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Emergency Surgical Management of Traumatic Cardiac Injury in Single Institution for Three Years
Journal of Trauma and Injury 2017;30(4):166-172
Published online December 30, 2017
© 2017 The Korean Society of Trauma.

Seok Joo, Dae Sung Ma, Yang Bin Jeon, and Sung Youl Hyun

Department of Trauma Surgery, Regional Trauma Center, Gachon University Gil Hospital, Incheon, Korea
Correspondence to: Dae Sung Ma, M.D., Department of Trauma Surgery, Regional Trauma Center, Gachon University Gil Hospital, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 21565, Korea, Tel: +82-32-460-3010, Fax: +82-32-460-3019, E-mail: pegamu@gilhospital.com
Received November 7, 2017; Revised December 14, 2017; Accepted December 18, 2017.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Purpose

Thoracic traumas represent 10–15% of all traumas and are responsible for 25% of all trauma mortalities. Traumatic cardiac injury (TCI) is one of the major causes of death in trauma patients, rarely present in living patients who are transferred to the hospital. TCI is a challenge for trauma surgeons as it provides a short therapeutic window and the management is often dictated by the underlying mechanism and hemodynamic status. This study is to describe our experiences about emergency cardiac surgery in TCI.

Methods

This is a retrospective clinical analysis of patients who had undergone emergency cardiac surgery in our trauma center from January 2014 to December 2016. Demographics, physiologic data, mechanism of injuries, the timing of surgical interventions, surgical approaches and outcomes were reviewed.

Results

The number of trauma patients who arrived at our hospital during the study period was 9,501. Among them, 884 had chest injuries, 434 patients were evaluated to have over 3 abbreviated injury scale (AIS) about the chest. Cardiac surgeries were performed in 18 patients, and 13 (72.2%) of them were male. The median age was 47.0 years (quartiles 35.0, 55.3). Eleven patients (61.1%) had penetrating traumas. Prehospital cardiopulmonary resuscitations (CPR) were performed in 4 patients (22.2%). All of them had undergone emergency department thoracotomy (EDT), and they were transferred to the operating room for definitive repair of the cardiac injury, but all of them expired in the intensive care unit. Most commonly performed surgical incision was median sternotomy (n=13, 72.2%). The majority site of injury was right ventricle (n=11, 61.1%). The mortality rate was 22.2% (n=4).

Conclusions

This study suggests that penetrating cardiac injuries are more often than blunt cardiac injury in TCI, and the majority site of injury is right ventricle. Also, it suggests prehospital CPR and EDT are significantly responsible for high mortality in TCI.

Keywords : Trauma, Heart injuries, Cardiac surgery
INTRODUCTION

Thoracic traumas represent 10–15% of all traumas and are responsible for 25% of all trauma mortalities [1]. Traumatic cardiac injury (TCI) is one of the major causes of death in trauma patients, rarely present in living patients who are transferred to the hospital. TCI is a challenge for trauma surgeons as it provides a short therapeutic window and the management is often dictated by the underlying mechanism and hemodynamic status [2]. Due to the improved transfer system in trauma, patients with TCI who survive to reach the hospital have increased.

This study is to describe our experiences about emergency cardiac surgery in TCI.

METHODS

This study is a retrospective clinical analysis of patients who had undergone emergency cardiac surgery in our trauma center from January 2014 to December 2016. Demographics, physiologic data, mechanism of injuries, the timing of surgical interventions, surgical approaches, and outcomes were reviewed.

Inclusion criteria were 1) the patients who underwent trauma and 2) the presence of surgically confirmed cardiac injury. The patients were excluded; who underwent emergency department thoracotomy (EDT) but had not surgically confirmed the cardiac injury.

Focused assessment with sonography for trauma (FAST) was conducted in all patients. No preoperative echocardiography was done. Preoperative chest computed tomography (CT) scan was performed by each surgeon’s assessment considering the medical condition of the patient. EDT was performed on the patients who were in extremis, or who lost their vital signs in transport or the trauma bay. All the operative procedures were conducted by four cardiothoracic surgeons with expertise in trauma management. Patients were operated upon under general anesthesia with single lumen endotracheal tube. The heart-lung machine was not used in any of the patients.

