Out-of-Hospital Cardiopulmonary Arrest Due to Penetrating Cardiac Injury Treated by Percutaneous Cardiopulmonary Support in the Emergency Room: Report of a Case

Penetrating cardiac injury tends to generally be repaired without cardiopulmonary bypass in the operating room. We herein report the case of penetrating cardiac injury repaired using percutaneous cardiopulmonary support in an emergency room. A 57-year-old man attempted suicide by stabbing himself in the left anterior chest with a knife. Although the patient suffered cardiopulmonary arrest for 7 min in the ambulance, spontaneous circulation was restored following pericardiotomy through emergency left thoracotomy in the emergency room. To prevent coronary artery injury and control the massive bleeding, percutaneous cardiopulmonary support was instituted without systemic heparinization and the cardiac injury was repaired in the emergency room. The patient was then transferred to another hospital on day 46 for further rehabilitation. Percutaneous cardiopulmonary support might be helpful for treating critical patients in an emergency room, even in the case of trauma patients.     

穿透性心脏损伤急诊室剖胸五例穿透性心脏损伤急诊室剖胸五例

目的探讨在急诊室剖胸对危急心脏穿透伤的疗效。方法在急诊室紧急开胸５例，４例濒于死亡，１例已无生命体征；火器伤２例，锐器伤３例；心脏压塞型２例，失血休克型３例。结果全组死亡３例，存活２例（２／５）；火器伤２例均无存活（０／２），锐器伤２例存活（２／３）；压塞型１例存活（１／２），失血休克型１例存活（１／３）。结论急诊室剖胸是救治危急心脏穿透伤的有效手段，濒于死亡的心脏穿透伤特别是锐器伤部分可能获救     

A successfully treated case of blunt traumatic right coronary ostium rupture

Cardiac tamponade due to coronary artery rupture, as a consequence of blunt trauma, is a rare but usually fatal condition. We successfully obtained primary hemostasis with emergency room thoracotomy, followed by delayed definitive treatment of the ruptured right coronary artery ostium in a motor vehicle accident victim with multifocal hemorrhagic lesions. Survival of patients with the described serious trauma has not been reported, and we discuss herein our treatment strategy.     

Emergency department initiation of percutaneous cardiopulmonary support for traumatic cardiac tamponade with coagulated pericardial effusion

Cardiac rupture following blunt trauma is associated with a high mortality rate. We present a rescued case of blunt traumatic cardiac tamponade successfully initiated with percutaneous cardiopulmonary support (PCPS) at the emergency department (ED) without pericardiocentesis.A 27-year-old woman was transferred to our hospital after a motor vehicle accident. She presented with profound shock, and the cardiac portion of the focussed assessment of sonography for trauma (FAST) showed almost coagulated pericardial effusion. We considered that the haemodynamic collapse was caused by cardiac tamponade, and we initiated PCPS in the ED. Subsequently, her systemic perfusion was preserved by PCPS, and she was transferred to the operating room safely. A laceration of the right atrium was successfully repaired. In cardiac tamponade, blood accumulation in the pericardium may be localised and the formation of blood clots may cause difficulty with aspiration. The initiation of PCPS afforded time to surgeons prior to definitive surgical repair and enabled the patient's transfer to the operating room securely.This report demonstrated the case of a rare, but successful outcome of resuscitation of a patient with blunt traumatic cardiac rupture with cardiac tamponade. PCPS is considered as an important treatment option in ED for traumatic cardiac tamponade, particularly if the effusion has clotted.     

National risk factors for blunt cardiac injury: Hemopneumothorax is the strongest predictor

Background

Blunt cardiac injury (BCI) can occur after chest trauma and may be associated with sternal fracture (SF). We hypothesized that injuries demonstrating a higher transmission of force to the thorax, such as thoracic aortic injury (TAI), would have a higher association with BCI.

