COVID-19 pathways for brain and heart injury in comorbidity patients: A role of medical imaging and artificial intelligence-based COVID severity classification: A review.

Artificial intelligence (AI) has penetrated the field of medicine, particularly the field of radiology. Since its emergence, the highly virulent coronavirus disease 2019 (COVID-19) has infected over 10 million people, leading to over 500,000 deaths as of July 1st, 2020. Since the outbreak began, almost 28,000 articles about COVID-19 have been published (https://pubmed.ncbi.nlm.nih.gov); however, few have explored the role of imaging and artificial intelligence in COVID-19 patients-specifically, those with comorbidities. This paper begins by presenting the four pathways that can lead to heart and brain injuries following a COVID-19 infection. Our survey also offers insights into the role that imaging can play in the treatment of comorbid patients, based on probabilities derived from COVID-19 symptom statistics. Such symptoms include myocardial injury, hypoxia, plaque rupture, arrhythmias, venous thromboembolism, coronary thrombosis, encephalitis, ischemia, inflammation, and lung injury. At its core, this study considers the role of image-based AI, which can be used to characterize the tissues of a COVID-19 patient and classify the severity of their infection. Image-based AI is more important than ever as the pandemic surges and countries worldwide grapple with limited medical resources for detection and diagnosis.

The use of computed tomography for penetrating heart injury screening. / O uso da tomografia computadorizada na triagem da lesão cardíaca penetrante.

OBJECTIVE: to determine if computed tomography represents a safe option for penetrating heart injury screening. METHODS: retrospective transversal study which confronted tomographic findings with the ones detected in surgical exploration in patients that had undergone surgery because of suspected cardiac trauma from January, 2016 to January, 2018. RESULTS: seventy-two cases were analysed; 97.2% of them were males, and the most prevalent age range was 20 to 29 years; 56.9% of them presented injuries caused by firearm shots and 43.1% by cutting weapons. In 20 cases, computed tomography suggested heart injury, confirmed in 13 cases during surgery. Sensitivity of computed tomography was 56.5%, reaching a specificity of 85.7%. CONCLUSION: computed tomography must not be adopted as a routine for the screening of penetrating heart injuries.

OBJETIVO: determinar se a tomografia computadorizada representa uma opção segura para triagem de lesões cardíacas penetrantes. MÉTODOS: estudo transversal retrospectivo, que confrontou os achados tomográficos com os detectados na exploração cirúrgica em pacientes operados por suspeita de trauma cardíaco no período de janeiro de 2016 a janeiro de 2018. RESULTADOS: setenta e dois casos foram analisados; 97,2% eram do sexo masculino e a faixa etária mais prevalente foi de 20 a 29 anos; 56,9% apresentaram ferimentos por projéteis de arma de fogo e 43,1% por arma branca. Em 20 casos, a tomografia computadorizada foi sugestiva de lesão cardíaca, confirmada em 13 casos durante a cirurgia. A sensibilidade da tomografia computadorizada foi de 56,5% e a especificidade de 85,7%. CONCLUSÃO: a tomografia computadorizada não deve ser adotada rotineiramente para triagem de ferimentos cardíacos penetrantes.

Misclassification of Myocardial Injury as Myocardial Infarction: Implications for Assessing Outcomes in Value-Based Programs.

Importance: Similar to other patients with acute myocardial infarction, patients with type 2 myocardial infarction (T2MI) are included in several value-based programs, including the Hospital Readmissions Reduction Program and the Hospital Value-Based Purchasing Program. To our knowledge, whether nonischemic myocardial injury is being misclassified as T2MI is unknown and may have implications for these programs. Objective: To determine whether patients with nonischemic myocardial injury are being miscoded as having T2MI and if this has implications for 30-day readmission and mortality rates. Design, Settings, and Participants: Using the new International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code, we identified patients who were coded as having T2MI between October 2017 and May 2018 at Massachusetts General Hospital. Strict adjudication using the fourth universal definition of MI was then applied. Main outcome and Measures: Clinical adjudication of T2MI and 30-day readmission and mortality rates as a function of T2MI or nonischemic myocardial injury. Results: Of 633 patients, 369 (58.3%) were men and 514 (81.2%) were white. After strict adjudication, 359 (56.7%) had T2MI, 265 (41.9%) had myocardial injury, 6 (0.9%) had type 1 MI, and 3 (0.5%) had unstable angina. Patients with T2MI had a higher prevalence of cardiovascular comorbidities than those with myocardial injury. Patients with T2MI and myocardial injury had high in-hospital mortality rates (10.6% and 8.7%, respectively; P = .50). Of those discharged alive (563 [88.9%]), 30-day readmission rates (22.7% vs 21.1%; P = .68) and mortality rates (4.4% vs 7.4%; P = .14) were comparable among patients with T2MI and myocardial injury. Conclusions and Relevance: A substantial percentage of patients coded as having T2MI actually have myocardial injury. Both conditions have high 30-day readmission and mortality rates. Including patients with high-risk myocardial injury may have substantial implications for value-based programs.

