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TRAUMATIC CARDIAC INJURIES. SHORT CASE STUDY HENNIE LATEGAN. 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
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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!
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.
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 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