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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 225-228

Penetrating cardiac trauma: A plea for a multi-disciplinary team approach


Department of Surgery, Summa Health - Akron City Hospital Akron, Ohio, USA

Date of Submission01-Feb-2016
Date of Acceptance03-Nov-2016
Date of Web Publication28-Dec-2016

Correspondence Address:
Michael S Firstenberg
Department of Surgery, Summa Health Care System - Akron City Hospital, 75 Arch Street, Suite 407, Akron, Ohio 44309
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-5568.196876

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  Abstract 


After head trauma, thoracic trauma is the most common cause of trauma-related death. Although only a fraction of thoracic trauma cases require operative exploration, these have high mortality risk. We advocate a multi-disciplinary approach to these complex patients, with early consideration of formal cardiothoracic surgical involvement. Some argue that many of the most severe penetrating cardiac injuries will not survive to hospital presentation and of those that survive, clearly a multi-disciplinary approach to each patient's unique problem is justified.
The following core competencies are addressed in this article: Patient care, professionalism, interpersonal and communication skills, systems-based practice.

Keywords: Chest trauma, median sternotomy, multidisciplinary trauma, penetrating cardiac injury


How to cite this article:
Vasiliou E, Espinal E, Firstenberg MS. Penetrating cardiac trauma: A plea for a multi-disciplinary team approach. Int J Acad Med 2016;2:225-8

How to cite this URL:
Vasiliou E, Espinal E, Firstenberg MS. Penetrating cardiac trauma: A plea for a multi-disciplinary team approach. Int J Acad Med [serial online] 2016 [cited 2022 Jan 19];2:225-8. Available from: https://www.ijam-web.org/text.asp?2016/2/2/225/196876




  Introduction Top


Chest trauma is the most common cause of trauma-related death after head trauma. Of thoracic trauma, 70–80% are blunt injuries, and most are attributed to motor vehicle crashes.[1] Most cases of chest traumas can be treated with observation alone and when surgical intervention is required, tube thoracostomy is usually sufficient.[2] Penetrating chest injuries are generally caused by gunshot wounds and knife wounds and those involving the heart have a high mortality rate, with fewer than 50% surviving to present to the hospital.[3] According to some studies, only 9–15% of thoracic trauma cases require operative exploration but these account for 20–25% of mortality.[4] Historically, such cases are initially managed with an emergent left thoracotomy performed by a trauma-trained or general surgeon. We advocate a multi-disciplinary approach to optimize the management – including early consideration for formal cardiothoracic surgical involvement with these potentially complex and catastrophic injuries.


  Case Report Top


Our patient is a 53-year-old male who presented to the Emergency Department at approximately 1800 with a 2–3 cm long stab wound to left chest approximately 4 cm lateral to midline in the region of the left nipple. During evaluation in the emergency department he became hypotensive and tachycardic, but remained alert and oriented. A surface thoracic echocardiogram performed in the Emergency Department, as part of a focused assessment with sonography in trauma exam, was suggestive of tamponade and chest X-ray demonstrated a left pleural effusion. Simultaneously, a chest tube was placed emergently in the trauma bay with return of 300–400cc blood. Because of concern for tamponade, it was felt that he would require emergent exploration. Since he was alert and neurologically intact, he was taken promptly to the operating room – as opposed to an emergent thoracotomy for physiologic instability. As this was believed to be a primary cardiac and/or mediastinal great vessel injury, the cardiothoracic surgical team (surgeon, specialty operating staff, and perfusionist) was consulted to assist in the operative management.

Upon arrival to the operating room, he was becoming more lethargic and hypotensive. Simultaneous intubation, central venous and arterial line placement, and patient preparation were performed. A multi-disciplinary discussion between the trauma and cardiothoracic teams in the operating room, decided that given the nature of his injury, a surgical approach via sternotomy would be a better approach to his potential injury than a left lateral thoracotomy. During intubation, the patient deteriorated further and required intravenous bolus administration of vasopressor agents to support his hemodynamics.

A standard median sternotomy was performed [Figure 1], exposing a bulging pericardium that was excised to evacuate a large amount of clotted blood. As the clot was being evacuated there was obvious ongoing bleeding that appeared arterial in nature. The source of the bleeding was found to be a small laceration approximately 0.5 cm lateral to the proximal left anterior descending artery (LAD) at the level of the proximal origin of the pulmonary artery. The laceration was actively pulsating. Using epicardial stabilization techniques (Medtronic, Minneapolis, MN, USA), with careful attention to avoiding injury to the LAD, the ventricular laceration was repaired with several pledgeted sutures [Figure 2]. Once this injury was controlled, a complex exploration of the chest was performed. A through and through injury to the peripheral left upper lobe was found and was wedged out using conventional lung biopsy stapling techniques. A small laceration in the pericardium was also encountered which probably explained the hemothorax – this did not require intervention. Evaluation of the chest wall showed that the left internal mammary artery (IMA) and vein were intact and not injured. As the patient was stabilized and no other injury was found, the entry wound was then copiously irrigated, and the chest was closed in a standard fashion. It was mutually determined that such a complex injury would have been extremely difficult – if not technically impossible– to appropriately identify and safely manage via thoracotomy.
Figure 1: Intraoperative image of median sternotomy incision with head towards bottom of image, feet towards top (with chest tubes) and left para-sternal laceration demonstrated