O uso da tomografia computadorizada na triagem da lesão cardíaca penetrante / The use of computed tomography for penetrating heart injury screening

RESUMO Objetivo: determinar se a tomografia computadorizada representa uma opção segura para triagem de lesões cardíacas penetrantes. Métodos: estudo transversal retrospectivo, que confrontou os achados tomográficos com os detectados na exploração cirúrgica em pacientes operados por suspeita de trauma cardíaco no período de janeiro de 2016 a janeiro de 2018. Resultados: setenta e dois casos foram analisados; 97,2% eram do sexo masculino e a faixa etária mais prevalente foi de 20 a 29 anos; 56,9% apresentaram ferimentos por projéteis de arma de fogo e 43,1% por arma branca. Em 20 casos, a tomografia computadorizada foi sugestiva de lesão cardíaca, confirmada em 13 casos durante a cirurgia. A sensibilidade da tomografia computadorizada foi de 56,5% e a especificidade de 85,7%. Conclusão: a tomografia computadorizada não deve ser adotada rotineiramente para triagem de ferimentos cardíacos penetrantes.

ABSTRACT Objective: to determine if computed tomography represents a safe option for penetrating heart injury screening. Methods: retrospective transversal study which confronted tomographic findings with the ones detected in surgical exploration in patients that had undergone surgery because of suspected cardiac trauma from January, 2016 to January, 2018. Results: seventy-two cases were analysed; 97.2% of them were males, and the most prevalent age range was 20 to 29 years; 56.9% of them presented injuries caused by firearm shots and 43.1% by cutting weapons. In 20 cases, computed tomography suggested heart injury, confirmed in 13 cases during surgery. Sensitivity of computed tomography was 56.5%, reaching a specificity of 85.7%. Conclusion: computed tomography must not be adopted as a routine for the screening of penetrating heart injuries.

Fatal cardiac trauma in the city of Manaus, Amazonas state, Brazil. / Trauma cardíaco fatal na cidade de Manaus/AM, Brasil.

OBJECTIVE: to determine the frequency of fatal cardiac trauma in the city of Manaus, Brazil, between November 2015 and October 2016, and to clarify the mechanisms of trauma and death, previous hospital treatment, as well as the injuries associated with cardiac trauma. METHODS: retrospective, observational, and cross-sectional study, which reviewed the necropsy reports of individuals whose cause of death was cardiac injury. RESULTS: the cardiac trauma rate was of 5.98% (138 cases) out of 2,306 necropsies performed in the study period by Instituto Médico Legal (IML) de Manaus (IML is a Brazilian institute responsible for necropsies and cadaveric reports). Males accounted for 92% of the cases. The median age was 27 years (14-83). Gunshot wounds (GSW) was the trauma mechanism in 62.3% and stab wound (SW) in 29.7%. Exsanguination was responsible for most of the deaths and cardiac tamponade was present in second place. On-site death occurred in 86.2% of the cases. The ventricles were the most common site of cardiac injury. Hemothorax was identified in 90.6% of the individuals. Only 23 patients (16.7%) were taken to the hospital (Emergency Room), but six (26.2%) were submitted only to chest drainage, not to thoracotomy. The lung was unilaterally affected in 57% of the cases and bilaterally in 43%. CONCLUSION: fatal cardiac trauma represented an index of 5.98% in the city of Manaus. Most patients die at the scene of the trauma, usually due to exsanguination caused by gunshot wound. About a quarter of patients who reached the hospital and died were not diagnosed with cardiac trauma in time.

