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Trauma to the Cardiac Box – Is It More Dangerous?

July 10, 2020

Written by Clay Smith

Spoon Feed
Penetrating injury to the cardiac box is more likely to cause cardiac injury and to need surgery than outside the box, but this was driven by stab wounds. Mortality was no different with injuries in the box vs not. FAST exam is probably more important than location of the wound.

Why does this matter?
The cardiac box (a.k.a. “the box”) is a rectangle: superior – sternal notch; inferior – xiphoid process; lateral – nipples. Penetrating trauma in this zone is supposed to indicate when a patient is at higher risk for cardiac injury. But cardiac injury occurs with wounds outside the box quite often. Does it really matter if a penetrating injury is in the box? Is any hole in the thorax bad?

Figure: The cardiac box (wish my pecs were that shimmery…)

Boxy but good
This was a retrospective study of 330 patients with penetrating injuries to the thorax over 6.5 years at a single level 1 trauma center. Of these, 42% were in the cardiac box; 58% were not. When we focus on the 138 patients with injuries in the box, 76% were stab wounds. Patients with injuries to the box had a higher rate of surgery (i.e. thoracotomy or sternotomy) and cardiac injury overall. When broken down by mechanism, there was no increase in cardiac injury for patients with GSW to the box vs not, but there was a marked increase in cardiac injury for stab wounds to the box, 18/138 (13%), vs not, 5/192 (2.6%). Overall, mortality was statistically the same whether penetrating trauma was to the box – 9/138 (6.5%); or not – 6/192 (3.1%), p=0.144. Mortality was higher for GSW to the box, 7/33 (21.2%), vs not, 4/67 (6%), indicating these injuries do more damage whether or not they hit the heart. In summary, getting stabbed or shot in the chest is bad. Getting stabbed or shot in the cardiac box is probably a little worse. The authors emphasize that the FAST exam is probably more important in determining cardiac injury than the location of the hole.

Penetrating Injury to the Cardiac Box.  J Trauma Acute Care Surg. 2020 May 26. doi: 10.1097/TA.0000000000002808. [Epub ahead of print] 

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