Download Cardiac Box... penetrating trauma

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 ?