OBJETIVO: determinar o índice de trauma cardíaco fatal na cidade de Manaus e esclarecer os mecanismos de trauma e de morte, o tratamento hospitalar prévio, assim como as lesões associadas ao trauma cardíaco. MÉTODOS: estudo retrospectivo, observacional, transversal, que revisou os laudos de necropsias do Instituto Médico Legal de Manaus entre novembro de 2015 e outubro de 2016, cuja causa mortis foi lesão cardíaca. RESULTADOS: o índice de trauma cardíaco foi de 5,98% (138 casos) dentre 2306 necropsias realizadas no período do estudo. Homens foram afetados em 92%. A mediana de idade foi de 27 anos (14 a 83). A arma de fogo foi o mecanismo de trauma em 62,3% e a arma branca em 29,7%. A exsanguinação foi responsável pela maioria das mortes e o tamponamento cardíaco esteve presente em segundo lugar. Óbito no local ocorreu em 86,2%. Os ventrículos foram as câmaras mais lesionadas. O hemotórax foi descrito em 90,6%. Apenas 23 (16,7%) doentes foram removidos até o pronto socorro, porém seis deles (26,2%) não foram submetidos à toracotomia, apenas à drenagem de tórax. O pulmão foi acometido em 57% unilateralmente e 43% bilateralmente. CONCLUSÃO: o trauma cardíaco fatal representou um índice de 5,98% na cidade de Manaus. A maioria dos doentes morre na cena do trauma, geralmente devido à exsanguinação causada por ferimento de arma de fogo. Cerca de um quarto dos pacientes que chegaram ao pronto socorro e morreram, não foram diagnosticados com trauma cardíaco em tempo hábil.

Trauma cardíaco fatal na cidade de Manaus/AM, Brasil / Fatal cardiac trauma in the city of Manaus, Amazonas state, Brazil

RESUMO Objetivo: determinar o índice de trauma cardíaco fatal na cidade de Manaus e esclarecer os mecanismos de trauma e de morte, o tratamento hospitalar prévio, assim como as lesões associadas ao trauma cardíaco. Métodos: estudo retrospectivo, observacional, transversal, que revisou os laudos de necropsias do Instituto Médico Legal de Manaus entre novembro de 2015 e outubro de 2016, cuja causa mortis foi lesão cardíaca. Resultados: o índice de trauma cardíaco foi de 5,98% (138 casos) dentre 2306 necropsias realizadas no período do estudo. Homens foram afetados em 92%. A mediana de idade foi de 27 anos (14 a 83). A arma de fogo foi o mecanismo de trauma em 62,3% e a arma branca em 29,7%. A exsanguinação foi responsável pela maioria das mortes e o tamponamento cardíaco esteve presente em segundo lugar. Óbito no local ocorreu em 86,2%. Os ventrículos foram as câmaras mais lesionadas. O hemotórax foi descrito em 90,6%. Apenas 23 (16,7%) doentes foram removidos até o pronto socorro, porém seis deles (26,2%) não foram submetidos à toracotomia, apenas à drenagem de tórax. O pulmão foi acometido em 57% unilateralmente e 43% bilateralmente. Conclusão: o trauma cardíaco fatal representou um índice de 5,98% na cidade de Manaus. A maioria dos doentes morre na cena do trauma, geralmente devido à exsanguinação causada por ferimento de arma de fogo. Cerca de um quarto dos pacientes que chegaram ao pronto socorro e morreram, não foram diagnosticados com trauma cardíaco em tempo hábil.

ABSTRACT Objective: to determine the frequency of fatal cardiac trauma in the city of Manaus, Brazil, between November 2015 and October 2016, and to clarify the mechanisms of trauma and death, previous hospital treatment, as well as the injuries associated with cardiac trauma. Methods: retrospective, observational, and cross-sectional study, which reviewed the necropsy reports of individuals whose cause of death was cardiac injury. Results: the cardiac trauma rate was of 5.98% (138 cases) out of 2,306 necropsies performed in the study period by Instituto Médico Legal (IML) de Manaus (IML is a Brazilian institute responsible for necropsies and cadaveric reports). Males accounted for 92% of the cases. The median age was 27 years (14-83). Gunshot wounds (GSW) was the trauma mechanism in 62.3% and stab wound (SW) in 29.7%. Exsanguination was responsible for most of the deaths and cardiac tamponade was present in second place. On-site death occurred in 86.2% of the cases. The ventricles were the most common site of cardiac injury. Hemothorax was identified in 90.6% of the individuals. Only 23 patients (16.7%) were taken to the hospital (Emergency Room), but six (26.2%) were submitted only to chest drainage, not to thoracotomy. The lung was unilaterally affected in 57% of the cases and bilaterally in 43%. Conclusion: fatal cardiac trauma represented an index of 5.98% in the city of Manaus. Most patients die at the scene of the trauma, usually due to exsanguination caused by gunshot wound. About a quarter of patients who reached the hospital and died were not diagnosed with cardiac trauma in time.

