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16 • Cardiac, Great Vessel, and Pulmonary Injuries 175
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scene or on arrival at the hospital.
20–22
This is secondary to
acute cardiac tamponade if the lateral walls of the pericardial sac are intact or to exsanguination when there is communication with a pleural cavity. Only rapid transport to a
trauma center or acute care hospital will save the lives of
patients with repairable cardiac injuries and signs of life in
the eld.23 This is because therapeutic procedures such as
pericardiocentesis, an open pericardial window, or an emergent anterolateral thoracotomy are not performed in the
prehospital setting in the United States or during military
conicts.
Blunt Trauma
In a review from the American College of Surgeons
National Trauma Data Bank, blunt cardiac rupture had
an incidence of 1/2400 admissions and occurred most
commonly after motor vehicle crashes (73%) followed by
automobile– pedestrian accidents (16%). In this study, blunt
cardiac injury was determined to have an overall mortality
of 89%.18 This is most commonly due to rupture of one or
more cardiac chambers, tears at the right atrial-caval junctions, or a blunt coronary artery dissection or tear.
19
PRESENTATION
Penetrating Trauma
Patients with stab wounds to the heart may present with
cardiac tamponade (60% to 90%), intrapleural hemorrhage (10% to 40%), or both. In contrast, patients with
gunshot wounds present with cardiac tamponade (20%),
intrapleural hemorrhage (80%), or both. Cardiac tamponade is caused by blood in an intact pericardial sac which
compresses the atria and impairs venous return and cardiac lling.24 The cardiovascular response to decreased
stroke volume is progressive tachycardia. Pulsus paradoxus
is present in essentially all patients, as well. Whereas blood
pressure decreases by as much as 10 mm Hg with inspiration secondary to a decrease in left ventricular stroke volume, this decrease may be 15 mm Hg or more in the setting
of cardiac tamponade. In the setting of tamponade, there is
a simultaneous progressive rise in central venous pressure
secondary to the impaired venous return. In this scenario,
patients often present with a dusky or deathlike appearance
that is noticeable regardless of race. Alert patients express
extreme anxiety (“Am I going to die?”) and frequently complain of a “heaviness” or pressure in the chest.
If the diagnosis of cardiac tamponade is delayed, myocardial ischemia and continued decreases in cardiac output occur. This spiral leads to cardiovascular collapse and
cardiac arrest in minutes in patients with wounds or ventricular rupture. In patients with wounds or ruptures of
the atria, compression of the hole by the extravasated blood
in the pericardium may stop further hemorrhage and progressive tamponade. The main hemodynamic nding in
such patients is the aforementioned progressive rise in central venous pressure to 20 to 30 mm Hg with profound
hypotension or a cardiac arrest as the terminal event. The
diagnosis of a compressed atrial wound may be delayed for
12 or more hours until clinical suspicion prompts a pericardial ultrasound, a pericardial window, a sternotomy, or
a thoracotomy. In most reports, the classic Beck's triad of
hypotension, distended cervical veins, and mufed heart
sounds is present in less than 10% of patients with tamponade, whereas the incidence of Kussmaul's sign or jugular
venous distension with inspiration is difcult to determine.
Bleeding from the injured heart into a pleural cavity most
often results from a gunshot wound, and the classic signs of
hypovolemic shock are typically present. Depending on the
patient’s hemodynamic status, an early resuscitative thoracotomy rather than a diagnostic test will be necessary.
Blunt Trauma
Blunt cardiac injury (BCI) encompasses a spectrum of
trauma including myocardial bruising (myocardial contusion), transmural infarction, or a rupture of the free wall
or septum. The spectrum of cardiac injury is described in
the American Association for the Surgery of Trauma's
(AAST) Organ Injury Scale reported in 1994.25 Clinical
manifestations that the trauma team must treat in rare
patients include unexplained hypotension, new-onset
arrhythmias, or cardiac tamponade. Mechanical problems
that have occurred after a BCI include injury to papillary
muscles, choradae tendineae, cardiac valves, and coronary arteries.
19
DIAGNOSIS
Penetrating Trauma
Other than the physical examination, diagnostic options
for patients with penetrating injuries (or blunt ruptures)
with secondary tamponade include the following: (1) an
electrocardiogram to assess for a “J” wave; (2) measurement of central venous pressure; (3) pericardiocentesis;
(4) subxiphoid pericardial window; (5) formal transthoracic (TTE) or transesophageal (TEE) ultrasound; and (6)
surgeon-performed TTE as part of focused assessment for
the sonographic evaluation of the trauma patient (FAST)
examination.
A “J” wave (small positive reection at the R-ST junction)
as a sign of an occult cardiac injury after a penetrating
thoracic wound was described by Nichol and Navsaria in
2014.26 In a group of 174 patients with penetrating thoracic wounds, the specicity to detect a hemopericardium
was 85%, sensitivity 44%, and positive predictive value
91% (P < .001).
Measurement of central venous pressure is invasive,
time-consuming, and may not conrm the diagnosis of
cardiac tamponade immediately. It is appropriate to use
when there is no desire to anesthetize the stable patient
to perform a diagnostic subxiphoid pericardial window or
when the ultrasound machine is broken or unavailable.
Any 10 mm Hg increase in central venous pressure over
time in the relaxed supine patient receiving only maintenance intravenous uids should prompt a subxiphoid pericardial window or median sternotomy or thoracotomy.
A pericardiocentesis may have a therapeutic effect in
the patient with tamponade and hemodynamic instability; however, the diagnostic sensitivity of this maneuver in
the stable patient with a small tamponade has always been
questioned.27 To rule out aspiration of intracardiac blood
mistaken as an early tamponade, the long spinal needle
used for the pericardiocentesis should be attached to a monitor lead to rule out a current of injury as the cardiac wall
is penetrated.
