TRAUMATIC CARDIAC INJURIES

SHORT CASE STUDY

HENNIE LATEGAN

CASE HISTORY

• 25 YEAR OLD, PENETRATING STAB TO THE CHEST (6th intercostal space, 1.5cm left lateral to sternum)

• BP: 70 systolic• Pulse: poor volume, 65bpm• GCS: 12/15• Ward Hb: 7g/dl• Fluid challenge: 3 litres of lactated ringers plus

500ml of voluven. Poor response to resucitative efforts.

• Heart sounds: muffled

WHAT NOW?

• If at GSH C14: Thoracotomy of course!• Tygerberg Trauma? Argue with the

nurses as to indications, outcome, yes they do it at C14 and yes you are able to possibly do it.

• Victoria Hospital: “Thora…..what? No no no Dr. over here we transfer to GSH C14.”

• GF Jooste: “well the nurse who normally does it is on tea, but I will help you”

General Cardiac Injuries

• Blunt cardiac injuries

• Penetrating cardiac injuries

Blunt Injuries

• Cardiac contusion commonest

• Usually partial thickness injury as rupture is fatal

• High speed deceleration

• Often assoc. with rib fractures, sternal and thoracic spine fractures.

• Clinical Features:– Low BP with Bradycardia– Raised JVP– Arrhythmias, MI type syndrome– Tamponade

• ECG Changes– S-T segment raised or depressed– Q waves in anterior leads– Brady or Tachyarrhythmias

Penetrating Injuries

• Several presentations:– Exsanguinating haemorrhage– Tamponade group– Asymptomatic cardiac injury

Pericardial included in Penetrating

• 1. Unstable cardiac tamponade

• 2. Stable cardiac tamponade

• 3. Asymptomatic/Subclinical pericardial injuries

Commonest cause is a precordial stab.

• Clinical Features– STABLE TAMPONADE

• PERIOD OF HYPOTENSION• REVERSED WITH 500-1000ML OF

CRYSTALLOID• BUT ELEVATED CVP/JVP

• Unstable Cardiac Tamponade– Shock with hypotension and tachycardia– Dyspnoea– Raised venous pressures: JVP/CVP– Pulsus paradoxus

Unreliable: distant heart sounds and impalpable apex.

• Subclinical Pericardial Injuries– Pericardial rub– Pneumopericardium– Raised ST – J waves– Straight left cardiac border– Globular heart

– Note: ECG screening tool– U/S no value, no fluid present

INDICATIONS

• The patient fits into 1 of 3 groups

• 1. Accepted indications

• 2. Relative indications

• 3. Contraindications

• This decision needs to be made very quickly.

• Some of the following slides may help!

Gunshot Chest

Underground Rock Fall

Gunshot Chest

Stab Back

Gunshot neck with cardiac injury

Crush injury

Blunt chest trauma, MVA

Accepted Indications

• PENETRATING– Traumatic arrest with previously witnessed cardiac

activity (pre-hospital or in-hospital)– Unresponsive hypotension ( systolic < 70 )

• BLUNT– Unresponsive hypotension (systolic < 70)– Rapid exsanguination from chest tube (>1500ml)

Relative Indications

• Penetrating thoracic– Traumatic arrest without previously witnessed

cardiac activity.

– Penetrating non-thoracic• Traumatic arrest with previously witnessed

cardiac activity. (pre-hospital or in-hospital)

• Rel. Indications Cont’d.

• Blunt Thoracic Injuries– Traumatic arrest with previously witnessed

cardiac activity. ( pre-hospital or in-hospital)

Contraindications

• Blunt Injuries:– Blunt thoracic with no witnessed cardiac

activity– Multiple blunt trauma– Severe head injury

So did this patient fit the criteria?

• Yes.

• Ultrasound machine was on hand to confirm Dx.

• Cardiac Ultrasound video

What other diagnostic modalities could be used?

• ECG

• Diagnostic pericardiocentesis

• CT

What ECG changes?

• Penetrating– Electrical alternans– J waves( more pericardial injury)

• Blunt– MI changes– Multiple PVC’s– Sinus tachycardia– Atrial fibrilation– Bundle branch blocks

• Previous slide: Electrical alternans

• Next slide: J waves

So we have the criteria, why actually do it?what is the evidence?”

• Survival is btw. 4-33% (protocol dependant)• GSH: 50% survival for penetrating

Blunt trauma: survival rates: 0-2.5%

• Stab wounds: Greater survival than gunshot wounds.

• Isolated thoracic stab wounds causing cardiac tamponade highest survival rate: 70%

Blunt? Should it be done?

• According to literature, YES

• When?– Isolated blunt trauma undergoing arrest in the

A&E

Debate: arresting in the prehospital setting.

Location of the cardiac injury

• Most survivors are of the isolated injury type

• Cardiac highest survival rates

• Great vessels poor

• Pulmonary hila even poorer

Back to the patient

• A supine anterolateral thoracotomy was performed.

• Video of procedure to follow

Briefly the step by step

• If the patient is reasonably stable:– CVP insertion– Intubation/RSI– Peripheral IV– CXR– Chest Drain– Cross match 4 units blood– Ultrasound– Subxiphisternal window to look directly if no US

• Incision: Left anterolateral. 5th intercostal space from the nipple to the ant/mid axillary line.

• Rib retractor to open up• Enter the 5th interspace and open the

pericardial sac longitudinally• Note: anterior to the phrenic nerve• Once open scoop out the clot

• Usually a clinical improvement is evident• Locate the ?hole in the heart• Place a finger in the hole• Either insert foleys catheter with 5mls of saline

or suture close.• Prolene thread• Pledgets of dacron can be used• Avoid coronary vessels when suturing

• Check for through and through wounds

• Tie off internal mammary if it has been cut

• Look for any other injuries

• At GSH the patients if they have survived are taken to theatre for closure of the thoracotomy.

Incision and pericardial splitting

Rib retraction/suturing

Pericardial opening

Pledgets

Cross Clamping

• The patient in the video survived and walk out of the unit 6 days later.

References

• 1.Emergency Department Thoracotomy: Karim Brohi, trauma.org 6:6, June 2001

• 2.Trauma Manaul: UCT 2002 Edition. Editor Peter Bautz3.ATLS Student course manual, 7th Edition4.Atlas of Emergency Medicine, Peter Rosen MD5. Basic surgical skills manual, Royal College of Surgeons, 2007