Annular rupture during transcatheter aortic valve replacement: classification, pathophysiology, diagnostics, treatment approaches, and prevention.

Annular rupture is an umbrella term covering different procedural-related injuries that may occur in the region of the aortic root and the left ventricular outflow tract during transcatheter aortic valve replacement. According to the anatomical location of the injury, there are 4 main types: supra-annular, intra-annular, subannular, and combined rupture. Annular rupture is a rare, unpredictable, and potentially fatal complication. It can be treated successfully if it is immediately recognized and adequately managed. The type of therapy depends on the location of the annular rupture and the nature of the clinical manifestations. Treatment approaches include conventional cardiac procedure, isolated pericardial drainage, and conservative therapy. This summary describes theoretical and practical considerations of the etiology, pathophysiology, classification, natural history, diagnostic and treatment strategies, and prevention approaches of annular rupture.

[Complications after cardiac injuries].

An analysis of 293 victims with cardiac and pericardium injuries was made. Cardiac complications could appear suddenly and be registered on any stage of treatment process. They differentiated by character and duration of wound process. Pericarditis took place in 288 patients. The syndrome of system inflammation reaction was noted in 47.9% of patients, a sepsis (sometimes severe sepsis) was in 14.3%. Complications in postoperative period were determined by posthypoxic and hemic hypoxia, coagulopathy. They were manifested by myocardial ischemia and thromboembolic complications. An acute myocardial infarction took place in 29 (9.8%) cases and rhythm and conductivity abnormalities were in 23 (7.8%) patients. The circulatory failure with clinical picture of pulmonary edema was developed in 12 (4.1%) cases. The lethality consisted of 44 (15%) patients.

Vancouver simplified grading system with computed tomographic angiography for blunt aortic injury.

OBJECTIVE: Delineation of blunt aortic injury by computed tomographic angiography guides management of this potentially fatal injury. Two existing grading systems are problematic to apply and not linked to outcomes. A simplified computed tomographic angiography-based grading system, linked to clinical outcomes, was developed, and feasibility and reliability were evaluated. METHODS: Retrospective review was performed of all blunt aortic injury cases presenting to a single provincial quaternary referral center designated for blunt aortic injury management between 2001 and 2009. Management, associated injuries, hospital survival, and cause of death were determined. Initial computed tomographic angiography was reviewed, and injuries were graded according to the new Vancouver simplified grading system by 2 study authors. Three additional trauma radiologists then graded the aortic injuries with the 2 existing systems and the simplified system. Interrater reliability was determined. RESULTS: Forty-eight patients were identified. Two had minimal aortic injury (grade I), 7 had an intimal flap larger than 1 cm (grade II), 32 had traumatic pseudoaneurysm (grade III), 6 had active contrast extravasation (grade IV), and 1 could not be rated. Survivals were 100%, 90%, and 33% for grades I and II, III, and IV, respectively. Of grade III injuries, 14% were medically managed, 68% repaired endovascularly, and 18% repaired with open surgery. Interrater correlation was best with the simplified score, with only 0.5% of cases unable to be classified. CONCLUSIONS: The Vancouver simplified blunt aortic injury grading system is easy to use and correlates with clinical outcomes. Prospective external validation is required.

Thoracic and neck trauma. Part three.

Previous parts to this series on thoracic and neck trauma discussed the anatomy and physiology of the thorax, assessment and initial nursing interventions, imaging and adjuncts to diagnosis. Part 2 describes specific chest wall and lung injuries, types of pneumothoraces and their diagnosis and management. This section, part 3 of 4, discusses other types of thoracic injuries and their management, such as trauma to the diaphragm and heart.

