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
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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
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–
–
–
–
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:
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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 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