The Journal of Emergency Med!c/ne, Vol 10, pp 31-33, 1992
COMPLETE
RECOVERY
James L. McCabe, *University
MD,*
Printed In the USA. CopyrIght 0 1992 Pergamon Press plc
FOLLOWING
Kathleen J. Grant,
MD,+
AN UNUSUAL CARDIAC STAB WOUND William Birsic,
MD,+
and Ronald V. Pelligrini,
MD+
Affiliated Residency in Emergency Medicine, +Department of Cardiothoracic and Vascular Surgery, The Mercy Hospital of Pittsburgh, Pennsylvania James L. McCabe, MD, Department of Emergency Medicine, Our Lady of Lourdes Hospital, 1600 Haddon Ave, Camden, NJ 08103
of Pittsburgh
Reprint address:
0 Abstract - A 17-year-old female was stabbed in the chest and found by paramedics in extremis. She arrived at the receiving hospital with spontaneous respirations and an improved blood pressure. Upon thoracotomy in the operating room, lacerations through the main pulmonary artery and the left atrium were found. The combined efforts of a sophisticated EMS system providing rapid in-field stabilization and transport, a ready in-house trauma team able to quickly assess and provide definitive care, and a prepared operating room team, including cardiopulmonary bypass capability, resulted in a complete and uncomplicated recovery from this rare and lethal injury.
management of acutely injured patients has been the development of quality paramedic training programs such as Basic Trauma Life Support (BTLS) and Prehospital Trauma Life Support (PHTLS) (24). Although up to 80% of patients with penetrating cardiac trauma die before reaching the hospital, nearly 90% of those arriving at an appropriate center with signs of life will survive (5,6). We report the successful resuscitation and definitive surgical treatment of a patient with an unusual cardiac stab wound to illustrate technological advances made from the activation of an emergency medical services (EMS) system to intraoperative management.
0 Keywords - cardiac trauma; chest trauma; stab wound; trauma center; cardiopulmonary bypass CASE REPORT INTRODUCTION
A 17-year-old female was stabbed with a long kitchen knife just above the left breast and in the right flank. City paramedics, on scene in 7 minutes, found the patient unconscious, with agonal respirations and a faint carotid pulse at a rate of 140. A peripheral blood pressure was unobtainable. She was immediately ventilated with high flow oxygen through a bag-valve-mask. A pneumatic antishock garment (PASG) was applied and all chambers inflated. Simultaneously, a large bore intravenous (IV) catheter was placed. Prior to transport a brief attempt at endotracheal intubation was unsuccessful, during which time the patient awoke and became combative. On scene time was 10 minutes. A second large bore IV was placed en route and 2 liters of lactated Ringer’s solution were infused. Within 25 minutes of EMS base station notification, the patient arrived
The incidence of penetrating trauma in urban areas continues to increase (1). The establishment of specialized trauma centers, able to manage immediately lifethreatening injuries, highly trained prehospital personnel equipped with advanced life support and communication technology, and the transition from conservative pericardiocentesis as the initial primary treatment to early thoracotomy have improved outcome in these patients. In addition to the development of the “trauma team,” one of the most important advances in the
Presented at the Pittsburgh Thoracic Surgery Society meeting, October 4, 1989.
RECEIVED:20 November ACCEPTED: 15 July 199 1
19901 FINAL SUBMISSIONRECEIVED:2 July 1991;
31
0736-4679192
$5.00 + .OO
32
J. L. McCabe,
K. J. Grant, W. Birsic, R. V. Pelligrini
Figure 1. Supine chest x-ray study of patient with cardiac stab wound. Notice bulging of the upper lefl aspect of the cardiac silhouette due to a large lntraperlcardlal hematoma.