Classification of myocardial contusion and blunt cardiac trauma.

Myocardial injury caused by blunt chest trauma has been recognized with increased frequency over the past 2 decades. Increased awareness by physicians and the increased use of various clinical and laboratory diagnostic modalities have contributed to this recognition. Injuries range from inconsequential to catastrophic and can affect any or all areas of the heart: pericardium, myocardium, coronary arteries and veins, chordae, papillary muscles, valves, and great vessels. In addition to the medical importance of the diagnosis, substantial forensic implications have been known to arise. It is important to assess and classify properly the extent of the trauma and its prognostication as to the possibility of residual sequelae. A proposed classification is presented that has both medical and legal application. The uses of stages 0 (suspect), I (mild), II (moderate), III (severe), and IV (catastrophic) are illustrated in detail.

Management and outcomes of coronary artery perforation during percutaneous coronary intervention.

Coronary perforation is a particularly feared complication of percutaneous coronary intervention. The optimal management and predictors of adverse outcomes for these patients remain to be defined. Advances in management such as the use of polytetrafluoroethylene-covered stents have not been critically examined in terms of efficacy. We analyzed a cohort of patients who sustained coronary perforation during percutaneous coronary intervention at our institution during a 9-year period to examine the trends in incidence, management, and outcomes. The patient medical records were reviewed, and detailed angiographic analysis was undertaken to identify the predictors of adverse outcomes, including the development of tamponade, the requirement for emergency coronary artery bypass grafting, and in-hospital death. One year of follow-up was attempted for all patients. Seventy-two cases of coronary perforation were identified, with an overall incidence of 0.19%. The perforation grade and presence of chronic renal insufficiency were the only predictors of mortality on multivariate regression analysis. The use of polytetrafluoroethylene-covered stents to manage perforations was not associated with any reduction in adverse outcomes, such as the development of tamponade, the need for emergency coronary artery bypass grafting, or in-hospital death. In conclusion, coronary perforation remains a feared complication in the contemporary interventional era with significant in-hospital mortality. Emphasis should be placed on preventing this complication whenever possible, including exercising particular caution in patients with chronic renal insufficiency. The treatment of such patients should be tailored to the severity of the perforation. The optimal treatment of these patients needs to be defined, and the efficacy of covered stents needs to be studied prospectively.

[Treatment of cardiac stab wounds. A thirty-one-year experience]. / Tratamentul plagilor cardiace înjunghiate. O experienta de 31 ani.

Penetrating cardiac wounds represent a dramatically pathology of the general surgery because of their clinical presentation and outcome. The cardiorrhaphy with the three successive times, carried out with maximum rapidity is the only safe and efficient surgical technique which leads to hemostasis and healing. The aim of this study was to evaluate our results and experience of penetrating cardiac injuries treated at the Clinic of Surgical Emergencies from Iasi. 20 patients, 17 men and 3 women, of mean age 34 years (range 18-51), with stab wounds, underwent cardiorrhaphy between 1974 and 2004. The clinical aspects were: "white injured" (hemorrhagic shock) in 3 patients, "blue injured" (cardiac tamponade) in 8 patients, both being implied with some patients, one of the aspects being predominant. 9 patients (45%) had only cardiac injuries and 11 (55%) had other associated injuries. There were 7 intraoperative cardiac arrests and 2 postoperative pulmonary complications. In 16 cases the outcome of patients with cardiac stab wounds was favourable. We recorded 4 deaths. Mortality results from the wounds of the right auricle. The high rate of survival (80%) proves that a penetrating cardiac injury with a heavy prognosis may be turned into a relative traumatism harmless for those patients who will remain alive until they arrive in hospital.

Use of description logic classification to reason about consequences of penetrating injuries.

The consequences of penetrating injuries can be complex, including abnormal blood flow through the injury channel and functional impairment of organs if arteries supplying them have been severed. Determining the consequences of such injuries can be posed as a classification problem, requiring a priori symbolic knowledge of anatomy. We hypothesize that such symbolic knowledge can be modeled using ontologies, and that the reasoning task can be accomplished using knowl-edge representation in description logics (DL) and automatic classification. We demonstrate the capabilities of automated classification using the Web Ontology Language (OWL) to reason about the consequences of penetrating injuries. We created in OWL a knowledge model of chest and heart anatomy describing the heart structure and the surrounding anatomic compartments, as well as the perfusion of regions of the heart by branches of the coronary arteries. We then used a domain-independent classifier to infer ischemic regions of the heart as well as anatomic spaces containing ectopic blood secondary to the injuries. Our results highlight the advantages of posing reasoning problems as a classification task, and lever-aging the automatic classification capabilities of DL to create intelligent applications.

