Shot Through the Heart (And You re to Blame): Penetrating Cardiac Trauma Yalaunda M. Thomas, MD, FACS The American College of Osteopathic Emergency Physicians Spring Seminar April 5, 2018
Disclosures I have no relevant financial relationships with manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity I do not intend to discuss an unapproved/investigative use of commercial product/device in my presentation
Objectives 1. Identify organ injury risks in penetrating chest trauma 2. Identify physical signs/symptoms of cardiac injury 3. Identify physical signs/symptoms of pulmonary injury 4. List treatment options for cardiac or pulmonary injuries
Thoracic Trauma Significant cause of mortality Blunt: < 10% require operation Penetrating: 15-30% require operation Majority: Require simple procedures Most life-threatening injuries are identified during the primary survey
Penetrating Chest Trauma
Thoracic Landmarks Studyblue flash cards
Thoracic Content: what s in the path? Distal trachea Lungs Heart Aorta Esophagus diaphragm
Penetrating Thoracic Trauma Patient presents with GSW left chest Airway/Breathing/Circulation (ABCs) intact Glascow Coma Scale (GCS) 15 Peritonitis
head liver right spleen left Posterior diaphragm
What s in the path of the missle/knife
What about in exhalation? Liver Stomach Spleen Colon potentially in line of fire
The Box Anterior Posterior B. Phillip
The BOX TOP: Clavicle/sternal notch SIDES: Mid-clavicular line/nipples BOTTOM: Costal margin/xyphoid GSWs & proximity to the heart K. Nagy. J. Trauma 1995
Workup Imaging Chest xray Echocardiogram EGD/Esophagram Bronchoscopy Most common injuries: Lungs Heart Occupy most of the space
Penetrating Trauma Bullets Ice picks Arrows Knives Stakes Stilletoes Pens/pencils
CASE 2 16 year old male brought to ED by his mother Back pain Shortness of breath w/ movement I got jumped by some dudes 4 days ago
Case 3 36 yo M suffers GSW to the right chest Arrives screaming, I can t breathe Breath sounds equal Vitals are stable
hemothorax
Raising the Bar Tension Pneumothorax Massive Hemothorax Sucking chest wounds Pericardial tamponade Traumatic Arrest
Massive Hemothorax Large collection of blood Crushing Lung Increased thoracic pressure Generally patient is NOT hemodynamically stable
Open Pneumothorax sucking chest wound Wound is least resistant path Air rushing in on inhalation Three sided dressing is temporary fix Chest tube
Tension Pneumothorax Mmheme S.Weigart
Tension Pneumothorax sharkmed
Pericardial Tamponade Beck s Triad -distended jugular vein -muffled heart sounds -hypotension Rx: pericardial drain pericardial window
Pericardial Tamponade Blood in the pericardial sac Loss of ventricular filling due to pressure from the surrounding blood Hypotension Anxiety Can t/won t lay flat because feel short or breath or chest fullness
Pericardial Tamponade
Pericardial Tamponade
Case 4 18 yo athlete suffers GSW to the right of sternum Initially ABC s (HR 64) intact GCS 15 single GSW left of sternum Chest xray no ptx/hemothorax FB in subcutaneous fat just left of xyphoid Echocardiogram no pericardial blood NO pain
TWO HOURS MULTIPLE EXAMS LATER Patient sweating Sitting forward upright Back pain Nervous HR 88 Repeat chest xray negative Repeat echo representation
In the OR.
Case 5 Young female wandering the street Screaming about payback and a stabbing Initially no obvious wound But clothes covered in blood and acting erratically
With nursing staff holding her down Airway is intact Breath sounds equal bilaterally Circulation - bounding pulses - 2 large bore iv placed Disability: Hysterical GCS 15 Exposure: - Laceration at sternum - No other wounds
Clinical change in status.. Patient becomes unresponsive Traumatic Arrest Emergency thoracotomy G. Merlotti
G. Merlotti
Summary Penetrating Thoracic trauma up to 30% require operative intervention Identify in the Primary Survey (ABCDE) Address IMMEDIATELY Often minor intervention (chest tube)
Summary Be aware that intraabdominal injury can occur The BOX content is not truly static Workup & Intervention limitations: expertise, location, patient condition
Summary Tension pneumothorax is life threatening -Needle thoracostomy followed by chest tube Massive hemothorax is life threatening - chest tube insertion, autotransfusion - >1500mL = operative intervention Open pneumothorax/sucking chest wounds - three sided dressing buys time
Summary Pericardial blood fluid on ultrasound is blood Pericardiocentesis can buy transport time Beck s triad may not actually be present despite presence of tamponade
Thank You Questions???