The bleeding from cardiac injuries was primarily controlled by applying digital pressure. And then the cardiac injuries were repaired using double-armed monofilament stitches with or without pledgets as interrupted or running sutures by the operating surgeon’s preference. All the patients were admitted and managed in the intensive care unit (ICU) in the postoperative period.

Statistical analyses

All descriptive statistics were expressed as the median and interquartile range for continuous variables. Categorical data were analyzed with Fisher exact test. Continuous data were compared using the Mann-Whitney U test. Differences were considered to be statistically significant with p values <0.05. Statistical analyses were performed using SPSS statistical software version 22.0 (SPSS Inc., Chicago, IL, USA).

RESULTS

The number of trauma patients who arrived at our hospital during the study period was 9,501. Among them, 884 had chest injuries, 434 patients were evaluated to have over 3 abbreviated injury scale (AIS) about the chest. Cardiac surgeries were performed in 18 patients.

Clinical characteristics of patients are listed in Table 1. Thirteen (72.2%) patients were male. The median age was 47.0 years (quartiles 35.0, 55.3). Eleven patients (61.1%) had penetrating traumas. Prehospital cardiopulmonary resuscitations (CPR) were performed in 4 patients (22.2%). All of them had undergone EDT, and they were transferred to the operating room for definitive repair of the cardiac injury, but all of them expired in the ICU. Nine patients (50.0%) were evaluated by chest CT before the operation.

Perioperative variables of patients are listed in Table 2. Most commonly performed surgical incision was median sternotomy (n=13, 72.2%). The majority site of injury was right ventricle (n=11, 61.1%), three at right atrium, three at pericardium and one at left atrium, respectively. Concomitant procedures were performed in 8 patients (44.4%), especially pulmonary repairs were performed in 4 patients. Only two cases were known to have the cardiac problem on postoperative echocardiography. Mortality rate was 22.2% (n=4). The causes of deaths were two hemorrhagic shocks, a DIC and a cardiac tamponade.

Comparison between survival group and fatality group is presented in Table 3. The median age was 50.0 years (quartiles 35.0, 59.3) in the survival group, 40.5 years (quartiles 31.6, 46.5) in fatality group, respectively (p=0.202). The median injury severity score (ISS) was 26.00 (quartiles 10.00, 30.00) in the survival group, 30.00 (quartiles 25.25, 64.75) in the fatality group, respectively (p=0.199). The median RTS was higher in the survival group than in the fatality group (6.904 [quartiles 5.389, 7.841] vs. 0.582 [quartiles 0, 2.991]; p=0.005). The median TRISS was higher in the survival group than in the fatality group (86.350 [quartiles 67.925, 94.725] vs. 0.850 [quartiles 0.425, 1.350]; p=0.003). The median AIS chest was 5.00 (quartiles 3.75, 5.00) in the survival group and 5.00 (quartiles 5.00, 5.75) in the fatality group, respectively (p=0.066). The median Gglasgow coma scale (GCS) was higher in the survival group than in the fatality group (13.0 [quartiles 7.0, 15.0] vs. 3 [quartiles: 3.0, 6.0]; p=0.006). In the survival group, the patients had higher initial systolic blood pressure than in the fatal group (97.00 [quartiles 64.75, 114.50] vs. 0; p=0.003). Regarding the time lag, the median time from field to operation room was 66.00 minutes (quartiles 46.25, 81.75) in the survival group, 46.50 minutes (quartiles 37.75, 59.75) in fatality group, respectively (p=0.111). And the median time from field to operation room was 146.00 minutes (quartiles 110.00, 218.50) in the survival group, 100.00 minutes (quartiles 76.25, 139.50) in fatality group, respectively (p=0.123). The median operation time was 135.00 minutes (quartiles 108.75, 172.50) in the survival group 183.50 minutes (quartiles 170.75, 218.75) in the fatality group, respectively (p=0.033).

DISCUSSION

TCI is an uncommon occurrence following chest trauma, which is a significant cause of mortality in trauma victims [2]. Patients with traumatic cardiac injury rarely survive, and most die at the scene or soon in the emergency room before the cardiac lesions are diagnosed [3].