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Figure 2: Heart gently suspending apex of heart and demonstrating the pledgetted repair (end of forceps) and arrows indicating the vicinity and course of the left anterior descending artery. Head is towards bottom of picture. LAD = Left anterior descending

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Once stabilized in the Intensive Care Unit, a transesophageal echocardiogram was performed to rule out an associated intra-cardiac injury (i.e., valvular injury or intra-cardiac shunt). No other injury was found and his biventricular function was normal. He was extubated within 24 h and the remainder of his hospital course was uneventful. He returned several weeks later with shortness of breath. Imaging demonstrated a loculated left pleural effusion that required a decortication for a retained hemothorax. Echocardiography demonstrated normal cardiac function and he was again discharged home doing well.


  Discussion Top


Penetrating chest trauma is a major cause of morbidity among trauma patients despite the fact that only 20–30% of thoracic trauma is penetrating. The proportion of penetrating chest trauma varies by region, but is generally far less than blunt trauma. Associated injuries are common, and the majority of injuries can be managed nonoperatively. Thoracotomy is required in 3–9% of patients sustaining thoracic trauma and is advocated for those patients who develop witnessed cardiovascular collapse or signs of ongoing bleeding.[5] Of those with penetrating trauma, 14% of stab wounds and 15–20% of gunshot wounds require thoracotomy and there is wide variability in mortality rate, likely due to differences in mechanism, location of injury, and trauma team experience. The ventricles are at highest risk for penetrating cardiac injury and of those who survive to present to the hospital, many require urgent operative repair.[6],[7] Unfortunately, cardiac injuries – particularly if anterior or involving right sided structures or great vessels, management via a thoraocotomy can be extremely difficult to identify and manage especially if advanced cardiothoracic techniques, such as cardiopulmonary bypass, are required. Bilateratal thoracotomies (i.e., “clamshell”) are often performed for injuries despite the significant morbidity associated with such incisions.[8] Although the rationale for a thoracotomy, in part, is to allow for cross-clamping the aorta to limit ongoing hemorrhage and preserve cardio-cerebral perfusion, the extremely poor outcomes and large amounts of resources associated with this intervention question it's appropriateness and validity. Nevertheless, a thoracotomy (left or right, depending on the nature of the injury) might be better suited for pulmonary, descending aortic, or esophageal injuries. A thoracotomy for trauma is also indicated for the release of tamponade and/or the repair of cardiac injuries.[9] However, we advocate that a sternotomy might be a better surgical approach to certain intra-thoracic injuries. Such an incision provides better exposure of the cardiac structures and great vessels and also allows for potential cannulation for cardiopulmonary bypass – an intervention that might be required to help stabilize the circulation, limit blood loss, and facilitate definitive repair. Furthermore, in experienced hands, a formal sternotomy can be performed in a safe and timely manner with minimal incisional related complications. One study investigating this topic demonstrated no survival difference comparing thoracotomy and sternotomy for access – but clearly illustrates that a single approach for all intra-thoracic injuries is less than ideal.[10]

In this case, not only was there a laceration to the left ventricle, complicated by its proximity to the LAD, but also a through and through injury to the left upper lobe of the lung, which was discovered on further exploration. Cases of penetrating thoracic trauma frequently are not isolated injuries, but it is not uncommon for a single wound to affect multiple organs and organ systems, because of the proximity of critical structures within the rigid thorax. It is imperative that a thorough search for additional injuries be completed prior to closure, and that the surgeon considers the high likelihood of associated injuries, and the morbidity of a missed injury. In particular it is essential that an intact IMA be visualized and the chest wall injury addressed so that further bleeding might be mitigated. The need for a thorough thoracic cavity exploration must also be considered when considering the surgical incision and approach.

In addition, another concern is which surgical discipline should be responsible to repair penetrating cardiac traumatic injuries. In our case, a cardiothoracic surgeon was immediately available to perform emergent exploration. At our institution, the cardiac surgical team consists of three full time surgeons board-certified in thoracic surgery. In addition, there are three perfusionists on call 24/7 who cover multiple hospitals in the geographic area, and who manage the cardiopulmonary bypass machines and assist in operative cases (including noncardiothoracic trauma) that require the use of a cell saver. Two specialty trained operative nurses or surgical technologists are also on call 24/7 only to be activated at the request of the cardiothoracic surgeon on call. The team also consist of three specialty trained Registered Nurse First Assistants who also are activated only at the request of the cardiothoracic surgeon. Once activated, those on call are required to be in the operating room within 30 min. All other operating room nursing staff has been “cross-trained” to assist in preparing for and starting cardiothoracic cases. No additional anesthesia staff is required to take call. Currently our program performs approximately 400 cases per year requiring cardiopulmonary bypass or bypass “back-up.“

