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TRAUMATIC CARDIAC INJURIES

This case study explores the management of a 25-year-old male who suffered a penetrating stab wound to the chest, resulting in significant trauma and hemodynamic instability. Initial vital signs showed systolic blood pressure of 70 mmHg and a pulse of 65 bpm, with a Glasgow Coma Scale of 12/15. Despite resuscitative efforts, including fluid challenges, the patient demonstrated poor response, necessitating urgent intervention. The complexities of initiating appropriate surgical procedures, such as thoracotomy, at various medical facilities and the clinical indicators for intervention in traumatic cardiac injuries are discussed.

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TRAUMATIC CARDIAC INJURIES

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  1. TRAUMATIC CARDIAC INJURIES SHORT CASE STUDY HENNIE LATEGAN

  2. 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

  3. 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”

  4. General Cardiac Injuries • Blunt cardiac injuries • Penetrating cardiac injuries

  5. 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.

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

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

  8. Penetrating Injuries • Several presentations: • Exsanguinating haemorrhage • Tamponade group • Asymptomatic cardiac injury

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

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

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

  12. 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

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

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

  15. Gunshot Chest

  16. Underground Rock Fall

  17. Gunshot Chest

  18. Stab Back

  19. Gunshot neck with cardiac injury

  20. Crush injury

  21. Blunt chest trauma, MVA

  22. 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)

  23. 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)

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

  25. Contraindications • Blunt Injuries: • Blunt thoracic with no witnessed cardiac activity • Multiple blunt trauma • Severe head injury

  26. So did this patient fit the criteria? • Yes. • Ultrasound machine was on hand to confirm Dx. • Cardiac Ultrasound video

  27. What other diagnostic modalities could be used? • ECG • Diagnostic pericardiocentesis • CT

  28. What ECG changes? • Penetrating • Electrical alternans • J waves( more pericardial injury) • Blunt • MI changes • Multiple PVC’s • Sinus tachycardia • Atrial fibrilation • Bundle branch blocks

  29. Previous slide: Electrical alternans • Next slide: J waves

  30. 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%

  31. 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.

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

  33. Back to the patient • A supine anterolateral thoracotomy was performed. • Video of procedure to follow

  34. 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

  35. 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

  36. 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

  37. 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.

  38. Incision and pericardial splitting

  39. Rib retraction/suturing

  40. Pericardial opening

  41. Pledgets

  42. Cross Clamping

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

  44. References • 1.Emergency Department Thoracotomy: Karim Brohi, trauma.org 6:6, 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

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