at the local trauma center awake, breathing spontaneously with a blood pressure of 82/40 torr. In the emergency department (ED), she remained awake with adequate respirations and was noted to have a deep laceration in the left second intercostal space at the rnidclavicular line, a similar laceration in the right flank, and distended neck veins. Lung sounds were clear bilaterally, and there was adequate air movement. Oxygen was administered, and after administration of a third liter of normal saline there was no change in blood pressure. Two units of 0 negative packed red cells blood were infused under pressure. A portable chest x-ray study done in the ED revealed a left pleural effusion and enlargement of the left upper cardiac border (Figure 1). She was transported to the operating room within 8 minutes of arrival in the ED with a stable airway and a blood pressure of 96160. In the operating room, following rapid induction of general anesthesia and bladder catheterization, a median sternotomy was performed. The time from arrival in the ED to sternotomy was 18 minutes. A tense hemopericardium was released with marked hemodynamic improvement. A 2-cm laceration of the main pulmonary artery was controlled and closed. Next, a large clot overlying the left atria1 appendage was removed, resulting in free bleeding of both saturated and unsaturated blood. Careful inspection revealed lacerations through the front and back walls of the left atrium, and a posterior pulmonary artery laceration that was 2 mm from the left main coronary artery. It was then decided
Figure 2. Diagram of an unusual cardiac stab wound.
that repair of these lacerations required placing the patient on cardiopulmonary bypass (CPB). While CPB was being set up, a laparotomy was performed that revealed the absence of intraperitoneal blood. Urinalysis was negative. Once on bypass, the left atria1 wounds were closed. The left main coronary artery was carefully mobilized off the base of the posterior pulmonary artery, which was then closed without difficulty (Figure 2). The patient was awake and extubated on the first postoperative day, and was discharged one week later after an unremarkable hospital course.
DISCUSSION The majority of penetrating cardiac trauma involves the right and left ventricles. The incidence of left atria1 involvement is approximately 6%, and of the main pulmonary artery even less (7). Injuries to the right ventricle are the most frequent, and also have a better outcome than injuries involving either the left ventricle or multiple chambers. We conducted a thorough search of the literature and were unable to find a single report of the injury described above. In addition to the unique anatomy of the injury, this case illustrates several other interesting points.
Cardiac
33
Stab Wound
Although the presence of cardiac tamponade is usually considered an ominous sign, it has been clearly shown to be a positive prognostic indicator in penetrating cardiac trauma (9), further evidenced by the favorable outcome of our patient. In a study by Moreno and colleagues (9), 100 patients with penetrating cardiac injuries were retrospectively evaluated and the group with pericardial tamponade was found to have a significantly greater survival rate as compared to those without tamponade. It is felt that tamponade, despite its deleterious effect on cardiac output, prevents the rapid exsanguination that can otherwise be seen with this type of injury. In the prehospital setting or in the emergency department, pericardiocentesis and placement of a pericardial catheter for periodic aspiration of 10 to 15 cc of blood until definitive surgical care is available can result in transient hemodynamic improvement and can be lifesaving. In our patient, a reasonable blood pressure was maintained with volume expansion, thereby obviating the need for pericardiocentesis. Cardiopulmonary bypass is used in the repair of only 2% of penetrating cardiac injuries (8). The need to mobilize the left main coronary artery away from the posterior pulmonary artery during repair, as well as the need to expose and repair the posterior wall of the left atrium, mandated this. An attempt at blind repair of the posterior PA laceration could easily have resulted in compromise of the entire left coronary circulation. Likewise, lifting the heart to expose the back wall of the left atrium resulted in hemorrhage. This case also reflects the importance of a well-run trauma center and a sophisticated EMS system. Through skilled airway management and rapid intravascular fluid resuscitation, paramedics were able to deliver this patient, initially moribund, to the hospital awake, breathing, with an improved blood pressure. City of Pittsburgh
paramedics, in addition to meeting state and national paramedic requirements, also undergo training in basic trauma life support, pediatric advanced life support, and continuing education lectures and skills laboratories. Within minutes of arrival, the patient was evaluated and taken to the operating room under the direction of an attending trauma surgeon. Mercy Hospital of Pittsburgh has an in-house attending trauma surgeon on duty 24 hours a day. The availability of CPB and an experienced cardiothoracic surgeon resulted in lifesaving definitive care. The use of the PASG in this patient is interesting in light of a recent study by Mattox and colleagues (10). Although this study has several major flaws, the data on use of the PASG in the subset of penetrating cardiac trauma convincingly argue against its use in this group of patients, and we have since discouraged its use in our system in this setting. The excellent outcome for this patient argues for the use of the PASG, and for its further evaluation in this type of patient. Although not required in our patient, emergency department thoracotomy has become the standard of care for cardiac arrest in the setting of penetrating chest trauma. Outcome is usually only favorable, however, in those who present with signs of life in the ED.
