The role of sternotomy and world war two in the treatment of
cardiac wound
All these pioneers entered the chest through an intercostal approach,
with or without rib resection. Herbert Nelson Milton was a british
medical officer at the Kasr El Aini Hospital in Cairo and had to operate
on many patients requiring emergent thoracic surgery. In 1897 he
reported a direct approach to the mediastinum as an “anterior median
thoracic incision” that is in fact a median sternotomy [8]. He
declared: “So easy is this incision of execution and so considerable is
the power of exploration thereby obtained that one is almost induced to
hope that future experience may justify the application to it of the
term normal thoracic incision”. This approach is nowadays the gold
standard for cardiac surgeons not only for cardiopulmonary bypass
surgery but also to safely and quickly manage a cardiac stab wound.
Medical and surgical knowledge particularly have always benefited from
wars and World War II was an opportunity to observed shell fragments and
other missiles in human hearts. Blalock and Ravith published in 1943 the
use of pericardiocentesis to deal with cardiac wounds in soldiers but it
is truly Dwight Harken who revolutionized this dreadful management
[9]. Harken was called to duty as a consultant thoracic surgeon and
he reported in 1946 an impressive experience that clearly inspired
surgeons regarding the development of cardiac surgery [10]. Indeed,
over a 10 months period, Harken removed 78 missiles that were within or
in proximity to the great vessels; he extracted 56 foreign bodies from
the heart, 13 of them from the cardiac cavities! He operated on 134
patients with chest and cardiac wounds without a single death. One
should keep in mind that cardiopulmonary bypass did not exist at that
time and Harken’s work helped to change the field of cardiac surgery.
Since World War II many improvements in the management of penetrating
cardiac injuries have been reported which include the use of
echocardiography, emergency department thoracotomy, pericardial
drainage, fluid management and use of vasoactive drugs for restoration
of blood pressure. Despite these evident improvements, the outcome of a
penetrating cardiac injury remains poor even in western countries urban
trauma centers…