1. TRAUMATIC CARDIAC INJURIES SHORT CASE STUDY HENNIE LATEGAN

3. CASE HISTORY 25 YEAR OLD, PENETRATING STAB TO THE CHEST (6 th 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

4. 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”

5. General Cardiac Injuries Blunt cardiac injuries Penetrating cardiac injuries

6. 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.

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

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

9. Penetrating Injuries Several presentations: –Exsanguinating haemorrhage –Tamponade group –Asymptomatic cardiac injury

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

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

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

13. 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

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

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

16. Gunshot Chest

17. Underground Rock Fall

18. Gunshot Chest

19. Stab Back

22. Gunshot neck with cardiac injury

23. Crush injury

24. Blunt chest trauma, MVA

25. 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)

26. 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)

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

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

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

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

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

34. Previous slide: Electrical alternans Next slide: J waves

36. 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%

37. 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.

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

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

40. 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

41. Incision: Left anterolateral. 5 th intercostal space from the nipple to the ant/mid axillary line. Rib retractor to open up Enter the 5 th interspace and open the pericardial sac longitudinally Note: anterior to the phrenic nerve Once open scoop out the clot

42. 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

43. 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.

44. Incision and pericardial splitting

45. Rib retraction/suturing

46. Pericardial opening

47. Pledgets

48. Cross Clamping

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

50. 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, 7 th Edition 4.Atlas of Emergency Medicine, Peter Rosen MD 5. Basic surgical skills manual, Royal College of Surgeons, 2007