CONCLUSIONS As the incidence and severity of penetrating cardiac trauma increases, so does the challenge of managing these patients. As this case illustrates, the combined efforts of prehospital services and a well-run trauma center will result in successful treatment of unique situations like the one described here.
REFERENCES 1. Mattox KL, Feliciano DV, Burch J, Beal AC, Jordan GL, DeBakey ME. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. J Trauma. 1989;209:698-707. 2. Asfaw I, Arbulu A. Penetrating wounds of the pericardium and heart. Surg Clin North Am. 1977;57:3748. 3. Pons PT, Honigman B, Moore EE, Rosen P, Antuna B, Democoeur J. Prehospital advanced trauma life support for critical penetrating wounds of the thorax and abdomen. J Trauma 1985;25: 828-32. 4. West JG, Cales RH, Gazzaniga AB. Impact of regionalization: the Grange County experience. Arch Surg. 1983;118:740-4. 5. Kane1 R, Shaffer MA, Franaszek JB. Emergency diagnosis, resuscitation, and treatment of acute penetrating cardiac trauma. Ann Emerg Med. 1982;11:504-17.
Trinkle JK, Toon RS, Franz JL, Arom AV, Grover FL. Affairs of the wounded heart: penetrating cardiac wounds. J Trauma. 1979;19:467-72. Chihvood WR, Austin EH. Cardiac trauma: penetrating and blunt. In: Moylan JA, ed. Trauma surgery. Philadelphia: Lippincott: 1988:130. Ha&an PK, Trinkle JK. Injury to the heart. In: Mattox KL, Moore EE, Feliciano DV, eds. Trauma. Norwalk. Connecticut: Appleton and Lange; 1988379. 9. Moreno C, Moore EE, Majure JA, Hopeman AR. Pericardial tamponade: a critical determinant for survival following penetrating cardiac wounds. J Trauma. 1989;29:821-4. 10. Mattox KL, Bickell W, Pepe PE, Butch J, Feliciano D. Prospective MAST study in 911 patients. J Trauma. 1990;29: 1104-I 1,
COMPLETE
RECOVERY
James L. McCabe, *University
MD,*
Printed In the USA. CopyrIght 0 1992 Pergamon Press plc
FOLLOWING
Kathleen J. Grant,
MD,+
AN UNUSUAL CARDIAC STAB WOUND William Birsic,
MD,+
and Ronald V. Pelligrini,
MD+
Affiliated Residency in Emergency Medicine, +Department of Cardiothoracic and Vascular Surgery, The Mercy Hospital of Pittsburgh, Pennsylvania James L. McCabe, MD, Department of Emergency Medicine, Our Lady of Lourdes Hospital, 1600 Haddon Ave, Camden, NJ 08103
of Pittsburgh
Reprint address:
0 Abstract - A 17-year-old female was stabbed in the chest and found by paramedics in extremis. She arrived at the receiving hospital with spontaneous respirations and an improved blood pressure. Upon thoracotomy in the operating room, lacerations through the main pulmonary artery and the left atrium were found. The combined efforts of a sophisticated EMS system providing rapid in-field stabilization and transport, a ready in-house trauma team able to quickly assess and provide definitive care, and a prepared operating room team, including cardiopulmonary bypass capability, resulted in a complete and uncomplicated recovery from this rare and lethal injury.
management of acutely injured patients has been the development of quality paramedic training programs such as Basic Trauma Life Support (BTLS) and Prehospital Trauma Life Support (PHTLS) (24). Although up to 80% of patients with penetrating cardiac trauma die before reaching the hospital, nearly 90% of those arriving at an appropriate center with signs of life will survive (5,6). We report the successful resuscitation and definitive surgical treatment of a patient with an unusual cardiac stab wound to illustrate technological advances made from the activation of an emergency medical services (EMS) system to intraoperative management.