The prevalence of TCI depends on the amount of violence in society, the volume of motor vehicle crashes, and access to the medical facility. Mishra et al. [2] reported that the incidence of TCI was 1.168% (21/1798) in traumatic chest injury. In our study, the incidence of TCI was 2.036% (18/884).

Survival rate following TCI has been reported from 19% to 74% in the literature [3,4]. In this study, survival rate following TCI was 77.8% (14/18), the Survival rate of blunt cardiac injury was 85.7% (6/7), and the survival rate of penetrating cardiac injury was 72.7% (8/11).

Hypotension at presentation in trauma bay was significantly related to high mortality [2]. In our study, all mortality cases had uncheckable blood pressure. Physiologic indices such as the RTS and GCS were statistically significant as predictors of outcomes [5]. We reported the median RTS was higher in the survival group than in the fatality group (6.904 [quartiles 5.389, 7.841] vs. 0.582 [quartiles 0, 2.991]; p=0.005). Also, the median GCS was higher in the survival group than in the fatality group (13.0 [quartiles 7.0, 15.0] vs. 3.0 [quartiles 3.0, 6.0]; p=0.006).

Associated injuries were more often seen with blunt injury than in penetrating injury [2]. Multi-organ traumatic injury, especially neurological insult, may adversely impact the survival even with timely repair of heart damage [3]. But we could not perform in depth evaluation of other organ injuries, especially in fatality group, because of the disastrous situation and the urgency of preparing for the emergency operation. Thus the possibility of the result being influenced by undetected or occult injuries is the limitation of this study.

Administration of intravenous fluids may be more harmful in TCI patients as it may precipitate tamponade. Meticulous examination by FAST and early intervention could improve the overall outcome [2]. If pericardial tamponade was detected, emergency thoracotomy and repair of underlying cardiac injury by trauma surgeon could improve the survival rate.

Definitive surgical procedure to manage TCI is surgical drainage of pericardial blood and repair of underlying cardiac injury. Clinical features depend on the type of mechanism of injury (blunt or penetrating), and the size of the wound in the heart or the pericardium [2]. Patients with TCI who survive to reach the hospital usually have sustained injuries limited to one cardiac chamber that can be repaired by trauma surgeons without cardiopulmonary bypass [2]. Rhee et al. [6] reported the number of chambers injured in an individual was predictive of outcome and single-chamber injuries (61%) were more common than multi-chamber injuries. In our study, all patients had single chamber injury and most frequently injured cardiac chamber was right ventricle (n=11, 61.1%).

When cardiac lesions are first identified on exploratory thoracotomy for a massive hemothorax, shifting to median sternotomy should be performed without hesitation if the visualization is limited and surgical assistance is difficult [3]. Use of the median sternotomy was a strong predictor of favorable outcomes; probably it is used in patients that present with lesser degrees of hemodynamic stability and who are able to reach the operation room [6]. In our study, most commonly performed surgical incision was median sternotomy (n=13, 72.2%).

Rapid and early diagnosis, multidisciplinary approach and prompt transfer to the operating room are the cornerstones in the management of TCI patient [1,2,57]. And speedy and optimal surgery is essential to improve outcome, the delay can adversely affect the outcome regarding both morbidity and mortality [7].

Fatimi et al. [7] reported, the average time lag between injury and arrival to the hospital was 2.17 hours, and the time lag between arrival to the hospital and incision time was 32.13 minutes. In our cases, the median time from field to trauma bay was 63.50 minutes (quartiles 36.00, 121.75). The median time from trauma bay to operation room was 61.50 minutes (quartiles 44, 75.75). The median time from field to operation room was 138.50 (quartiles 102.50, 199.50). The median operation time was 142.50 minutes (quartiles 125.00, 182.75). We need to shorten the time lag because rapid transfer and early diagnosis and approach are essential to improve outcome. We should educate about prehospital trauma care and transfer. It is necessary to review the processes of managing TCI patients, and then, revise and improve the management protocol in the trauma bay. Although the operation time was thought to be affected by the surgical situation and concomitant operative procedure for other organs, it took too much time. We need to practice operative skills to shorten the operation time and to improve the outcomes.