Pericardial tamponade type injury: A 17-year study in an urban trauma center in Japan

(Received for publication on Apr. 30, 1998; accepted on Mar. 11, 1999)     

心脏大血管损伤并急性心包压塞的外科治疗（附15例报告）

目的心脏大血管损伤并急性心包压塞的救治体会。方法通过对15例心脏大血管损伤并急性心包压塞患者的救治体会,描述抢救过程及方法。结果术中发现右心室贯通伤2例,左心室心肌裂伤5例,右心室心肌刺裂伤5例,主动脉弓穿透破裂1例,纵隔心包内钢钎异物存留1例,单纯心包破裂1例,8例合并有肺裂伤。心肌破裂口在0.3cm～1.5cm13例,2.5cm1例,1例主动脉破裂口约0.6cm。15例中14例治愈出院,1例右心室心脏贯通伤患者死于术中失血性休克。结论对心脏大血管损伤并急性心包压塞的患者,尽早手术探查止血,清除心包内的积血、凝血块、解除心脏压迫,是最有效的抢救手段。     

Identifying the broken heart: predictors of mortality and morbidity in suspected blunt cardiac injury

Background

Blunt cardiac injury (BCI) is an infrequent but potentially fatal finding in thoracic trauma. Its clinical presentation is highly variable and patient characteristics and injury pattern have never been described in trauma patients. The aim of this study was to identify predictors of mortality in BCI patients.

Methods

We performed an 8-year retrospective analysis of all trauma patients diagnosed with BCI at our Level 1 trauma center. Patients older than 18 years, blunt chest trauma, and a suspected diagnosis of BCI were included. BCI was diagnosed based on the presence of electrocardiography (EKG), echocardiography, biochemical cardiac markers, and/or radionuclide imaging studies. Elevated troponin I was defined as more than 2 recordings of greater than or equal to .2. Abnormal EKG findings were defined as the presence of bundle branch block, ST segment, and t-wave abnormalities. Univariate and multivariate regression analyses were performed.

Results

A total of 117 patients with BCI were identified. The mean age was 51 ± 22 years, 65% were male, mean systolic blood pressure was 93 ± 65, and overall mortality rate was 44%. Patients who died were more likely to have a lactate greater than 2.5 (68% vs 31%, P = .02), hypotension (systolic blood pressure < 90) (86% vs 14%, P = .001), and elevated troponin I (86% vs 11%, P = .01). There was no difference in the rib fracture (58% vs 56%, P = .8), sternal fracture (11% vs 21%, P = .2), and abnormal EKG (89% vs 90%, P = .6) findings. Hypotension and lactate greater than 2.5 were the strongest predictors of mortality in BCI.

Conclusions

BCI remains an important diagnostic and management challenge. However, once diagnosed resuscitative therapy focused on correction of hypotension and lactate may prove beneficial. Although the role of troponin in diagnosing BCI remains controversial, elevated troponin may have prognostic significance.     

Imaging in blunt cardiac injury: Computed tomographic findings in cardiac contusion and associated injuries

BackgroundBlunt cardiac injury (BCI) may manifest as cardiac contusion or, more rarely, as pericardial or myocardial rupture. Computed tomography (CT) is performed in the vast majority of blunt trauma patients, but the imaging features of cardiac contusion are not well described.PurposeTo evaluate CT findings and associated injuries in patients with clinically diagnosed BCI.Materials and methodsWe identified 42 patients with blunt cardiac injury from our institution's electronic medical record. Clinical parameters, echocardiography results, and laboratory tests were recorded. Two blinded reviewers analyzed chest CTs performed in these patients for myocardial hypoenhancement and associated injuries.ResultsCT findings of severe thoracic trauma are commonly present in patients with severe BCI; 82% of patients with ECG, cardiac enzyme, and echocardiographic evidence of BCI had abnormalities of the heart or pericardium on CT; 73% had anterior rib fractures, and 64% had pulmonary contusions. Sternal fractures were only seen in 36% of such patients. However, myocardial hypoenhancement on CT is poorly sensitive for those patients with cardiac contusion: 0% of right ventricular contusions and 22% of left ventricular contusions seen on echocardiography were identified on CT.ConclusionCT signs of severe thoracic trauma are frequently present in patients with severe BCI and should be regarded as indirect evidence of potential BCI. Direct CT findings of myocardial contusion, i.e. myocardial hypoenhancement, are poorly sensitive and should not be used as a screening tool. However, some left ventricular contusions can be seen on CT, and these patients could undergo echocardiography or cardiac MRI to evaluate for wall motion abnormalities.     

Emergency thoracotomy as a rescue treatment for trauma patients in Iceland

Objective

Emergency thoracotomy (ET) can be life-saving in highly selected trauma patients, especially after penetrating chest trauma. There is little information on the outcome of ET in European trauma centres. Here we report our experience in Iceland.

Material and methods

This was a retrospective analysis of all patients who underwent ET in Iceland between 2005 and 2010. Patient demographics, mechanism, and location of major injury (LOMI) were registered, together with signs of life (SOL), the need for cardiopulmonary resuscitation (CPR), and transfusions. Based on physiological status from injury at admission, the severity score (ISS), revised trauma score (RTS), and probability of survival (P_S) were calculated.