0 Keywords - cardiac trauma; chest trauma; stab wound; trauma center; cardiopulmonary bypass CASE REPORT INTRODUCTION
A 17-year-old female was stabbed with a long kitchen knife just above the left breast and in the right flank. City paramedics, on scene in 7 minutes, found the patient unconscious, with agonal respirations and a faint carotid pulse at a rate of 140. A peripheral blood pressure was unobtainable. She was immediately ventilated with high flow oxygen through a bag-valve-mask. A pneumatic antishock garment (PASG) was applied and all chambers inflated. Simultaneously, a large bore intravenous (IV) catheter was placed. Prior to transport a brief attempt at endotracheal intubation was unsuccessful, during which time the patient awoke and became combative. On scene time was 10 minutes. A second large bore IV was placed en route and 2 liters of lactated Ringer’s solution were infused. Within 25 minutes of EMS base station notification, the patient arrived
The incidence of penetrating trauma in urban areas continues to increase (1). The establishment of specialized trauma centers, able to manage immediately lifethreatening injuries, highly trained prehospital personnel equipped with advanced life support and communication technology, and the transition from conservative pericardiocentesis as the initial primary treatment to early thoracotomy have improved outcome in these patients. In addition to the development of the “trauma team,” one of the most important advances in the
Presented at the Pittsburgh Thoracic Surgery Society meeting, October 4, 1989.
RECEIVED:20 November ACCEPTED: 15 July 199 1
19901 FINAL SUBMISSIONRECEIVED:2 July 1991;
31
0736-4679192
$5.00 + .OO
32
J. L. McCabe,
K. J. Grant, W. Birsic, R. V. Pelligrini
Figure 1. Supine chest x-ray study of patient with cardiac stab wound. Notice bulging of the upper lefl aspect of the cardiac silhouette due to a large lntraperlcardlal hematoma.
at the local trauma center awake, breathing spontaneously with a blood pressure of 82/40 torr. In the emergency department (ED), she remained awake with adequate respirations and was noted to have a deep laceration in the left second intercostal space at the rnidclavicular line, a similar laceration in the right flank, and distended neck veins. Lung sounds were clear bilaterally, and there was adequate air movement. Oxygen was administered, and after administration of a third liter of normal saline there was no change in blood pressure. Two units of 0 negative packed red cells blood were infused under pressure. A portable chest x-ray study done in the ED revealed a left pleural effusion and enlargement of the left upper cardiac border (Figure 1). She was transported to the operating room within 8 minutes of arrival in the ED with a stable airway and a blood pressure of 96160. In the operating room, following rapid induction of general anesthesia and bladder catheterization, a median sternotomy was performed. The time from arrival in the ED to sternotomy was 18 minutes. A tense hemopericardium was released with marked hemodynamic improvement. A 2-cm laceration of the main pulmonary artery was controlled and closed. Next, a large clot overlying the left atria1 appendage was removed, resulting in free bleeding of both saturated and unsaturated blood. Careful inspection revealed lacerations through the front and back walls of the left atrium, and a posterior pulmonary artery laceration that was 2 mm from the left main coronary artery. It was then decided
Figure 2. Diagram of an unusual cardiac stab wound.
that repair of these lacerations required placing the patient on cardiopulmonary bypass (CPB). While CPB was being set up, a laparotomy was performed that revealed the absence of intraperitoneal blood. Urinalysis was negative. Once on bypass, the left atria1 wounds were closed. The left main coronary artery was carefully mobilized off the base of the posterior pulmonary artery, which was then closed without difficulty (Figure 2). The patient was awake and extubated on the first postoperative day, and was discharged one week later after an unremarkable hospital course.
DISCUSSION The majority of penetrating cardiac trauma involves the right and left ventricles. The incidence of left atria1 involvement is approximately 6%, and of the main pulmonary artery even less (7). Injuries to the right ventricle are the most frequent, and also have a better outcome than injuries involving either the left ventricle or multiple chambers. We conducted a thorough search of the literature and were unable to find a single report of the injury described above. In addition to the unique anatomy of the injury, this case illustrates several other interesting points.
