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The Cardiac Box: Penetrating Trauma

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Presentation on theme: "The Cardiac Box: Penetrating Trauma"— Presentation transcript:

1 The Cardiac Box: Penetrating Trauma
Bradley J. Phillips, M.D. Burn-Trauma-ICU Adults & Pediatrics

2 “The Cardiac Box” Boundaries

3 Ballistics: Pathophysiology

4 Cardiothoracic trauma accounts for
Epidemiology Cardiothoracic trauma accounts for 25% of trauma deaths Types Blunt 70% MVA 70% Penetrating 30% Stab wounds 60-70% GSW 40-30%

5 Chest Trauma - Incidence
Blunt Penetrating No. Mortality No. Mortality Diaphragm % % Heart % % Hemothorax % % Pneumothorax % % Lungs % % Great vessels % % MIEMS, 1990

6 Deadly Dozen Lethal Six Hidden Six Thoracic aortic disrupt
Airway obstruction Tension PTX Cardiac tamponade Open PTX Massive hemothorax Flail chest Hidden Six Thoracic aortic disrupt Tracheobronchial injury Blunt cardiac injury Diaphragmatic tear Esophageal injury Pulmonary contusion

7 “The Box”: Injuries Cardiac/pericardium “Great” vessels Esophagus
Intrathoracic trachea/main bronchus

8 Penetrating Cardiac Injury
Death (bleeding and/or tamponade) All penetrating cardiac injury = 81% GSW quicker death Reach hospital In “extremis” 1/3 can be saved successful ED thoracotomy if < 5 mins of arrest OR (signs of life/recordable BP) survival rates GSW = 70% survival rats SW = 85%

9 Cardiac Injury: Pathophysiology
Pericardial Tamponade Survive 15 to 30 mins after injury = small injury “double-edged sword” prolonged life by reducing blood loss fatal by interfering with venous return/diastolic filling Increases the likelihood of successful ED thoracotomy Intrapericardial pressure cc without increase additional cc = double the pressure

10 Diagnosis Physical exam Beck’s triad
distended neck veins, hypotension, muffled heart tones not sensitive or specific false + or - in 1/3 of cases neck vein distension requires partial fluid resuscitation rapid fluid resuscitation = improvement in vital signs other etiologies tension PTX, cardiac failure, mediastinal hematoma Kussmaul signs increased neck vein distension during inspiration pulsus paradoxus

11 Diagnostic Tests CVP tracings EKG Echocardiography CT scan
Pericardiocentesis Subxiphoid pericardiotomy

12 Echocardiography Transthoracic (TTE) or transesophageal (TEE) Problems
availability experience of technician false positive/negative: 5-10%

13 Echocardiography Normal Positive

14 Role of Echocardiography
Rozycki et al, J Trauma, 1999 (Grady) Accurate for acute hemopericardium Sonographer Surgeon (course trained) or cardiology (4 centers) Technicians ( 1 center) Patients = 261 Positive exam = immediate operation

15 Role of Echocardiography
Rozycki et al, J Trauma, 1999

16 Role of Echocardiography
Results Mean time 12 minutes Overall True negatives 225 (86%) True positives (11%) False negatives 0 False positives (3%) Sonographer Surgeons: 100% sensitive, 97% specific Cardiologist: 100% sensitive, 100% specific Rozycki et al, J Trauma, 1999

17 Role of Echocardiography
False Positives Rozycki et al, J Trauma, 1999

18 Role of Echocardiography
Potential deficiencies no prospectively randomized to U/S vs window not a consecutive sample not all patients received follow-up after d/c Lessons immediate availability of U/S learning curve of technique ? role of repeat echo not as effective in massive PTX/hemothorax/obesity

19 CT scan ? Role to r/o pericardial fluid Mediastinal trajectory
may avoid unnecessary tests requires hemodynamically stable patient Grossman et al, J Trauma, 1998 (U Penn) Retrospective study (6 years) Thoracic CT 15 patients 9/15 excluded transmediastinal trajectory 6/15 additional studies performed (2 required OR) no complications in CT excluded group

20 Pericardiocentesis Used more in “medical-tamponade”
Removal of 5-10 cc =CO by 25-50% Problems not sensitive or specific Demetriades, Ann Surg, 1985 false-negative = 80% false-positive = 33% iatrogenic injury to the heart (frequent R ventricle) delay in needed operation blood clotted (1/2 to 2/3 of amount)

21 Pericardiocentesis

22 Pericardial Window Hemodynamically “stable” Types
subxphoid intraperitoneal Local vs general anesthesia Diagnostic/therapeutic Problems only 18% positive for blood ? Non intervention = ? outcome

23 Pericardial Window: technique

24 Treatment Cardiac Injury
Aggressive fluid adminstration +/- Pericardiocentesis +/- Pericardial window ED thoracotomy (penetrating) have OR staff and surgeon rapidly available unable to make to the OR clinically dead on arrival signs of life in transit or within 5 minutes of arrival deteriorating status and no obtainable blood pressure survival 33% if above true

25 Treatment Cardiac Injury
Incisions unstable patient injury on left/midline = left thoracotomy injury on right = right thoracotomy difficult exposure = bilateral (“clamshell”) stable anterior injury = median sternotomy Cardiac arrest/hypotension clamp thoracic aorta thoracic aorta = 60% of cardiac output improve coronary/cerebral blood flow