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An open surgical subxiphoid pericardial window is performed under general anesthesia and mandates a bloodless
operative approach.28 It is most helpful during an emergency
laparotomy after a gunshot or stab wound when the track of
the missile or knife appears to be in proximity to or appears
to penetrate the pericardial sac. Also, it is used in many centers when non-surgeon or surgeon-performed ultrasound is
unavailable or when there is not acceptable accuracy with
the technique. The operative approach is through a 5- to
10-cm midline abdominal incision starting on the xiphoid
process, which may be excised as needed for exposure. The
linea alba is divided, and extraperitoneal dissection is performed bluntly in a superior direction toward the pericardium. Exposure is enhanced by lifting the xiphoid process
(if still in place) and the lower sternum up with one medium
Richardson retractor or two Navy-Army retractors. Once
cardiac pulsations are palpated, the inferior pericardial sac is
grasped with two long Allis clamps, and a 2-cm vertical pericardiotomy is made between the clamps. If this maneuver
results in the release of blood from the pericardial sac, most
surgeons transition to a median sternotomy followed by a
longitudinal pericardiotomy, evacuation of the tamponade,
and control of bleeding. Patients who manifest progressive
hemodynamic deterioration during the subxiphoid pericardial window should undergo left anterolateral thoracotomy
and opening of the pericardium through that approach.
Following the lead of the Trauma Centre faculty at the
University of Cape Town, South Africa, some centers choose
to wash blood out of the pericardial sac after a positive window in the reasonably stable patient and observe for further
bleeding without opening the pericardial sac.
29–32
The rationale for this is that pericardial wounds only or wounds that
injure the cardiac wall supercially (epicardium and outer
myocardium) may have stopped bleeding by the time the
pericardial window has been performed. Should there be no
further bleeding during a period of intraoperative observation with the pericardial sac open, a few groups around the
world close the incision without performing a median sternotomy or anterolateral thoracotomy.
A formal TTE or TEE ultrasound performed by a cardiologist or anesthesiologist is an accurate technique to detect
cardiac tamponade. This maneuver can also diagnose intracardiac lesions such as septal defects or valvular injuries
and can calculate an ejection fraction. Unfortunately, the
majority of penetrating cardiac injuries come to the emergency department on weeknights or weekends when the
specialists who perform formal TTE or TEE ultrasound may
not be available. Additionally, the sedation required to properly perform TEE would be contraindicated in the unstable
patient with this injury scenario.
Over the past 25 years, reports have documented that
limited TTE performed in the emergency center by surgeons
or specialists in emergency medicine using a 3.5-MHz general access transducer is the diagnostic test of choice
33–35
(Fig. 16.5; Table 16.1). The FAST examination begins with
a pericardial view in patients with either penetrating or
blunt trauma. During the FAST, the probe is placed in a longitudinal direction in the subxiphoid area at an angle of 30
degrees off of the epigastrium with rm pressure. This usually results in a clear view of the apex of the heart, the pericardium, and the left lobe of the liver. The beating heart in
this real-time ultrasound approach should lie immediately
Liver
Heart
Fig. 16.5 Cardiac tamponade detected on surgeon-performed ultrasound using a 3.5-MHz transducer.
Table 16.1 Accuracy of Transthoracic Ultrasound in
Diagnosing Cardiac Tamponade.
Author
Rozycki et al.,
33
1996
Rozycki et al.,
34
1998
Rozycki et al.,
35
1999
Nichol et al.,
36
2015
a
Two false-positives, no false-negatives.
b
Seven false-positives, no false-negatives.
c
18 false-negatives.
Number of
Patients True-Positives Accuracy
236 10 100%
313 22 99.4%
261 29 97.3%
172 — 86.7%
Blood
Vena cava
adjacent to the liver. Should tamponade be present, a black
stripe will separate the beating heart from the liver. The
black or anechoic stripe with an ultrasound density that is
the same as blood in the inferior vena cava represents blood
outside the heart, i.e., a tamponade. Failure to visualize an
adequate sagittal view through the subxiphoid window is
often secondary to the patient's complaining about pain or
discomfort. Also, this cardiac window may be diminished in
obese patients.
The ultrasound probe is next placed in a horizontal direction in the 4th or 5th left parasternal space to
obtain a coronal view of the same cardiac structures. In
the study by Rozycki et al., 246 patients with penetrating
thoracic wounds were evaluated by surgeon-performed
ultrasound.33 There were 236 true-negative results and
10 true-positive results. In the latter group, the mean
time from ultrasound to operation was 12 minutes and
all patients survived after repair of their cardiac wounds.
A follow-up study by Rozycki et al. in 313 patients with
penetrating precordial or transthoracic wounds resulted
in 289 true-negative examinations, 2 false-positive examinations, and 22 true-positive examinations.34 In the latter
group, all patients survived when surgery was immediately
a
b
c
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performed by the surgeon-sonographer. Finally, Rozycki
et al. completed a multicenter study in which emergency
pericardial sonograms were performed by ultrasound
technicians, cardiologists, or surgeons.35 In a series of
261 patients with penetrating precordial or transthoracic
wounds evaluated at ve level I trauma centers, 29 (11%)
had true-positive studies, and 28 survived after emergency
cardiac repair. The accuracy (97%), specicity (97%), and
sensitivity (100%) were equivalent to those reported in the
previous study from Grady Memorial Hospital.