Our study had several limitations. First, it was limited to a small number of patients. A lot of variables did not reach statistical significance presumably due to the small number. Second, it was a retrospective study, and all cohort is under the emergency situation. We could not include more detailed information regarding the variables (comorbidity, concomitant injury, medical history, etc.), especially in fatality group. Third, heterogeneity of the cohort is a kind of limitations of this investigation. To further validate our results, prospective collection of data through TCI registry and a larger group of patients are needed. Further multi-institutional studies may provide further information regarding the optimal protocols and prognostic factors in TCI patients.

CONCLUSION

We have detailed our experiences about emergency cardiac surgery in TCI. This study suggests that penetrating cardiac injuries are more common than blunt cardiac injury in TCI and the majority site of injury is right ventricle. Also, it suggests prehospital CPR and EDT are significantly responsible for high mortality in TCI.

ACKNOWLEDGEMENTS

This article was presented at the 25th Annual Meeting of the Asian Society for Cardiovascular and Thoracic surgery, Seoul, Korea from 23–26 March, 2017.

TABLES

Clinical characteristics of patients

CaseSexAge (years)MechanismSeverity of traumaPCPRTime F to TB (min)ConsciousnessISSRTSTRISSAIS chestGCSSBP (mmHg)EDTCT
1M36Stab injuryCardiac tamponade, tension hemopneumothoraxN66Verbal107.10889.151480NN
2M63Stab injuryCardiac tamponade, liver lacerationN73Painful266.90467.159112NN
3F32Stab injuryCardiac tamponadeN117Painful266.90493.359122NOutside
4F40Stab injuryHemopericardiumN136Alert347.84199.031593NN
5M54Stab injuryCardiac tamponadeN37Verbal385.43976.451250NN
6M64Occupant TAMassive hemothorax right, cardiac tamponadeN165Painful245.23546.75786NOutside
7M30Stab injuryCardiac arrestY56unresponse3400.8570YN
8F25Pedestrian TACardiac tamponadeN25Painful203.47930.85749PericardiocentesisY
9M60Occupant TACardiac tamponadeN180Verbal107.84189.5415130NY
10F36Stab injuryCardiac arrest, IVC laceration, liver lacerationY33Unresponse263.6000.9530YN
11M51Occupant TAHemopericardium, hemothorax, multiple rib fractureN386Painful263.56568.24564NY
12M19Stab injuryHemopericardiumN100Alert97.84199.1315108NY
13F59Stab injuryHemopericardiumN61Alert277.55088.8515101NOutside
14M50Pedestrian TAHemopericardiumN45Verbal336.37683.951465NY
15M50Occupant TAHemopericardiumN31Painful295.67677.157103NY
16M47Pedestrian TACardiac tamponade, cardiac arrestY111Unresponse751.1630.3630NN
17M45Stab injuryRight ventricle perforation, left upper lobe perforationY29Unresponse2501.5530YN
18M47Stab injuryHemothorax left, left lung injuryN54Alert107.84199.0315139NY

PCPR: prehospital cardiopulmonary resuscitation, F to TB (min): field to trauma bay (minutes), ISS: Injury severity score, RTS: revised trauma score, TRISS: trauma and injury severity score, AIS: abbreviated Injury scale, GCS: Glascow coma scale, SBP: systemic blood pressure at trauma bay, EDT: emergency department thoracotomy, CT: computed tomography, N: no, TA: traffic accident, Y: yes, IVC: inferior vena cava.


