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