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The Cardiac Box: Penetrating Trauma Bradley J. Phillips, M.D. Burn-Trauma-ICU Adults & Pediatrics “The Cardiac Box” Boundaries Ballistics: Pathophysiology Epidemiology Cardiothoracic trauma accounts for 25% of trauma deaths • Types – Blunt 70% • MVA 70% – Penetrating 30% • Stab wounds 60-70% • GSW 40-30% Chest Trauma - Incidence Blunt Penetrating No. Mortality No. Mortality Diaphragm 16 38% 40 28% Heart 125 12% 15 60% Hemothorax 97 44% 62 26% Pneumothorax 161 25% 45 18% Lungs 129 26% 28 25% Great vessels 15 50% 15 27% MIEMS, 1990 Deadly Dozen • Lethal Six • Hidden Six – Airway obstruction – Tension PTX – Thoracic aortic disrupt – Cardiac tamponade – Open PTX – Blunt cardiac injury – Diaphragmatic tear – Massive hemothorax – Esophageal injury – Flail chest – Pulmonary contusion – Tracheobronchial injury “The Box”: Injuries • • • • Cardiac/pericardium “Great” vessels Esophagus Intrathoracic trachea/main bronchus 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% 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 • 80-100 cc without increase • additional 20-40 cc = double the pressure 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 Diagnostic Tests • • • • • • CVP tracings EKG Echocardiography CT scan Pericardiocentesis Subxiphoid pericardiotomy Echocardiography • Transthoracic (TTE) or transesophageal (TEE) • Problems – availability – experience of technician – false positive/negative: 5-10% Echocardiography Normal Positive 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 Role of Echocardiography Rozycki et al, J Trauma, 1999 Role of Echocardiography • Results – Mean time 12 minutes – Overall • True negatives 225 (86%) • True positives 29 (11%) • False negatives 0 • False positives 7 (3%) – Sonographer • Surgeons: 100% sensitive, 97% specific • Cardiologist: 100% sensitive, 100% specific Rozycki et al, J Trauma, 1999 Role of Echocardiography False Positives Rozycki et al, J Trauma, 1999 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 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 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 = – false-positive = 80% 33% – iatrogenic injury to the heart (frequent R ventricle) – delay in needed operation – blood clotted (1/2 to 2/3 of amount) Pericardiocentesis Pericardial Window • Hemodynamically “stable” • Types – subxphoid – intraperitoneal • Local vs general anesthesia • Diagnostic/therapeutic • Problems – only 18% positive for blood – ? Non intervention = ? outcome Pericardial Window: technique 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 Treatment Cardiac Injury • Incisions – unstable patient • injury on left/midline • injury on right • difficult exposure = = = left thoracotomy right thoracotomy bilateral (“clamshell”) – stable • anterior injury = median sternotomy • Cardiac arrest/hypotension – clamp thoracic aorta • thoracic aorta = 60% of cardiac output • improve coronary/cerebral blood flow Anterior Injury classic approach “quick & easy” Used as an adjunct to modified approaches 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 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) 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 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 Esophagography • Performed in all patients with suspicion • Gastrograffin vs barium • False negative exams – Gastrograffin = up 50% – Barium = < 25% Esophageal Leak Delayed diagnosis of leak found by chest tube EGD • Suspicion and negative esophagogram • Flexible vs rigid – Flexible easier technique – Flexible may miss upper esophageal injuries – ? Concern over esophageal dilation with flexible Indication for EGD Flowers et al, J Trauma, 1996 EGD Sensitivity Esophageal Injury Treatment • • • • NPO/NGT Nutrition Antibiotics Treatment – – – – amount of time between injury and diagnosis amount of local inflammation location of injury preexisting pathology 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 Esophageal Injury • Complications – Sepsis – Fistulas • 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 Penetrating Great Vessel Injury • Incidence – 108/30,000 admissions (Detroit, 1980-1990) – 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 Penetrating Great Vessel Injury • Diagnosis –H&P • type of weapon • trajectory • pulse exam – CXR • hemothorax/PTX • widening of the mediastium • pleural cap Penetrating Great Vessel Injury • Diagnosis – CT scan • False negative 5% • Findings – hematomas adjacent to vessel – pseudoaneurysm – irregularity of vessel – Arteriogram • “Gold Standard” Penetrating Great Vessel Injury • Treatment – Unstable - ED thoracotomy – Stable • most treated with thoracostomy tube/fluid • 9% require thoracotomy • Indications – > 1500 to 2000 cc with 12-24 hrs with bleeding – blood loss 200-300 cc/hr for 4-5 hrs and CXR with persistent effusion despite proper positioned CT ED Thoracotomy Only with Penetrating ! Time is of the essence classic steps… in sequence !! 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” Posterolateral Standard thoracic incision 5th intercostal space “up & around the scapula” Rarely done in major trauma Right Subclavian Also can be extended along the clavicle Remember: proximal & distal control ! Left Subclavian “flap incision” “trapdoor” difficult, timely, associated morbidity 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% Indications for OR Back et al, J Trauama, 1997 Traditional Transmediastinal Work-up Cost of Mediastinal Work-up Grossman et al, J Trauma, 1998 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? The Cardiac Box: Penetrating Trauma any questions ?