33
Some centers around the world have not had the same
accuracy of surgeon-performed ultrasound in detecting
intrapericardial blood,
36,37
and all centers recognize the
compromised accuracy of surgeon-performed pericardial
ultrasound when a left hemothorax is present. Nichol et al.,
using a similar description of the expanded cardiac box as
later described by Jhunjhunwala et al., offered a new management algorithm for the hemodynamically stable patient
in 2015.
1,36
First, a patient with a “screening ultrasound”
positive for intrapericardial blood would be taken to the OR
for a subxiphoid pericardial window under general anesthesia. Second, a patient with an equivocal screening ultrasound would undergo a pericardial window or a CT scan of
the chest. And, third, a patient with a negative screening
ultrasound should have an immediate CT scan of the chest
or a repeat ultrasound in 24 hours.
Blunt Trauma
As previously noted, 90% of blunt cardiac injuries are
caused by precordial trauma sustained during motor vehicle or automobile–pedestrian crashes. Arrhythmias such as
sinus tachycardia, premature atrial or ventricular contractions, and heart block are the most common manifestations
of blunt cardiac injury.38 For this reason, the admission electrocardiogram (ECG) is the most logical diagnostic tech nique
of choice. The usefulness of an ECG is often discounted by
studies advocating radioisotope scanning, TTE, and TEE
as diagnostic modalities for blunt cardiac injury. Multiple
reports, however, have documented that an ECG is an excellent initial test when evaluating patients with blunt thoracic
trauma.
20,39
In essence, these studies have shown that a normal ECG in the emergency department effectively excludes
signicant blunt cardiac injury.
There is continued interest in using a measure of serum
cardiac troponin I (TnI) in addition to the admission ECG to
detect blunt cardiac injury.40 In one study from Los Angeles
County Hospital, 27 of 80 patients (34%) with an abnormal ECG and TnI level after blunt chest trauma developed
signicant BCI.41 BCI in this and other studies is dened as
arrhythmias requiring treatment or the presence of cardiogenic shock or cardiac structural injury. The authors concluded that a normal ECG and serum TnI on admission and
8 hours after injury excluded blunt cardiac injury. TTE or
TEE may be used as an adjunct in patients with persistent
ECG abnormalities or with unexplained hypotension after
blunt chest trauma.
NONOPERATIVE MANAGEMENT OF BCI
Admission to the hospital for a possible or likely BCI is justied when the following are present after thoracic trauma: (1)
history of cardiac disease (i.e., angina pectoris, myocardial
infarction, arrhythmias, coronary revascularization); (2)
unexplained hypotension; and (3) new onset arrhythmia
or conduction disturbance on an admission ECG. A patient
with blunt thoracic trauma and a history of cardiac disease
or the presence of non–life-threatening arrhythmias such
as sinus tachycardia or atrial brillation should be admitted
to a telemetry unit for monitoring and observation. When
hypotension is present or when the ECG change is potentially lethal (i.e., ventricular tachycardia, ventricular brillation, third-degree heart block), treatment is initiated in
the emergency center before transfer to the ICU.
When an operation for another injury is indicated in a
patient with blunt cardiac injury, not including cardiac rupture, the prognosis is generally excellent. In a 1986 report
by Flancbaum et al., 19 patients with BCI had an emergency operation, including 15 on the day of admission.42
Pulmonary artery catheters were placed in 12 patients, and
inotropes were used in 11. The duration of anesthesia was
6 hours, and there were no cardiac-related complications
or deaths.
OPERATIVE MANAGEMENT IN THE EMERGENCY
DEPARTMENT AND OPERATING ROOM
Incisions
As previously noted, a left or bilateral anterolateral thoracotomy (i.e., clamshell thoracotomy) is performed in the
emergency department for release of suspected or documented tamponade, for control of cardiac hemorrhage,
and for resuscitation. The same incision(s) would be used
in the OR for agonal patients or for those in cardiac arrest.
These incisions allow for expedited control of hemorrhage
from cardiac perforation(s) and for cross-clamping of the
descending thoracic aorta. The anterolateral thoracotomy
approach may also be kept separate from any abdominal midline incision needed to address an intraabdominal
injury. The median sternotomy is performed in the OR in
patients who are more hemodynamically stable and who
have solitary anterior stab wounds. In such patients, multiple cardiac perforations are unlikely and cross-clamping
of the descending thoracic aorta is usually not needed.
Pericardiotomy
Opening the left chest via an anterolateral thoracotomy and
insertion of a Finochietto retractor are followed by a longitudinal left lateral pericardiotomy performed anterior to
the left phrenic nerve. In obese patients where fat obscures
the phrenic nerve, the accompanying pericardiacophrenic
vessels mark the location. Even if the pericardium is difcult to grab with a forceps secondary to distention of the
sac with blood, the surgeon should resist performing a pericardiotomy with a scalpel. This is a particularly dangerous
as right-sided tamponade from a wound to the atrium or
ventricle may push the heart to the left so that it lies immediately underneath or abuts the left pericardial sac. In this
position, the left anterior descending coronary artery is at
risk of injury if a scalpel is passed too deeply while opening
the pericardium. A better technique is to lift the pericardium
with a toothed forceps and to open the sac with the tip of a
straight Mayo scissors. Once it has been opened, the pericardium generally lifts away from the surface of the heart
allowing the incision to be extended in a superior direction
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until the pericardial fold on the great vessels is reached. The
longitudinal left pericardiotomy is completed in an inferior
direction until the left hemidiaphragm is reached. Exposure
of the injured heart is enhanced by making a transverse
pericardial incision to the right as well. This pericardial incision is made at a right angle to the left lateral pericardiotomy and extends to 1 cm anterior to the right phrenic nerve.