Perioperative variables of patients

CaseTime TB to OR (min)Time F to OR (min)IncisionCardiac repairConcomitant procedureOP time (min)Ventilator (days)ICU stay (days)Post OP echo findingOutcomeCause of death
184150Median sternotomyRight ventriclePulmonary repair: left upper lobe14015RWMA at LAD territory, depressed LV systolic function (EF: 47%)2nd OP discharge
237110Median sternotomyRight ventricleLaparotomy (liver, omental laceration)14515Discharge
333150Median sternotomyRight ventricle20502NormalDischarge
459195Median sternotomyRight ventricle11000aTransfer
53875Median sternotomyRight ventricleLIMA ligation10503NormalDischarge
670235Median sternotomyLeft atrium18058Postoperative constrictive physiology, reduced LV systolic function(EF:35~45), moderate global hypokinesiaTransfer
764120EDTRight ventriclePulmonary repair: left upper lobe, Laparotomy (colon laceration)23000aExpireDIC
8117142Median sternotomyRight atrium13513NormalDischarge
967241Median sternotomyPericardium13012NormalDischarge
104780EDT, clamshellRight ventriclePulmonary repair: right lower lobe Laparotomy (IVC laceration)18501ExpireHemorrhagic shock
1174460Median sternotomyPericardium1301018NormalTransfer
12113213Left anterior thoracotomyPericardium7502NormalDischarge
1359120Median sternotomyRight ventricle17001NormalTransfer
1465110Median sternotomyRight atrium13503Transfer
154980Median sternotomyRight atrium10512Discharge
1635146EDT, Median sternotomyRight ventriclePeritoneal pelvic packing18200aExpireCardiac tamponade
174675EDT, clamshellRight ventricleWedge resection: left upper lobe, primary repair: right upper lobe16711ExpireHemorrhagic shock
1881135Left thoracotomyRight ventriclePulmonary repair: left upper lobe, left arm repair21002Discharge

TB to OR (min): field to operation room (minutes), F to OR (min): field to operation room (minutes), OP: operation, ICU: intensive care unit, RWMA: regional wall motion abnormality, LAD: left anterior descending coronary artery, LV: left ventricle, EF: ejection fraction, LIMA: left internal mammary artery, EDT: emergency department thoracotomy, DIC: disseminated intravascular coagulation, IVC: inferior vena cava.

aExpired on admission day.


Comparison between survival group and fatality group

VariablesTotal (n=18, 100%)Survival (n=14, 77.778%)Fatality (n=4, 22.222%)p-value
Sex1.000
 Male13 (72.2%)10 (71.4%)3 (75.0%)
 Female5 (27.8%)4 (28.6%)1 (25.0%)

Age (years)47.0 (35.0, 55.3)50.0 (35.0, 59.3)40.5 (31.6, 46.5)0.202

Mechanism1.000
 Blunt7 (38.9%)6 (42.9%)1 (25.0%)
 Penetrating11 (61.1%)8 (57.1%)3 (75.0%)

Prehospital CPR4 (22.2%)04 (100%)<0.001

ISS26.00 (17.50, 33.25)26.00 (10.00, 30.00)30.00 (25.25, 64.75)0.199

RTS6.026 (3.544, 7.623)6.904 (5.389, 7.841)0.582(0, 2.991)0.005

TRISS76.750 (23.475, 90.450)86.350 (67.925, 94.725)0.850 (0.425, 1.350)0.003

AIS chest5.00 (4.00, 5.00)5.00 (3.75, 5.00)5.00 (5.00, 5.75)0.066

GCS9.0 (6.5, 15.0)13.0 (7.0, 15.0)3.0 (3.0, 6.0)0.006

ISBP at TB (mmHg)83.00 (36.75, 109.00)97.00 (64.75, 114.50)00.003

EDT4 (22.2%)04 (100%)<0.001

Pericardiocentesis1 (5.6%)1 (7.1%)01.000

Time F to TB (min)63.50 (36.00, 121.75)69.50 (43.00, 143.25)44.50 (30.00, 97.25)0.243

Time TB to OR (min)61.50 (44.00, 75.75)66.00 (46.25, 81.75)46.50 (37.75, 59.75)0.111

Time F to OR (min)138.50 (102.50, 199.50)146.00 (110.00, 218.50)100.00 (76.25, 139.50)0.123

OP time (min)142.50 (125.00, 182.75)135.00 (108.75, 172.50)183.50 (170.75, 218.75)0.033

CPR: cardiopulmonary resuscitation, ISS: injury severity scale, RTS: revised trauma score, TRISS: trauma and injury severity score, AIS: abbreviated Injury scale, GCS: Glascow coma scale, ISBP: initial systolic blood pressure, TB: trauma bay, EDT: emergency department thoracotomy, F to TB (min): field to trauma bay (minutes), TB to OR: trauma bay to operation room, F to OR: field to operation room, OP: operation.


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