' following penetrating thoracic trauma were identified from 2005-2010. Demographic and injury related data were obtained. The types and location of cardiac injury, as well as patient outcomes, were determined from operative reports.
  
  
  RESULTS
  1701 patients with penetrating chest trauma were admitted during the study period. 260 patients were identified as having high-risk injuries and were included in the review. 37 patients underwent resuscitative thoracotomy, with a survival rate of 8 %. 76 patients (29 %) suffered a cardiac injury. 72 % of these patients had a preoperative FAST exam, which had a sensitivity and specificity of 56.5 and 82.5 % respectively. 82 % underwent a pericardial window, which had a positive predictive value of 81.4 %. 61 % (n = 46) of the patients with a cardiac injury survived, while the overall death rate in this cohort was 21 %. No patients in the cohort required cardiopulmonary bypass for emergent repair of cardiac injury and acute care surgeons performed all cases.
  
  
  CONCLUSIONS
  Penetrating injury to the heart is highly lethal and time-sensitive. Increasingly, FAST and subxyphoid pericardial window are relied upon to make the diagnosis in patients arriving in varying stages of shock to the resuscitation room. Acute care surgeons are the most appropriate surgeons to care for these injuries and provide safe and effective care.
authors.affiliation: University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: E W
authors.initials: EW
authors.lastname: Stranch
authors.affiliation: Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: B L
authors.initials: BL
authors.lastname: Zarzaur
authors.affiliation: Indiana University School of Medicine, Indianapolis, IN, USA. stasava@iupui.edu.
authors.forename: S A
authors.initials: SA
authors.lastname: Savage
mesh_terms: D000328:Adult; D004636:Emergency Service, Hospital; D005260:Female; D006335:Heart Injuries / Q000175:diagnosis* / Q000401:mortality / Q000601:surgery; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D010808:Physical Examination; D012680:Sensitivity and Specificity; D016019:Survival Analysis; D013714:Tennessee; D014950:Wounds, Penetrating / Q000175:diagnosis* / Q000401:mortality / Q000601:surgery; D055815:Young Adult
keywords: Acute care surgery; Cardiac injury; Cardiopulmonary bypass; Penetrating thoracic trauma