One single institution study demonstrated that 90% of thoracic trauma cases were managed by a cardiothoracic surgeon. They advocated for early consultation with a cardiothoracic surgeon if available. This study concluded that outcomes were improved with early cardiothoracic consult and attributed this to the wide range in definition of trauma surgery and variable fellowship training.[4] While in theory, cardiothoracic expertise is desirable; unfortunately such expertise is not always available, in part due to busy operative schedules during the day and variable availability for immediate salvage surgical interventions at night. Kim et al. concluded that trauma surgeons could provide adequate care in such cases with outcomes comparable to those of trauma surgeons.[11] However, since a formal cardiac surgery rotation is no longer required by the American College of Surgeons to complete a surgical residency and there is limited experiences with advanced cardiac techniques (including the use of cardiopulmonary bypass), we argue that noncardiac surgeons might be less likely to be able to successfully manage such complex anatomical and physiologic injuries. Although trauma-trained surgeons have historically performed these cases in the past, a decline in operative trauma volumes, particularly operative thoracic trauma, has further limited the experiences of surgical residents and trauma attending surgeon experience with open thoracic surgery. This decline in case volume has been attributed to increasing use of nonoperative trauma management and advancement in radiologic imaging technology and therapeutic options.[11] The shift toward involving the cardiothoracic surgeons in these cases reflects the changing climate of trauma surgery and decrease in thoracic operative experience resulting in trauma fellowship trained surgeons who are less comfortable exploring the chest. In addition, cardiac surgeons have expertise in techniques, such as repairing acquired and congenital cardiovascular (and great vessel) pathology and the use of advanced tools, such as cardiopulmonary bypass, that might be required. Clearly, a balanced and multi-disciplinary Team approach, as with other complex traumatic injuries, is required.[8]


  Conclusions Top


Although the approach does not necessarily confer survival advantage, it is best to tailor the incision and surgical team according to the suspected injury. There is some controversy over whether thoracic injuries requiring surgical intervention are optimally performed by a trauma trained surgeon or a cardiothoracic surgeon. Some argue that many of the most severe penetrating cardiac injuries will not survive to hospital presentation and of those that survive, as with so many other areas of medical therapies, clearly a multi-disciplinary approach to each patient's unique problem is justified.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
LoCicero J 3rd, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am 1989;69:15-9.  Back to cited text no. 1
    
2.
Mattox KL, Wall MJ, Pickard LR. Thoracic trauma. In: Feliciano DV, Moore EE, Mattox KL, editors. Trauma. Stamford, CT: Appleton-Lange; 1996. p. 345.  Back to cited text no. 2
    
3.
Kulshrestha P, Munshi I, Wait R. Profile of chest trauma in a level I trauma center. J Trauma 2004;57:576-81.  Back to cited text no. 3
    
4.
Mollberg NM, Tabachnik D, Farjah F, Lin FJ, Vafa A, Abdelhady K, et al. Utilization of cardiothoracic surgeons for operative penetrating thoracic trauma and its impact on clinical outcomes. Ann Thorac Surg 2013;96:445-50.  Back to cited text no. 4
    
5.
Dubose JA, O'Connor JV, Scalea TM. Lung, trachea, esophagus. In: Mattox KL, Moore EE, Feliciano DV, Editors. Trauma. McGraw-Hill Medical; 2013. p. 25.  Back to cited text no. 5
    
6.
Demetriades D, Velmahos GC. Penetrating injuries of the chest: Indications for operation. Scand J Surg 2002;91:41-5.  Back to cited text no. 6
    
7.
Wall MJ, Tsai P, Mattox K. Heart and thoracic vascular injuries. In: Mattox KL, Moore EE, Feliciano DV, editors. Trauma. McGraw-Hill Medical; 2013. p. 26.  Back to cited text no. 7
    
8.
Seamon MJ, Shiroff AM, Franco M, Stawicki SP, Molina EJ, Gaughan JP, et al. Emergency department thoracotomy for penetrating injuries of the heart and great vessels: An appraisal of 283 consecutive cases from two urban trauma centers. J Trauma 2009;67:1250-7.  Back to cited text no. 8
    
9.
Beşir Y, Gökalp O, Eygi B, İner H, Peker İ, Gökalp G, et al. Choice of incision in penetrating cardiac injuries: Which one must we prefer: Thoracotomy or sternotomy? Turk J Trauma Emerg Surg 2015;21:266-70.  Back to cited text no. 9
    
10.
Bulinski P, Bachulis B, Naylor DF Jr., Kam D, Carey M, Dean RE. The changing face of trauma management and its impact on surgical resident training. J Trauma 2003;54:161-3.  Back to cited text no. 10
    
11.
Kim FJ, Moore EE, Moore FA, Read RA, Burch JM. Trauma surgeons can render definitive surgical care for major thoracic injuries. J Trauma 1994;36:871-5.  Back to cited text no. 11
    


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