Results

Of nine ET patients (all males, median age 36 years, range 20–76) there were five long-term survivors. All but one made a good recovery. There were five blunt traumas (3 survivors) and four penetrating injuries (2 survivors). The most frequent LOMI was isolated thoracic injury (n = 6), but three patients had multiple trauma. Thoracotomy was performed in five patients, sternotomy in two, and two underwent both procedures. One patient was operated in the ambulance and the others were operated after arrival. Median ISS and NISS were 29 (range 16–54) and 50 (range 25–75), respectively. Median RTS was 7 (range 0–8) with estimated P_S of 85% (range 1–96%). Median blood loss was 10 L (range 0.9–55). A median of 23 units of packed red blood cells were transfused (range 0–112). For four patients, CPR was required prior to transport; two others required CPR in the emergency room. Three patients never had SOL and all of them died.

Conclusion

ET is used infrequently in Iceland and the number of patients was small. More than half of them survived the procedure. This is especially encouraging considering how severely injured the patients were.     

Activated Prothrombin Complex Concentrate for coagulopathy reversal secondary to ischemic hepatic injury due to cardiac tamponade: A case report

Introduction and importanceCorrection of coagulopathy is needed before invasive procedures. However, there is limited evidence to support using Prothrombin Complex Concentrate (PCC) to reverse coagulopathy secondary to liver disease.Case presentationWe report a case of a 68-year-old male patient a known case of heart failure with preserved ejection fraction, who developed cardiac tamponade, resulting in hemodynamic instability and ischemic liver injury leading to coagulopathy of INR 2.3. Activated PCC (FEIBA) was used to reverse coagulopathy. INR dropped to 1.9 and the procedure was performed uneventfully with successful elimination of tamponade signs evidenced by echocardiography.Clinical discussionIn this case, the patient required an urgent pericardiocentesis. Activated PCC used successfully to reverse coagulopathy, which was important prior to the procedure.ConclusionIn view of the need for urgent pericardiocentesis, coagulopathy due to ischemic liver injury could be reversed with the use of activated PCC.     

Cardiac magnetic resonance imaging in suspected blunt cardiac injury: A prospective,pilot, cohort study

Introduction.The aim of this study was to evaluate the incidence and severity of blunt cardiac injury (BCI) as determined by cardiac magnetic resonance imaging (CMR), and to compare this to currently used diagnostic methods in severely injured patients.Materials and methods.We conducted a prospective, pilot cohort study of 42 major trauma patients from July 2013 to Jan 2015. The cohort underwent CMR within 7 days, enrolling 21 patients with evidence of chest injury and an elevated Troponin I compared to 21 patients without chest injury who acted as controls. Major adverse cardiac events (MACE) including ventricular arrhythmia, unexplained hypotension requiring inotropes, or a requirement for cardiac surgery were recorded.Results.6/21 (28%) patients with chest injuries had abnormal CMR scans, while all 21 control patients had normal scans. CMR abnormalities included myocardial oedema, regional wall motion abnormalities, and myocardial haemorrhage. The left ventricle was the commonest site of injury (5/6), followed by the right ventricle (2/6) and tricuspid valve (1/6). MACE occurred in 5 patients. Sensitivity and specificity values for CMR at predicting MACE were 60% (15–95) and 81% (54–96), which compared favourably with other tests.Conclusion.In this pilot trial, CMR was found to give detailed anatomic information of myocardial injury in patients with suspected BCI, and may have a role in the diagnosis and management of patients with suspected BCI.     

Emergency pericardial drainage without aortic repair for type A intramural haematoma complicated by cardiac tamponade

From April 2011 to March 2020, 87 patients with type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta were treated at Kitasato University Hospital. The initial watch-and-wait strategy without emergency aortic repair was taken in 52 cases in which the maximum aortic diameter was ≤50 mm, pain score on arrival at our hospital was ≤3/10 on the numerical rating scale and there was no ulcer-like projection (ULP) in the ascending aorta. Eleven patients who fulfilled the criteria but developed cardiac tamponade underwent emergency pericardial drainage without aortic repair. Among these 11 patients, 3 patients developed an aortic event during the hospitalization; 1 patient developed enlargement of the ULP 18 days later but refused surgery, another patient developed rupture of the dissected brachiocephalic artery 4 days later and underwent emergency repair of the ascending aorta and the brachiocephalic artery and the other patient developed a new ULP in the ascending aorta 14 days later and underwent aortic repair. All 11 patients were discharged home. During follow-up (3.0 ± 2.4 years), 1 patient developed a recurrent type A acute aortic dissection and underwent emergency aortic repair 29 months later. There was no aorta-related death.     