26 Used as an adjunct to modified approaches
Anterior Injury classic approach “quick & easy” Used as an adjunct to modified approaches

27 Treatment Cardiac Injury
Cardiac wounds controlled with finger or foley atrial control with clamp (Satinsky) suture wound atrial 3-0 prolene ventricle 2-0 silk/prolene pledgetted horizontal mattress beneath near major coronary avoid unnecessarily wide/multiple sutures near coronary

28 Special Cardiac Injuries
Coronary artery LAD most commonly injured Ligation of small coronary vessels Proximal coronary injury ligation if no cardiac dysfunction primary/bypass if cardiac dysfunction/arrhythmia Interventricular defects (3-4%, delay repair) Valves (delay repair) Ventricular aneurysms (left ventricle)

29 Intrathoracic Esophageal Injury
Incidence infrequent (major centers 1-2/yr) too deep for SW rapidly fatal from cardiac/aortic injury 3/200 ED thoracotomies (Washington et al, Ann Thorac Surg, 1985) High morbidity/mortality if missed/delayed Mediastinitis Timing of definitive repair 0-12 hours: 5-25% mortality 12-24 hours: 10-44% mortality > 24 hours: 25-66% mortality

30 Penetrating Esophageal Injury
Diagnosis PE (not sensitive or specific) Bloody emesis SQ air isolated to neck Hamman’s sign CXR mediastinal emphysema pleural effusion CT scan localized fluid collection /air

31 Esophagography Performed in all patients with suspicion
Gastrograffin vs barium False negative exams Gastrograffin = up 50% Barium = < 25%

32 Delayed diagnosis of leak found by chest tube
Esophageal Leak Delayed diagnosis of leak found by chest tube

33 EGD Suspicion and negative esophagogram Flexible vs rigid
Flexible easier technique Flexible may miss upper esophageal injuries ? Concern over esophageal dilation with flexible

34 Indication for EGD Flowers et al, J Trauma, 1996

35 EGD Sensitivity

36 Esophageal Injury Treatment
NPO/NGT Nutrition Antibiotics Treatment amount of time between injury and diagnosis amount of local inflammation location of injury preexisting pathology

37 Operative Repair - Esophagus
General dictums debride back to healthy tissue mucosal injury longer than muscular injury interrupted absorbable suture inner and outer buttressedwith adjacent viable tissue drainage of chest/mediastium drainage of stomach insertion of JT

38 Esophageal Injury Complications Sepsis Fistulas Strictures Chyle leak
neck - usually heal 2-3 weeks chest - sepsis and death if uncontrolled trachea dx by esophagogram close or bypass as soon as diagnosed Strictures Chyle leak

39 Penetrating Great Vessel Injury
Incidence 108/30,000 admissions (Detroit, ) Arrival to hospital = temporarily occluded bleeding site 48 successful repairs (Symgas and Sehdeva, Ann Surg, 1970) 14 fistulous communication with the heart 9 innominate vein 8 pulmonary vessel 17 intrapericardial aorta or small wound to the lower descending aorta

40 Penetrating Great Vessel Injury
Diagnosis H & P type of weapon trajectory pulse exam CXR hemothorax/PTX widening of the mediastium pleural cap

41 Penetrating Great Vessel Injury
Diagnosis CT scan False negative 5% Findings hematomas adjacent to vessel pseudoaneurysm irregularity of vessel Arteriogram “Gold Standard”

42 Penetrating Great Vessel Injury
Treatment Unstable - ED thoracotomy Stable most treated with thoracostomy tube/fluid 9% require thoracotomy Indications > 1500 to 2000 cc with hrs with bleeding blood loss cc/hr for 4-5 hrs and CXR with persistent effusion despite proper positioned CT

43 classic steps… in sequence !!
ED Thoracotomy Only with Penetrating ! Time is of the essence classic steps… in sequence !!

44 Penetrating Mediastinal Tracheal Injury
Incisions anterior lateral thoracotomy severe shock posterior lateral thoracotomy excellent exposure to hemithorax median sternotomy +/- extension (neck/chest) thoracic inlet innominate artery proximal carotid/subclavian arteries bilateral “clamshell”

45 Posterolateral Standard thoracic incision 5th intercostal space
“up & around the scapula” Rarely done in major trauma

46 Right Subclavian Also can be extended along the clavicle
Remember: proximal & distal control !

47 difficult, timely, associated morbidity
Left Subclavian “flap incision” “trapdoor” difficult, timely, associated morbidity

48 Mediastinal Tracheal Injury
Incidence Rare Bertelsen and Howitz, Thorax, 1972 9/1,178 only 5/9 involved intrathoracic trachea Kelly et al, Ann Thoracic Surg, 1985 100 penetrating tracheal injuries 13/100 involved intrathoracic trachea mortality neck = 14% thorax = 54%

49 Indications for OR Back et al, J Trauama, 1997

50 Traditional Transmediastinal Work-up

51 Cost of Mediastinal Work-up
Grossman et al, J Trauma, 1998

52 Challenges to Traditional Dogma
Role of echocardiography Is TTE as good as TEE? Can it be used with confidence to rule out cardiac and aortic injury? Liberal use of CT scan for trajectory Is it appropriate to use CT scan to eliminate further tests and procedures? Role of EGD Is esophagogram the only test needed to rule out esophageal injury?

53 The Cardiac Box: Penetrating Trauma any questions ?

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