Case Report
M A N A G E M E N T O F C A R D I A C P E N E T R A T I N G I N J U R I E S : A P R O P O S O F A C A S E K o r a y A le, M . D . * / O ğ u z h a n Ö z y u r t k a n , M . D . * * / S e r d a r A k g ü n , M . D . * B e d r e t t in Y ı l d ı z e l i , M . D . * * / M u s t a f a Y ü k s e l , M . D . * * * D e p a r tm e n t o f C a rd io v a s c u la r S u rg e ry , S c h o o l o f M e d ic in e , M a r m a r a U n iv e rs ity , Is ta n b u l, T u rk e y . * * D e p a r tm e n t o f T h o ra c ic S u rg e ry , S c h o o l o f M e d ic in e , M a r m a r a U n iv e rs ity , Is ta n b u l, T u rk e y . A BSTRACTA 24 year old policeman presented with m assive subcutaneous em physem a on the left side of the thorax with severe dyspnea after a motor vehicle accident. There were no clinical and radiographic signs of cardiac injury before the operation
except the pneumediastinum. An incomplete
laceration of the left ventricle and combined lung injury due to broken ribs w e re su c c e sfu lly
repaired. Th e rib frac tu re s and
pneumomediastinum m ay be considered a s an alert sign for the possibility of concomitant cardiac injury after blunt thoracic trauma.
IN T R O D U C T IO N
Blunt thoracic trauma can result in various types of lung injury with or without cardiac problems.
Th o ra cic traum a patients need careful
investigation and management because of the unexpected features of the cardiac injuries. Blunt thoracic trauma has been observed in different clinical entities from ca rd iac co n cu ssio n / contusion, to the laceration and rupture of intracard iac stru ctu re s. M ostly, penetrating traum as to the heart may be eithher gunshot
wounds. However, bone fragm ents and rib
fractures usually result in other visceral injuries including laceration of the heart (1 - 3). Th e most affected parts of the heart after penetrating injuries, are the right ventricle followed by the left ventricle, right atrium and the left atrium (4). Herein we report an incomplete laceration of the left ventricle and concomitant lung injuries a s a result of direct puncture from thé broken ribs after blunt thoracic trauma.
CASE R E P O R T
A 24 year old policem an w a s brought to the Em ergency Department after being struck by a car while riding his m otorcycle. On arrival at the Em ergency Department he had a blood pressure of 100 / 70 mmHg, a heart beat of 120 per minute with normal electrocardiogram and a respiratory rate of 30 breaths per minute. He w a s very agitated and mentally confused. His physical exam ination revealed m a ssive su b cu tan eo u s em physem a on the left side of the thorax and superficial abrasions on the left arm without any sign of pericardial tam ponade.
Plain chest roentgenogram show ed pulmonary contusion and hemothorax on the left hemithorax with two broken rib s, without any sign of
Correspondence to: Koray Ak, M.D, - Department of Cardiovascular Surgery, Marmara University Hospital. Tophanelioğlu Caddesi, No: 13-15 81190 Altunizade, Istanbul, Turkey,
e.mail address: akkoray@hotmail.com
(Accepted 27 July, 2002)
Marmara Medical Journal 2002,15(4):264-266
Cardiac penetrating injuries
p ericard ial tam po nad e. A c h e st tube w a s immediately inserted. Tw o hundred ml of blood w a s e va c u a te d . T h e patient w a s intubated b ecau se of gradually worsening dyspnea. A computed tom ography (C T ) w a s performed and it showed pneum om ediastinum and upper lobe
contusion. T h e neurologic and abdomen
exam inations revealed nothing rem arkable. The patient w a s taken directly to the operating room for em ergency thoracotomy after a sudden chest tube drainage exceeding 2000 ml in half an hour. Fiberoptic bronchoscopy before the operation revealed no dam age of the bronchial tree. On the operating sce n e it w a s found that broken ribs had lacerated the upper lobe and the lingula of the lung. Five-h u nd red ml of hem othorax w as e va cu a te d . C a re fu l exam ination of the mediastinum revealed a tear in the pericardium and a hem atom a on the left ventricle. There w as an incomplete laceration on the lateral wall of the left ventricle including bleeding from the first branch of the obtuse margin artery and venous bleeding due to tear effect of the neighboring broken 6th rib. Th e bleeding artery and the vein were ligated and surrounding venous bleedings ce a se d after additional teflon supported sutures. The laceration of the left ventricle w as incomplete and relatively superficial on the 4 x 4 cm 2 part of the ve n tricle . A 5 cm 2 G o re-tex (G ore & A sso cia te s, Flugstaff, Arizona, U S) patch w as sewn over the lacerated region. Lingulectomy w as performed with staplers for the concomitant lacerations of the upper lobe. The pericardium w as left open. Another chest tube w as inserted after diagnosis of the pneumothorax on the right hem ithorax in the Intensive C a re Unit. The patient w a s extubated on the third postoperative day. T h e rest of the postoperative recovery w as uneventful and the patient w a s discharged on the 8 th p o stop erative d ay. T h e control ech o card iog ram sho w ed no sign of wall abnormality of the left ventricle on the lateral wall.