In patients undergoing bilateral anterolateral thoracotomy, either the pericardiotomy described previously or the
midline pericardiotomy described later can be used. After a
median sternotomy and insertion of a Finochietto retractor,
the fat anterior to the pericardium and the anterior extensions of the parietal pleura are swept laterally with the
ngers over laparotomy pads. This maneuver exposes the
anterior surface of the pericardial sac which is grasped with
toothed forceps and opened in a midline longitudinal direction from the great vessels to the diaphragm.
Control of Hemorrhage From the Heart (Table 16.2)
After the pericardiotomy is performed, blood and clots are
removed from the pericardial sac manually and with irrigation and suction. Inspection of the anterior surface of the
heart and great vessels is performed. If no anterior perforation or blunt rupture is noted, the surgeon should note the
patient's blood pressure on the monitor. A profoundly hypotensive patient may not tolerate inspection of the posterior
aspect of the heart, which requires elevation of the apex.
Lifting the heart to inspect the underside compresses or kinks
the vena cavae, restricting right-sided lling. This maneuver
also carries with it a risk of sucking air into an open hypovolemic ventricle. With left ventricular perforation, air has the
potential to rapidly move into the coronary arteries causing
an air embolism and cardiac arrest. As such, manual palpation of the posterior surface of the heart without elevation of
the apex is all that is advised until the patient is resuscitated
with a relatively normal blood pressure. Palpation of a posterior defect or jet of blood as a ventricle contracts mandates
leaving the nger in place for control of hemorrhage until the
patient’s hypovolemia is corrected.
Once the patient has been stabilized and the surgeon is
ready to lift the apex of the heart to inspect the posterior
aspect, he or she should notify the anesthesia team so that
they are aware and can assist in managing any associated
hypotension. If there is bleeding from the posterior aspect
of the heart that will require prolonged elevation and/or
Table 16.2 Techniques for the General Surgeon to
Control Hemorrhage From a Cardiac Perforation or
Rupture.
Finger Atrium/ventricle
Stapler Atrium/ventricle
Satinsky vascular clamp Atrium
Row of Allis clamps Lateral atrium adjacent to
Foley balloon catheter Atrium/ventricle
Crossed mattress sutures Ventricle
Inflow (superior vena cava/inferior
vena cava) occlusion
3-mg intravenous adenosine to
induce 10–20 s asystole
pericardium
Large ventricular hole or
multiple chamber wounds
Large ventricular hole or
multiple chamber wounds
suturing, the surgeon should consider placing a cross-clamp
on the descending thoracic aorta to preserve central pressure and cerebral circulation. This will, however, increase
bleeding through the cardiac wound.
A nger or compression with ngers will control hemorrhage from a cardiac perforation or cardiac rupture in 95%
of patients. This is because patients with larger defects die at
the scene or in transit. Suture repair of a ventricular wound
can be performed under the occluding nger. When a nger
is not successful in controlling bleeding or when more denitive control is needed, the techniques in Table 16.2 may be
applied. Disposable skin staplers with long rotating heads
can be used to quickly close atrial or ventricular defects.
43–45
Whether staple repair lines placed in the emergency department should be buttressed or replaced with sutures in the
OR is controversial. The safest policy is to buttress any left
ventricular repair with Teon pledgets in the OR in patients
who stabilize after the initial hemorrhage control and resuscitation maneuvers.
Elevation of an atrial wound with the ngers, forceps, or
Allis clamps will frequently allow placement of a Satinsky
vascular clamp under the perforation. Atrial wounds or
ruptures in the lateral aspect adjacent to the pericardium
cannot be controlled with a Satinsky clamp. With such
injuries, Allis clamps grabbing both sides of the defect are
placed in a row similar to the method described for wounds
to the vena cava for the past 100 years. For atrial wounds
adjacent to the ventricle or other difcult cardiac lacerations, use of a Foley balloon catheter to control hemorrhage
was rst described in 1966.46 Insertion of the tip and balloon of the catheter into the defect is followed by ination
of the balloon and gentle traction on the end of the catheter
hanging out of the heart.
On rare occasions, the length of a ventricular laceration
will lead to exsanguinating hemorrhage that will preclude
the use of the stapler or the balloon catheter. With manual
compression of the defect, a horizontal mattress suture is
rapidly placed on either side of the defect, the two ends on
each side are placed in the hands, and the hands holding
the suture ends are crossed. This should prevent exsanguination as a continuous over-and-over suture row or a row
of staples is placed. A temporary closure as described would
then be buttressed with Teon pledgets in the OR.
Because few surgeons are familiar with the manual technique for control of hemorrhage from the heart described over
a century ago by Ernst Ferdinand Sauerbruch (1875–1951),
the related technique of inow occlusion is used occasionally
to control major hemorrhage from the heart. Inow occlusion slows the heart and improves one’s ability to control cardiac bleeding.47 With difcult-to-visualize cardiac wounds or
in the case of large ventricular wounds, as described previously, application of vascular clamps to the superior and
inferior vena cavae is appropriate. This maneuver decreases
hemorrhage from the injured heart and rapidly causes a profound bradycardia which together allow for clamp or suture
control of hemorrhage from complex cardiac wounds. Prior
to tying down the last suture of a ventricular repair, the
clamps on the cavae are removed to allow relling of the ventricle. Evacuation of ventricular air is accomplished by elevation of the apex of the heart as relling occurs and before the
nal suture of the repair is tied down. The exact time limit on
inow occlusion is unknown, but 1 to 2 minutes will usually
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allow for restoration of a cardiac rhythm after the repair has
been completed.
