Download AAST Organ Injury Scale Cardiac

Operative Management of Penetrating
Cardiac Injuries
Daniel Pust, MD
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Hippocrates stated that all wounds of the heart
were deadly
Ambrose Pare, a French trauma surgeon
described two cardiac injuries from autopsie
studies in 1643
Wolf in 1642 described the first healed cardiac
wound
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Cappelen from Norway repaired the first
cardiac injury, a 2 cm left ventricular laceration
including ligation of a brunch of the LAD in
1895
Farina in Italy repaired a left ventricle in 1896
both patient died
Rehn in Germany repaired successfully a
wound of a right ventricle in 1896
Hill in the US repaired successfully a left
ventricular injury in 1902
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Duval described the median sternotomy
incision in 1907
Spangaro described the left anterolateral
thoracotomy incision in 1907
Beck in 1942 described the technique of placing
mattress sutures under the bed of coronary
arteries
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Griswold recommended that every large
general hospital should have a sterile set of
instruments and an operating room available
24 hours a day
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Beall was the first who described the
emergency room thoracotomy
Mattox et all refined and protocolized ER
thoracotomy and cardiorraphy including the
use of cardiopulmonary bypass
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Mattox et al described the 30 year experience at
Ben Taub hospital in Houston with 539 cardiac
injuries ( 18 / year)
Asensio et al: two series with a total of 165
cardiac injuries in 3 years at LAC
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63 % GSW
36 % SW
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Beck’s triad: muffled heart sounds, jugular
venous distention, hypotension
only seen in 10 % of cases
Patients may present with normal vital signs or
be in shock and not uncommon if full cardiac
arrest
Cardiac tamponade
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Moreno et al reported 100 patients with
penetrating cardiac injuries
77 had pericardial tamponade
The survival rate of patients presenting with
cardiac tamponade was much higher 73 %
versus 11% thereby ascribing tomponade a
protective affect
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However Asensio et al did not show any
protective effect of cardiac tamponade in 105
patients presenting with penetrating cardiac
injury
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Physical examination
May present hemodynamically stable or
unstable or in cardiac arrest
Often associated hemopneumothoraxes
FAST US to evaluate for tamponade
Does not rule out cardiac injury
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Penetrating cardiac injury with cardiac arrest:
ER thoracotomy
Suspected cardiac injury and hemodynamically
unstable immediate transfer to OR for
thoracotomy or sternotomy
Suspected cardiac injury and hemodynamically
stable: OR for pericardial window
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Indication: penetrating thoraxic or abdominal
trauma in cardiac arrest
Cardiac arrest during transport or in trauma
bay
1. control of airway with intubation and
mechanical ventilation
2. left anterolateral thoracotomy
3. simultaneously right side chest tube and
right subclavian introducer line
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1. evacuation of pericardial tamponade
2. control of massive hemorrhage
3. repair of cardiac injuries
4. internal cardiac massage
5. aortic cross clamping
6. prevention of air emboli
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Incision: left anterolateral thoracotomoy
starting at the left sternal boarder, extending
below the nipple line all the way to the
latissimus dorsi muscle
Sharp transection of intercostal muscles and
parital pleura
Placement of Finochietto retractor
Elevation of left lower lunge lobe medially
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Blunt dissection of thoracic aorta just above the
diaphragm
Encircled between the thumb and index finger
Placement of aortic cross clamp
longitudinal opening of the pericardial sac is
made anterior to the phrenic nerve using
Metzenbaum scissors
Evacuation of blood clot
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Immediately note the presence or absence and
type of cardiac rhythm
Location and control of cardiac injuries
Digital control of cardiac injury and
simultaneous suture repair to control further
hemorrhage
Prolene 2-0 or 3-0
Sometimes balloon control using a Foley
catheter, however that may enlarge the injury
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Some use staples for temporary control
Atrial injuries can be controlled temporally by
placement of a Satinsky clamp or Allice clamps
Internal defibrillation with 30-50 J for
ventricular fibrillation
Pharmacologic support
If cardiac rhythm and PB restored transfer to
OR for permanent repairs
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Asensio 2006: 47 / 830
Mattox 1985: 50 / 119
Ivatury 1987: 28 / 91
Tyburski 2000: 12 / 152
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Duval median sternotomy vs Spangaro
anterolateral thoracotomy
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Adjunct Maneuvers:
Total inflow occlusion of the heart:
Complex maneuver
Cross-clamping of SVC and IVC in their
intrapericardial location
Arrest total blood flow to the heart
 Indicated for lateral atrial injuries
 1- 3 minute time
 Cross-clamping of pulmonary hilum
 Indicated for associated pulmonary injuries
with active bleeding within the hilum
Often poorly tolerated by the right ventricle
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Elevation of the heart to reach posterior injuries
Slow elevation by placing multiple laparotmoy
pads
Elevation of the heart leads often to
arrhythmias
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Initially can be often controlled by placement
of a Satinsky clamp ( partial occlusion)
Monofilament suture of 2-0 Polypropylene
on a MH needle
Running or interrupted fashion
Teflon pledges are not recommended for atrial
injuries
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Should be digitally controlled
Horizontal mattress sutures of Halsted
Pledgets or Teflon strips are often needed to
buttress the suture line
2-0 Prolene on MH needle
Injuries close to a coronary vessel is repaired by
using a horizontal mattress of Halsted with the
suture placed underneath the bed of the coronary
vessel to avoid narrowing of the vessel
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Divided into 3 segments:
Proximal, middle, distal
Proximal and middle segment require repair
Often requires cardiopulmonary bypass or at
least stabilization system
distal segments can be ligated
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Grade I:
Blunt cardiac injury with minor ECG
abnormality (nonspecific ST or T wave
changes, premature atrial or ventricular
contraction or persistent sinus tachycardia)
Blunt or penetrating pericardial wound
without cardiac injury, cardiac tamponade or
cardiac herniation
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Grade II:
Blunt cardiac injury with heart block or
ischaemic changes without cardiac failure
Penetrating tangential cardiac wound up to but
not extending through endocardium, without
tamponade
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Grade III
Blunt cardiac injury with sustained or multifocal ventricular
contractions
Blunt or penetrating cardiac injury with septal rupture,
pulmonary or tricuspid incompetence, papillary muscle
dysfunction or distal coronary artery occlusion without
cardiac failure
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Blunt pericardial laceration with cardiac herniation
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Blunt cardiac injury with cardiac failure
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Penetrating tangential myocardial wound up to but not
through endocardium, with tamponade
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Grade IV:
Blunt or penetrating cardiac injury with septal
rupture, pulmonary or tricuspid incompetence,
papillary muscle dysfunction or distal coronary
artery occlusion producing cardiac failure
Blunt or penetrating cardiac injury with aortic or
mitral incompetence
Blunt or penetrating cardiac injury of the right
ventricle, right or left atrium
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Grade V:
Blunt or penetrating cardiac injury with
proximal coronary artery occlusion
Blunt or penetrating left ventricular perforation
Stellate injuries <50% tissue loss of the right
ventricle, right or left atrium
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Grade VI:
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Blunt avulsion of the heart
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Penetrating would producing >50% tissue loss
of a chamber
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Asensio et al showed correlation between
AAST-OIS with mortality rate:
Grade IV: 56 %
Grade V: 76%
Grade VI: 91%