D IS C U S S IO N
Penetrating card iac injuries are the most fatal events among traum a patients. Th e majority of these patients (50 - 80 % ) die before arrival at the Em erg ency W ard. Most authors reported a significant mortality rate (18 - 37% ) after cardiac injury with hem odynam ic unstability (4 - 6) . After
rapid e m e rg e n cy room evaluation and
resuscitation, patients in whom tamponade is suspected should undergo urgent exploratory surgery. Pericardial tamponade sings and the physical condition of the patient would create sufficient evidence to diagnose serious injury to the heart. Common life-threating conditions after penetrating cardiac injury are listed in Table I. During the initial evaluation and resuscitation, survival of the patient depends on immediate detection of those conditions. Rib fractures are found In 52 % of the patients with documented blunt cardiac injury ve rsu s 27 % without cardiac injury. The presence of rib fracture (s) should be evaluated carefu lly for concom itant ca rd iac injury. An algorhythm for em erg en cy room
evaluation is shown in figure 1. In
hemodynamically stable patients, C T has been shown to be useful for the evaluation of pulmonary, airway, skeletal and diaphragmatic Injuries (7, 8 ). H ow ever, C T is not alw a ys
accu rate for detecting pericardial and
concomitant cardiac injury. Pneumomediastinum reported as a sign of bronchial airw ay dam age is not a lw a y s due to a se rio u s problem (9). D iagnostic p e rica rd io ce n te sis can also be performed with a certain rate of misleading resu lts (25 % ) (10). D ecision on w hether em ergency room or operating room thoracotomy should depend on the patient’s medical status and the technical facilities of the hospital. The initial surgical step could be either diagnostic
subxiphoid window opening or direct
thoracotomy. Left anterior thoracotomy is one of the most suitable incisions for both resuscitative
Table I: Life-threating penetrating cardiac injury
a. Immediate threat to life Open Pneumothorax Airway Obstruction Flail Chest Tension Pneumothorax Massive Hemothorax Pericardial Tamponade
b. Relative threat to life Aortic Rupture
Rupture / Tear of Tracheabronchial Tree Rupture of Diaphram
Rupture of Esophagus Pulmonary Contusion Myocardial Contusion
Koray Ak, et a!
and therapeutic procedures. The key issue
regarding mortality is diagnosis of the cardiac
injury before going into the operating theatre.
Additional supportive measures before surgery
should be taken, especially for unexpected life-
threatening cardiac injuries. We repaired the
incomplete laceration by using gore-tex patch.
We did not attempt to perform primary repair as
we thought the lacerated part was too large for
simple suturing.
Fig-1 : A n a lg o rh y th m fo r th e m a n a g e m e n t o f p a tie n ts w ith b lu n t o r p e n e tra tin g lo w e r n e c k , c h e s t o r u p p e r a b d o m in a l tra u m a . (C u llifo rd A T . P e n e tra tin g c a rd ia c in ju rie s . In: H o o d , B o yd , C u llifo rd , e d s . T h o ra c ic T ra u m a T e x tb o o k , 9. e d itio n . W B S a u n d e rs C o m p a n y , 1 9 8 9:1 8 4 .)