There have been several reports about the administration of 3 mg of adenosine intravenously to aid in the repair
of cardiac injuries.
48,49
Approximately 20 seconds after
administration of adenosine, the heart will stop beating
(i.e., induced asystole) for 10 to 25 seconds allowing for initiation of a rapid suture repair. Further intravenous doses
are given to complete the repair as needed. The annoying
side effects associated with adenosine use, including facial
ushing, thoracic discomfort, dyspnea, and headache, are
not noticeable under general anesthesia.
Restoring a Cardiac Rhythm
After hemorrhage has been controlled, patients with preterminal bradycardia or new onset asystole need immediate
cardiac resuscitation. If the heart feels empty, the descending
thoracic aorta should be cross-clamped if this has not been
performed previously. If a median sternotomy was the original approach, a left anterolateral thoracotomy will have to be
performed to complete this maneuver. Cardiac resuscitation
would then include administration of blood components as
part of DCR, along with bimanual cardiac massage to perfuse
the coronary and carotid arteries. It is critical not to lift the
apex of the heart because this may cause impingement of the
vena cavae or air embolism from the partially empty cardiac
chamber with perforation if resuscitation has preceded repair.
When the heart does not respond to the infusion of
volume and internal cardiac massage, cardioactive medications should be administered. These include 1 mg intravenous atropine for bradycardia, 1 to 3 mg intravenous
epinephrine for bradycardia and hypotension, or 1 mg of
intracardiac (into left ventricle) epinephrine for profound
bradycardia or asystole. The onset of ventricular brillation
is treated with internal electrical debrillation using two
paddles in contact with the heart anteriorly and posteriorly
and 10 to 20 J as the initial electrical charge. After restoration of a satisfactory cardiac rhythm and blood pressure,
suture repair of the cardiac perforation may be performed if
not completed previously.
Suturing Techniques
Suturing of the injured heart is often complicated by tachycardia and the side-to-side motion of the heart in the pericardial sac. A most helpful maneuver to stabilize the beating
heart as repair is being performed is “clamp control of the
right ventricular angle” as described at Temple University.50
To accomplish this maneuver, a Satinsky clamp is applied to
the apex of the right ventricle, and an assistant holding this
clamp will eliminate much of the side-to-side motion of the
beating heart.
Repair of an atrial perforation or rupture above a Satinsky clamp is performed with a purse string or continuous
4-0 or 5-0 polypropylene suture. An alternate approach
to a hole in the atrial appendage is to place a 2-0 silk tie
under the Satinsky clamp much like in performing a decannulation maneuver following cardiopulmonary bypass. As
noted, Allis clamps are used to control hemorrhage from
atrial wounds in the lateral aspect adjacent to the pericardium. Repair is accomplished with a continuous or interrupted mattress technique using 4-0 polypropylene suture
passed under the row of Allis clamps.
With a wound of the ventricle being controlled by the
surgeon or the assistant's nger, horizontal mattress 3-0
or 4-0 polypropylene sutures can be placed under the nger and tied. When a Foley balloon catheter has been used
to control hemorrhage from a ventricle, the surgeon must
be mindful that placement of the sutures for the cardiac
repair can rupture the underlying balloon. Therefore, as
the continuous 3-0 or 4-0 polypropylene suture is placed
around the controlled defect, the balloon must be temporarily pushed down into the ventricle with each passage of
the needle. Hemorrhage will occur with this maneuver, but
rupture of the balloon is prevented.
Teon pledgets are used to buttress left ventricular repairs
performed with sutures alone in the emergency department
and any repairs performed in the OR. Commercially available pledgets or pledgets cut from Teon strips may be used.
When synthetic pledgets are not available, pieces of the
pericardium may be used. The technique is to rst pass the
two needles of a 4-0 polypropylene suture through a pledget
6- to 10-mm long and 3- to 5-mm wide. The same needles
are separately passed through both sides of the ventricular perforation under the surgeon or assistant's nger as
described earlier. The two needles are then passed through
another Teon pledget of similar size and then cut off. As
the two ends are pulled up tight, the second pledget is moved
down to its side of the ventricular wound aided by ample
irrigation on the monolament sutures. Tying the polypropylene suture with appropriate tension will bring the Teflon pledgets in apposition, will seal the cardiac perforation,
and prevent the sutures from tearing through edematous
myocardium.
One technique for a cardiac surgeon to repair a wound
is the use of a sutureless patch and bioglue. This technique
appears to be most useful for small wounds in difcult-torepair areas of the heart, such as the coronary sinus.51
Cardiac wounds adjacent to a coronary artery are repaired
with pledgets as described previously, but the needles are
passed through both sides of the ventricular perforation and
under the adjacent coronary artery. Even with this modied
technique, tying the pledgets together to control hemorrhage may cause compression of the coronary artery and
ischemia of the distal myocardium. A direct, but limited,
laceration of a proximal coronary artery may be repaired
with interrupted single 6-0 or 7-0 polypropylene sutures on
rare occasions. In contrast, a laceration of a distal coronary
artery near the apex of the heart is treated with ligation
and a 15-minute period of observation to assess myocardial
ischemia.
Acute Need for Cardiopulmonary Bypass
The majority of patients who reach the hospital with signs
of life despite a cardiac perforation or rupture have a limited
injury that can be repaired by a general surgeon, trauma
fellow, or a senior surgical resident. Approximately 1% to
3% of such patients have a more complex injury that can
only be repaired by a cardiac surgeon using cardiopulmonary bypass (Table 16.3; Fig. 16.6).
