TRAUMATIC CARDIAC INJURIES

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TRAUMATIC CARDIAC INJURIES

• SHORT CASE STUDY
• HENNIE LATEGAN

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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

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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

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General Cardiac Injuries

• Blunt cardiac injuries
• Penetrating cardiac injuries

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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.

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

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

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Penetrating Injuries

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

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Pericardial included in Penetrating

• 1. Unstable cardiac tamponade
• 2. Stable cardiac tamponade
• 3. Asymptomatic/Subclinical pericardial injuries
• Commonest cause is a precordial stab.

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• Clinical Features
• STABLE TAMPONADE
• PERIOD OF HYPOTENSION
• REVERSED WITH 500-1000ML OF CRYSTALLOID
• BUT ELEVATED CVP/JVP

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• Unstable Cardiac Tamponade
• Shock with hypotension and tachycardia
• Dyspnoea
• Raised venous pressures JVP/CVP
• Pulsus paradoxus
• Unreliable distant heart sounds and impalpable
  apex.

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• 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

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INDICATIONS

• The patient fits into 1 of 3 groups
• 1. Accepted indications
• 2. Relative indications
• 3. Contraindications

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• This decision needs to be made very quickly.
• Some of the following slides may help!

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Gunshot Chest
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Underground Rock Fall
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Gunshot Chest
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Stab Back
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Gunshot neck with cardiac injury
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Crush injury
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Blunt chest trauma, MVA
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Accepted Indications

• PENETRATING
• Traumatic arrest with previously witnessed
  cardiac activity (pre-hospital or in-hospital)
• Unresponsive hypotension ( systolic lt 70 )
• BLUNT
• Unresponsive hypotension (systolic lt 70)
• Rapid exsanguination from chest tube (gt1500ml)

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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)

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• Rel. Indications Contd.
• Blunt Thoracic Injuries
• Traumatic arrest with previously witnessed
  cardiac activity. ( pre-hospital or in-hospital)

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Contraindications

• Blunt Injuries
• Blunt thoracic with no witnessed cardiac activity
• Multiple blunt trauma
• Severe head injury

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So did this patient fit the criteria?

• Yes.
• Ultrasound machine was on hand to confirm Dx.
• Cardiac Ultrasound video

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What other diagnostic modalities could be used?

• ECG
• Diagnostic pericardiocentesis
• CT

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What ECG changes?

• Penetrating
• Electrical alternans
• J waves( more pericardial injury)
• Blunt
• MI changes
• Multiple PVCs
• Sinus tachycardia
• Atrial fibrilation
• Bundle branch blocks

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• Previous slide Electrical alternans
• Next slide J waves

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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

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Blunt? Should it be done?

• According to literature, YES
• When?
• Isolated blunt trauma undergoing arrest in the
  AE
• Debate arresting in the prehospital setting.

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Location of the cardiac injury

• Most survivors are of the isolated injury type
• Cardiac highest survival rates
• Great vessels poor
• Pulmonary hila even poorer

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Back to the patient

• A supine anterolateral thoracotomy was performed.
• Video of procedure to follow

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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

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• 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

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• 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

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• 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.

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Incision and pericardial splitting
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Rib retraction/suturing
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Pericardial opening
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Pledgets
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Cross Clamping
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• The patient in the video survived and walk out of
  the unit 6 days later.

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References

• 1.Emergency Department Thoracotomy Karim Brohi,
  trauma.org 66, June 2001
• 2.Trauma Manaul UCT 2002 Edition. Editor
  Peter Bautz
• 3.ATLS Student course manual, 7th Edition
• 4.Atlas of Emergency Medicine, Peter Rosen MD
• 5. Basic surgical skills manual, Royal College
  of Surgeons, 2007