Cardiac
33
Stab Wound
Although the presence of cardiac tamponade is usually considered an ominous sign, it has been clearly shown to be a positive prognostic indicator in penetrating cardiac trauma (9), further evidenced by the favorable outcome of our patient. In a study by Moreno and colleagues (9), 100 patients with penetrating cardiac injuries were retrospectively evaluated and the group with pericardial tamponade was found to have a significantly greater survival rate as compared to those without tamponade. It is felt that tamponade, despite its deleterious effect on cardiac output, prevents the rapid exsanguination that can otherwise be seen with this type of injury. In the prehospital setting or in the emergency department, pericardiocentesis and placement of a pericardial catheter for periodic aspiration of 10 to 15 cc of blood until definitive surgical care is available can result in transient hemodynamic improvement and can be lifesaving. In our patient, a reasonable blood pressure was maintained with volume expansion, thereby obviating the need for pericardiocentesis. Cardiopulmonary bypass is used in the repair of only 2% of penetrating cardiac injuries (8). The need to mobilize the left main coronary artery away from the posterior pulmonary artery during repair, as well as the need to expose and repair the posterior wall of the left atrium, mandated this. An attempt at blind repair of the posterior PA laceration could easily have resulted in compromise of the entire left coronary circulation. Likewise, lifting the heart to expose the back wall of the left atrium resulted in hemorrhage. This case also reflects the importance of a well-run trauma center and a sophisticated EMS system. Through skilled airway management and rapid intravascular fluid resuscitation, paramedics were able to deliver this patient, initially moribund, to the hospital awake, breathing, with an improved blood pressure. City of Pittsburgh
paramedics, in addition to meeting state and national paramedic requirements, also undergo training in basic trauma life support, pediatric advanced life support, and continuing education lectures and skills laboratories. Within minutes of arrival, the patient was evaluated and taken to the operating room under the direction of an attending trauma surgeon. Mercy Hospital of Pittsburgh has an in-house attending trauma surgeon on duty 24 hours a day. The availability of CPB and an experienced cardiothoracic surgeon resulted in lifesaving definitive care. The use of the PASG in this patient is interesting in light of a recent study by Mattox and colleagues (10). Although this study has several major flaws, the data on use of the PASG in the subset of penetrating cardiac trauma convincingly argue against its use in this group of patients, and we have since discouraged its use in our system in this setting. The excellent outcome for this patient argues for the use of the PASG, and for its further evaluation in this type of patient. Although not required in our patient, emergency department thoracotomy has become the standard of care for cardiac arrest in the setting of penetrating chest trauma. Outcome is usually only favorable, however, in those who present with signs of life in the ED.
CONCLUSIONS As the incidence and severity of penetrating cardiac trauma increases, so does the challenge of managing these patients. As this case illustrates, the combined efforts of prehospital services and a well-run trauma center will result in successful treatment of unique situations like the one described here.
REFERENCES 1. Mattox KL, Feliciano DV, Burch J, Beal AC, Jordan GL, DeBakey ME. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. J Trauma. 1989;209:698-707. 2. Asfaw I, Arbulu A. Penetrating wounds of the pericardium and heart. Surg Clin North Am. 1977;57:3748. 3. Pons PT, Honigman B, Moore EE, Rosen P, Antuna B, Democoeur J. Prehospital advanced trauma life support for critical penetrating wounds of the thorax and abdomen. J Trauma 1985;25: 828-32. 4. West JG, Cales RH, Gazzaniga AB. Impact of regionalization: the Grange County experience. Arch Surg. 1983;118:740-4. 5. Kane1 R, Shaffer MA, Franaszek JB. Emergency diagnosis, resuscitation, and treatment of acute penetrating cardiac trauma. Ann Emerg Med. 1982;11:504-17.
Trinkle JK, Toon RS, Franz JL, Arom AV, Grover FL. Affairs of the wounded heart: penetrating cardiac wounds. J Trauma. 1979;19:467-72. Chihvood WR, Austin EH. Cardiac trauma: penetrating and blunt. In: Moylan JA, ed. Trauma surgery. Philadelphia: Lippincott: 1988:130. Ha&an PK, Trinkle JK. Injury to the heart. In: Mattox KL, Moore EE, Feliciano DV, eds. Trauma. Norwalk. Connecticut: Appleton and Lange; 1988379. 9. Moreno C, Moore EE, Majure JA, Hopeman AR. Pericardial tamponade: a critical determinant for survival following penetrating cardiac wounds. J Trauma. 1989;29:821-4. 10. Mattox KL, Bickell W, Pepe PE, Butch J, Feliciano D. Prospective MAST study in 911 patients. J Trauma. 1990;29: 1104-I 1,