Blunt cardiac injury.

In summary, the incidence of BCI following blunt thoracic trauma patients has been reported between 20% and 76%, and no gold standard exists to diagnose BCI. Diagnostic tests should be limited to identify those patients who are at risk of developing cardiac complications as a result of BCI. Therapeutic interventions should be directed to treat the complications of BCI. Finally, the prognosis and outcome of BCI patients is encouraging

Correlation of clinical characteristics and outcomes with injury scoring in blunt cardiac trauma.

BACKGROUND: Clinical sequelae from blunt cardiac trauma (BCT) may range from minor electrocardiographic abnormalities to death from free-wall rupture. There are no established clinical characteristics or injury scoring systems that are able to predict survival in these patients. METHODS: A retrospective review of medical records from a Level I trauma center identified 47 patients with BCT. A grade assigned on the basis of the American Association for the Surgery of Trauma Organ Injury Scale (OIS) was assigned to each case studied. Clinical data, including the Injury Severity Score (ISS), and outcomes were analyzed for association with OIS grade. RESULTS: The average ISS was 27.9, and the overall mortality rate was 31.9%. The majority of patients were either grade II or IV, with the latter having the highest mortality. Hypotension at admission, cardiac arrest, lack of vital signs at admission, ISS, hours to diagnosis, and death all had significant association with assigned OIS grade. Factors associated with mortality included ISS; OIS grade; shorter time to diagnosis; cardiac tamponade; cardiac rupture; lack of vital signs at admission; and concomitant injury to either the thoracic aorta or to the liver, spleen, or kidneys. CONCLUSION: The OIS grade, assigned on the basis of anatomic site of injury and electrocardiographic abnormalities, appears to correlate with severity of injury and survival. Although injury scoring should not be used exclusively to guide management in trauma patients, the grading system studied may be useful in predicting outcomes in patients with BCT.

Pericardial tamponade type injury: a 17-year study in an urban trauma center in Japan.

We defined injuries to the heart and the pericardium together with hemopericardium as pericardial tamponade type injury regardless of symptoms or signs due to pericardial tamponade. The aim of the study is to examine the important factors related to the diagnosis and treatment of this type of injury. A retrospective chart review was conducted of traumatized patients admitted with hemopericardium to our institution between 1978 and 1995. Ten out of the 19 consecutive patients with pericardial tamponade type injury demonstrated shock and showed a higher Injury Severity Score and mortality (7/11) than the remaining 9 without shock. The majority of our cases received an emergency room thoracotomy or a surgical fenestration and thereafter some of them needed a (re-)thoracotomy in the operating room. We consider a fenestration through the pericardium to be the first choice for the relief of acute hemopericardium due to trauma, while surgeons should not perform pericardiocentesis for the either diagnosis or relief of this type of injury.

The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study.

BACKGROUND: Ultrasound is quickly becoming part of the trauma surgeon's practice, but its role in the patient with a penetrating truncal injury is not well defined. The purpose of this study was to evaluate the accuracy of emergency ultrasound as it was introduced into five Level I trauma centers for the diagnosis of acute hemopericardium. METHODS: Surgeons or cardiologists (four centers) and technicians (one center) performed pericardial ultrasound examinations on patients with penetrating truncal wounds. By protocol, patients with positive examinations underwent immediate operation. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded. RESULTS: Pericardial ultrasound examinations were performed in 261 patients. There were 225 (86.2%) true-negative, 29 (11.1%) true-positive, 0 false-negative, and 7 (2.7%) false-positive examinations, resulting in sensitivity of 100%, specificity of 96.9%, and accuracy of 97.3%. The mean time from ultrasound to operation was 12.1+/-5 minutes. CONCLUSION: Ultrasound should be the initial modality for the evaluation of patients with penetrating precordial wounds because it is accurate and rapid.