22,52
Treatment in the Operating Room
After Cardiorrhaphy
If a left anterolateral or bilateral anterolateral thoracotomy
has been performed, the superior and inferior transected
180 SECTION 4 • The Management of Vascular Trauma
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Table 16.3 Indications for Cardiopulmonary Bypass for
Cardiac Injuries.
Acute
Unable to complete repair because of size and location
Repair fails after blood pressure stabilizes or inotropes are administered
Injury to proximal coronary artery treated by ligation (off pump bypass
appropriate in certain patients)
Delayed
Injury to cardiac valve, papillary muscle, chordae tendineae, or atrial or
ventricular septum
Intracardiac fistula
Late pseudoaneurysm of ventricular repair
Left anterior
descending
coronary artery
Emergency
aortocoronary
bypass
Left
ventricular
stab wound
Fig. 16.6 Repair of left ventricular stab wound compressed the adjacent left anterior descending coronary artery and prompted an emergency aortocoronary bypass to restore perfusion.
Left
lung
ends of the internal mammary arteries should be clamped
and ligated with 3-0 silk ties. If the heart is edematous after
a repair, the pericardial sac is not closed. On occasion, there
may appear to be a risk of postoperative cardiac herniation
through a left lateral pericardiotomy performed through a
left anterolateral thoracotomy. Closure of this lateral defect
with interrupted 2-0 silk sutures would then be appropriate. The pericardial sac is drained with a right-angle 36-Fr
thoracostomy tube inserted through the epigastric area of
the abdominal wall. A second 36-Fr thoracostomy tube
is placed anterior to the heart. If either pleural cavity has
been opened, one or two 36-Fr thoracostomy tubes are
placed through the 5th intercostal space between the ipsilateral anterior and middle axillary lines.
On occasion, epicardial pacing wires may have to be
sewn to the heart when arrhythmias continue despite cardiac repair and resuscitation. An unstable patient who is
not fully responsive to continuing resuscitation and inotropes may benet from the transfemoral insertion of an
intraaortic balloon pump before transfer to the ICU. For
patients who will not tolerate wire closure of the sternum
after a cardiac repair, a plastic silo (a genitourinary irrigation bag opened on three seams) should be sewn to the skin
edges of the median sternotomy with continuous sutures of
2-0 nylon as a temporary closure maneuver. As the patient
enters the diuretic phase of recovery in the subsequent 48
to 72 hours, the silo is removed, and the sternum is closed
at a reoperation.
MAJOR COMPLICATIONS
Cardiac Failure
Cardiac failure after repair of a traumatic injury may require
the use of inotropic medications and/or an intraaortic balloon pump. Possible causes of cardiac failure are: (1) tamponade from a coagulopathy, hemorrhage from the repair,
or hemorrhage from a missed injury; (2) cardiac compression from closure of the sternum; (3) posttraumatic myocardial infarction without injury to a coronary artery53; (4)
posttraumatic myocardial infarction with injury to a coronary artery; and (5) undiagnosed injury to a cardiac valve,
a papillary muscle, the chordae tendineae, or the atrial or
ventricular septum. An immediate ECG and TTE or TEE will
assist in making the diagnosis. Cardiac compression from
closure of the sternum is usually diagnosed at the completion of the rst operation and is easily reversed by removing
the sternal wires.
Delayed Diagnosis of Intracardiac Lesions
For more than 55 years, it has been recognized that patients
who survive acute repair of a wound or rupture of the atrium
or ventricle may also have an internal cardiac injury.54 Postoperative cardiac failure or the presence of a murmur on
auscultation in a previously healthy patient is a clinical sign
of such an internal injury. Other patients, particularly those
with internal stulas (i.e., right atrium to left ventricle) may
be asymptomatic in the postoperative period.55 There is disagreement about studying all surviving patients with TTE
before discharge. In the 2016 report from Grady Memorial
Hospital, only 25 of 46 patients who survived after a penetrating cardiac wound from 2000 to 2010 had a post-repair
two-dimensional TTE.22 All three of the patients who had
“positive” echocardiograms (two ventricular septal defects;
one cardiac failure) were symptomatic at the time.
An abnormal or inconclusive TTE would usually be followed by a TEE or cardiac catheterization. A patient with
a hemodynamically signicant injury to a valve, papillary muscle, chordae tendineae, or a septum should have
delayed repair on cardiopulmonary bypass.
56
SURVIVAL
Survival after penetrating cardiac trauma depends on the
mechanism of injury (stab vs. gunshot), the number of signs
of life on admission (cardiovascular and respiratory components of trauma score), the location of the thoracotomy
(emergency department vs. OR), the cardiac rhythm at the
time of the pericardiotomy (rhythm vs. asystole), the
number of chambers injured, and the associated inju-
12,22,57
ries.
in Table 16.4.
Survival rates from two large series are listed
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Table 16.4 Survival Rates After Penetrating Cardiac
Injuries.
Asensio et al.
1994–96 1975–85 1986–96 2000–10
Patients 105 113 79 79
SW/GSW 37/68 77/36 53/26 34/45
Survival SW 24/37 (65%) 59/77
Survival GSW 11/68 (16%) 23/36
Survival
overall
Survival EDT 10/71 (14%) 2/23 (9%) 13/28
EDT, Emergency department thoracotomy; GSW, gunshot wound; SW, stab
wound.
a
Data from Asensio JA, Berne JD, Demetriades D, et al. One hundred five
penetrating cardiac injuries: a 2-year prospective evaluation. J Trauma.
1998;144:1073–1082.
b
Data from Morse BC, Carr JS, Dente CJ, et al. Penetrating cardiac injuries: a
36-year perspective at an urban, level I trauma center. J Trauma Acute Care
Surg. 2016;81:623–631.