Benign mediastinal teratoma complicated by cardiac tamponade: Report of a case

(Received for publication on May 13, 1998; accepted on May 27, 1999)     

Pediatric aortoiliac injury following blunt abdominal trauma: A case report

IntroductionThe most common mechanism of aortic injury involves motor vehicle collisions resulting in aortic disruptions, occurring almost exclusively in the chest. Injury to the abdominal aorta following blunt trauma is nearly twenty times less likely to occur than the thoracic aorta. Because of the low incidence, there are few reports regarding the presentation and repair of these particular injuries, especially in the pediatric population.Presentation of caseWe present a case of a 7-year-old boy involved in a high speed motor vehicle accident with an abdominal aorta transection at the aortic bifurcation extending into the left iliac artery. The injury was repaired using bovine pericardium with the adventitia and intima of the vessel approximated over the bovine bridge.DiscussionPrimary repair of thoracic aortic injury has been thoroughly described in the literature with good outcomes yet, abdominal aortic repair remains ambiguous. Few techniques and materials have been described with even less data surrounding the long-term outcomes.ConclusionBovine pericardium is a strong and stable acellular collagenous material with the potential to accelerate endothelialization and tissue regeneration. This remains an interesting field of research as stenosis and pseudo-coarction data have yet to be determined.     

Gauze-based negative pressure wound therapy to infected deep sternotomy wound complicated by cardiac tamponade: a case report

Negative pressure wound therapy is the standard of care for infections after median sternotomy. Foam-based systems are commonly used even in scenarios when the myocardium is exposed. Gauze-based systems have recently gained popularity. We describe a case of deep sternal dehiscence that lead to a life-threatening complication secondary to wound filler choice.     

Iatrogenic paraplegia caused by surgicel used for hemostasis during a thoracotomy: Report of a case

A 46-year-old Japanese woman underwent a right lower lobectomy through a posterolateral incision made in the fifth intercostal space under general and epidural anesthesia on January 23, 1995. During the procedure, oxidized regenerated cellulose (Surgicel) was used to prevent postoperative rebleeding from the dorsal branch of the fifth intercostal artery. The following day it became evident that complete paraplegia had developed below the Th5 level, the cause of which was revealed by an emergency laminectomy, performed within 20 h after the thoractomy, to be the Surgicel treatment. By 50 days after the operation the patient had begun to show improvement, and was able to move her lower extremities against gravity. Her condition is continuing to improve.     

Delayed cardiac tamponade caused by a staple line after wedge resection of the lung

An 80-year-old woman was diagnosed with an adenocarcinoma of the left lower lobe, clinical stage IA3. Taking the patient’s age and medical history into consideration, a wedge resection was performed. After the resumption of rivaroxaban on postoperative Day 3, the patient suddenly developed cardiac tamponade on postoperative Day 5. A drainage tube was placed by pericardiocentesis, and the haemodynamics recovered immediately. No recurrence of cardiac tamponade was observed. The confluence of staple lines is a risk factor for tissue damage. Some covering is recommended, especially when the stapling line contacts the pericardium on the left side.     

Combined fenestrated/chimney thoracic endovascular repair for the treatment of blunt traumatic aortic injury: A case report

Blunt traumatic thoracic aortic injury (BTAI) is an extremely serious medical condition with a high rate ofassociated mortality. Recent advances in techniques such as thoracic endovascular repair offer new opportunities to manage the critical BTAI patients in an efficacious yet less invasive manner. A 65 yearold-male suffered from multiple injuries after a fall, including BTAI in the aortic arch, which resulted in dissection of the descending thoracic-abdominal aorta and iliac artery, development of an intimal flap in the left common carotid artery, and dissection of the left subclavian artery. Based on the imaging information of this patient and our clinical experience, the combined treatment of fenestrated thoracic endovascular repair and a chimney technique was immediately planned to fully repair these dissections and moreover prevent further dissection of the branching vessels, additionally to ensure sufficient blood flow in the left subclavian artery and left common carotid artery. The intervention yielded satisfactory early outcomes. Follow-up assessment at six months reported no symptoms or complications associated with the stent-graft. Computed tomography angiography further confirmed adequate stent-graft coverage of the aortic injury.