World J Surg Surg Res | Volume 4, Issue 1 | Research Article | Open Access

The Chaos of Triage: A Model for Early Exclusion of Cardiac Injury in Chest Gunshot Wound Patients

Chih-Yuan Fu1, Francesco Bajani2, Ghulam H Saadat2*, Matt Kaminsky2, Andrew Dennis2, Fredric Starr2, Thomas Messer2, Stathis Poulakidas2 and Faran Bokhari2

1Chang Gung Memorial Hospital, Chang Gung University, Taiwan
2Department of Trauma and Burns, John H. Stroger Hospital of Cook County, USA

*Correspondance to: Ghulam H Saadat 

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Introduction: Heart injuries caused by thoracic Gunshot Wounds (GSW) are especially life
threatening and require prompt diagnosis and treatment. Heart injury is especially life threatening
and requires prompt diagnosis and treatment. During pre-hospital phase and initial triage in
the Emergency Department (ED), early recognition of a patient with heart GSW is difficult but
important. The purpose of this study was to evaluate the predictability of heart injury in patients
with chest GSWs.
Methods: The National Trauma Data Bank was queried for patients with chest GSW treated at all
US trauma centers from July 01st, 2009 to June 30th, 2016. Patients with and without heart injuries
(ICD-9: 861.00-03, 861.10-13) were compared and analyzed. Multivariate logistic regression was
performed to evaluate independent factors of heart injury which could be obtained during prehospital
or triage phase only. Step-backward selection was used to establish a model for such
patients. We used Receiver Operating Characteristic (ROC) curve to test the accuracy of this model
and Youden’s J statistic to find the cutoff value of sensitivity/specificity. Level 1 trauma registry
data from Stroger Hospital of Cook County (July 01st, 2016 to June 30th, 2017) was used for external
validation of this prediction model.
Results: 47,044 patients with chest GSW were evaluated in the ED and 8.6% of them had heart
injuries. The mortality rates of patients without cardiac injury versus those with cardiac injury were
9.0% (3864/42997) and 21.7% (879/4047) respectively. Patients with heart injuries were significantly
younger (28.4 vs. 29.3, p<0.001), had lower SBP (34.7 vs. 103.8 mmHg, p<0.001), had lower GCS
(5.1 vs. 11.2, p<0.001) and a higher probability of apnea (58.3% vs. 14.7%, p<0.001), higher rate of
pulselessness (59.9% vs. 12.0%, p<0.001), and more self-inflicted injuries (9.7% vs. 8.5%, p<0.001)
than patients without heart injuries. The cutoff values of SBP and GCS for prediction of heart injury
were 61 mmHg (AUC: 0.783) and 5.5 (AUC: 0.768) respectively. Integration of six independent
factors (age, SBP, GCS, apnea, lack of pulse and suicide intent) with multivariate logistic regression
showed an AUC: 0.823 and specificity of 88.8% in the heart injury prediction model. External
validation with the local database showed 95.6% specificity.
Conclusion: Early diagnosis of heart injury is important in the management of patients with chest
GSWs. Our model has high specificity and can be beneficial for early triage of cardiac injury in
patients with GSW to the chest.


Penetrating chest trauma; Cardiac injuries; GSW; Predictors of outcome; NTDB


Fu C-Y, Bajani F, Saadat GH, Kaminsky M, Dennis A, Starr F, et al. The Chaos of Triage: A Model for Early Exclusion of Cardiac Injury in Chest Gunshot Wound Patients. World J Surg Surgical Res. 2021; 4: 1324..

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