35/105 (33%) 82/113
a
(77%)
(64%)
(73%)
Morse et al.
47/53
(89%)
15/26
(58%)
62/79
(78%)
(46%)
b
26/34
(76%)
20/45
(44%)
46/79
(58%)
9/16
(56%)
Injuries to the Great Vessels
DEFINITION/CLASSIFICATION
The great vessels in the chest and thoracic outlet are variously dened, but most consider this category to include the
large vessels originating from the aortic arch and those in
what is traditionally considered zone I of the neck. In this
context, the terminology includes the ascending, transverse, and descending thoracic aorta as well as the innominate (brachiocephalic), common carotid, and subclavian
arteries. Because of their sizes and proximal locations, the
innominate and central jugular veins may also be included
as great vessels of the chest. Table 16.5 provides the AAST
Thoracic Vascular Organ Injury Scale for vascular trauma
in this region.
25
Table 16.5 Thoracic Vascular Organ Injury Scale.
a
Grade
I Intercostal artery/vein 901.81 2–3
II Azygous vein 901.89 2–3
III Carotid artery 900.01 3–5
IV Thoracic aorta, descending 901.0 4–5
V Thoracic aorta, ascending and arch 901.0 5
VI Uncontained total transection of
AIS-90, Abbreviated Injury Scale; ICD-9, International Classification of
Diseases.
a
Increase one grade for multiple grade III or IV injuries if >50% circumference. Decrease one grade for grade IV and V injuries if <25%
circumference.
b
Based on most accurate assessment at autopsy, operation, or radiologic
study.
From Moore EE, Malangoni MA, Cogbill TH, et al. Organ injury scaling IV.
Thoracic vascular, lung, cardiac, and diaphragm. J Trauma. 1994;36:
299–300.
Injury Description
Internal mammary artery/vein 901.82 2–3
Bronchial artery/vein 901.89 2–3
Esophageal artery/vein 901.9 2–3
Hemiazygos vein 901.89 2–3
Unnamed artery/vein 901.9 2–3
Internal jugular vein 900.1 2–3
Subclavian vein 901.3 3–4
Innominate vein 901.3 3–4
Innominate artery 901.1 3–4
Subclavian artery 901.1 3–4
Inferior vena cava (intrathoracic) 902.10 3–4
Pulmonary artery, primary intraparenchymal branch
Pulmonary vein, primary intraparenchymal branch
Superior vena cava 901.2 3–4
Pulmonary artery, main trunk 901.41 4
Pulmonary vein, main trunk 901.42 4
thoracic aorta or pulmonary hilum
b
ICD-9 AIS-90
901.41 3
901.42 3
901.0 5
901.41 4
901.42 4
HISTORY
Several authors have cited the repair of a stab wound of the
ascending aorta in 1922 by Dfhanelidze in Russia as one of
the earliest examples of a repair of a great vessel injury.
Emergency ligation of injured great vessels and delayed
repair of aneurysms and arteriovenous stulas of the same
were described in reports after World War II.
est civilian reports on techniques of exposure and repair of
great vessel trauma (exclusive of blunt rupture of the thoracic aorta) were from Johns Hopkins and Baylor College of
Medicine.
63–65
INCIDENCE
Penetrating Trauma
If wounds to the heart and coronary arteries (#553) are
excluded from the 30-year review of 5760 cardiovascular injuries at Ben Taub Hospital in Houston, injuries to
the great vessels accounted for approximately 10% of
60–62
The earli-
58,59
cases.17 The mechanism of these injuries is overwhelmingly penetrating (90%). Of patients who undergo emergent thoracotomy after penetrating thoracic injury, less
than one-third have a great vessel injury as the cause of
hemorrhage.
Blunt Trauma
Blunt injuries to the great vessels (exclusive of the descending
thoracic aorta, which will be described in Chapter 17 of this
textbook), are uncommon. When they do occur, these injuries
almost always involve the proximal innominate or subclavian
artery. In an older series describing 43 patients with injury to
the innominate artery from 1960 to 1992, a blunt mechanism
was the cause in 17% of patients.66 Another even-older series
on 93 patients with subclavian vascular trauma from 1955 to
1978 noted that only 2% of patients had a blunt mechanism
of injury.67 Both of these reviews, however, included periods
of time when shoulder-harness restraints either were not
available on passenger vehicles or were not commonly used.
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ETIOLOGY
Penetrating Trauma
A gunshot wound to the chest has less than a 5% chance
of injuring a thoracic great vessel.59 This low incidence
in patients arriving at trauma centers reects the lethal
nature of penetrating wounds in this region. Stab wounds
are also uncommon and are reported to injure a great vessel
in only 2% of instances.59 This low percentage reects the
fact that a stab wound causing a great vessel injury must
fall within a limited parasternal, thoracic outlet, or supraclavicular area.
Blunt Trauma
Blunt injuries to the innominate and subclavian arteries
most commonly occur in individuals wearing shoulderharness restraints in frontal motor vehicle crashes. The proposed mechanism for this injury is direct compression to the
upper sternum or clavicle/rst rib with partial or complete
avulsion off the aortic arch (innominate artery) or thrombosis (subclavian artery) (Fig. 16.7). Another mechanism
involves hyperextension and lateral rotation of the cervical spine away from the side of the shoulder harness. This
mechanism occurs as the victim slides under the shoulder
harness and may cause stretching and avulsion of the vessel. Either mechanism may lead to disruption of the intima
with or without injury to part or all of the media and adventitia. Similar mechanisms have been proposed to explain
blunt injury to the carotid and vertebral arteries. Disruptive
injuries to cervical vertebrae contribute to select patterns of
zone I vascular trauma, as well.
PRESENTATION
Penetrating Trauma
Patients with penetrating wounds to the thoracic outlet and
superior mediastinum will present with one of three different clinical scenarios. First, some will be asymptomatic with
normal vital signs and a normal chest x-ray. These patients
may have proximity of the penetrating wound only to zone I
of the neck and to the great vessels (Fig. 16.8). Second,
some patients will be asymptomatic with a normal blood
pressure, but will have a contained hematoma in the suprasternal, mediastinal, or supraclavicular area. This otherwise
asymptomatic hematoma may be seen on physical examination, chest x-ray, or both (Fig. 16.9). The third group
of patients will have proximity of a penetrating wound to
zone I structures with hard signs of vascular trauma such
as external bleeding, expanding hematoma, hemorrhagic
shock, a hemothorax on a surgeon-performed ultrasound,
or a lung outlined by blood or a hematoma visible on a
chest x-ray (Fig. 16.10). Those in the latter two groups with
injuries to the subclavian artery may have a difference in
blood pressure between upper extremities with the affected
side notably less than the unaffected side. Because of the
extensive collateral ow around the subclavian and axillary
arteries, a patient with proximal thrombosis of the subclavian artery may still have palpable pulses in the ipsilateral
upper extremity (Figs. 16.11 and 16.12). Measurement and
comparison of upper extremity blood pressure using either
a stethoscope or the continuous wave Doppler has enough
sensitivity for the clinician to identify this type of injury.
Blunt Trauma
If the injured patient was not wearing a restraint and there
was no deployment of an air bag, a sternal contusion may
suggest a blunt injury to the descending thoracic aorta.
Patients with partial avulsion of the innominate artery
from the aortic arch may present with hypotension, diminished or absent pulses in the right upper extremity, and a large
hematoma in the superior mediastinum seen on a chest x-ray.
A less severe injury would be an intimal tear of the innominate or subclavian artery without thrombosis. Therefore,
Fig. 16.7 Shoulder-harness restraint caused proximal occlusion of the
right subclavian artery.
Fig. 16.8 An arteriogram that was performed in an asymptomatic
patient with a stab wound to the thoracic outlet demonstrated a 5-cm
traumatic false aneurysm of the right common carotid artery (arrows).
16 • Cardiac, Great Vessel, and Pulmonary Injuries 183
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Fig. 16.9 (A) Chest x-ray of a patient with a gunshot wound in proximity to the left subclavian artery and a palpable hematoma in the left supraclavicular
area. (B) Computed tomography angiogram reconstruction of injury to the left subclavian artery in same patient as (A). Also, note injury to left scapula.
(C) Intraoperative angiogram performed with combined contrast through thoracic aorta and left brachial artery prior to insertion of endovascular stent.
it is external markers of mediastinal injury, asymmetric
upper extremity blood pressures, and/or an abnormal chest
x-ray that should prompt further imaging. Of interest, some
patients with injury to the proximal innominate artery have
a particular pointed appearance to the right side of the superior mediastinum on chest x-ray (Fig. 16.13).
As previously noted, a blunt injury to the proximal
subclavian artery typically causes a ow-limiting intimal
abnormality or thrombosis. Although most blunt injuries
to the common carotid artery occur in zone II of the neck,
more proximal injuries to the common carotid artery (i.e.,
zone I) can occur. Indicators of such an injury include
the previously mentioned external mark of trauma from
a shoulder-harness restraint on the lower neck or supraclavicular area. Also, a blunt injury to the carotid artery
should be suspected in patients who present with abnormal
neurological ndings with a normal CT scan of the brain.
In those with a proximal (zone I of the neck) injury to
the common carotid artery, there may also be a widened
superior mediastinum on the initial chest x-ray. Other classic ndings associated with blunt cerebrovascular injury
include cervical spine fracture, LeFort II or III facial fractures, Horner syndrome, and skull-base fracture. The presence of one or more of these ndings should heighten the
trauma team's suspicion of the presence of a blunt injury to
the common or internal carotid artery.
184 SECTION 4 • The Management of Vascular Trauma
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Fig. 16.10 A profoundly hypotensive patient with superior mediastinal
hematoma from a gunshot wound to posterior transverse aortic arch
and the left common carotid artery was taken to the operating room
directly. (With permission from Feliciano DV. Vascular injuries. In: Maull KI,
Cleveland HC, Strauch GO, et al., eds. Advances in Trauma, Vol. 2. Chicago:
Mosby-Year Book; 1987:179–206.)
Fig. 16.12 The same patient as in Fig. 16.11. Delayed film demon-
strates reconstitution of the left axillary artery in this patient with an
intermittently normal left radial pulse. (With permission from Graham
JM, Feliciano DV, Mattox KL. Combined brachial, axillary, and subclavian
artery injuries of the same extremity. J Trauma. 1980;20:899–901.)
Fig. 16.11 A patient with thrombosis of the proximal left subclavian
artery on arteriogram after sustaining a gunshot wound to the lateral
left arm. (With permission from Graham JM, Feliciano DV, Mattox KL.
Combined brachial, axillary, and subclavian artery injuries of the same
extremity. J Trauma. 1980;20:899–901.)
Fig. 16.13 A patient with a pointed appearance of the right side of
the widened superior mediastinum had blunt rupture of the innominate artery on a computed tomography arteriogram. (With permission
from Feliciano DV, Burch JM, Graham JM. Vascular injuries of the chest and
abdomen. In: Rutherford RB, ed. Vascular Surgery. 3rd ed. Philadelphia: WB
Saunders; 1989:588–603.)
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