CASE REPORT

Survival following resuscitative thoracotomy forcombined left ventricle and left atrium rupturessecondary to blunt trauma

Mark Fitzgerald a,*, Abhishek Basu a, Fatima Rahman a, T. John Russell b,Jane Hines a, Julian Gooi c, Silvana Marasco c, Lamia Bezer b,Peter Effeney d, Kerryn Bunbury d

a Emergency & Trauma Centre, The Alfred Hospital, Melbourne, AustraliabDepartment of Trauma Surgery, The Alfred Hospital, Melbourne, AustraliacDepartment of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, AustraliadDepartment of Anaesthesia and Perioperative Medicine, The Alfred Hospital, Melbourne, Australia

Accepted 24 April 2008

Injury, Int. J. Care Injured (2008) 39, 1089—1092

www.elsevier.com/locate/injury

KEYWORDSTrauma systems;Cardiac trauma;Cardiac tamponade;Resuscitativethoracotomy;FAST

Summary Improvements in pre-hospital care and the development of integratedTrauma Systems have streamlined access for the severely injured to sophisticated,specialist Trauma Centre reception and resuscitation. We describe the initial care of asurvivor of combined ruptures of the left ventricle and left atrium secondary to bluntinjury. This case emphasises the contribution of such a Trauma System in achieving afavourable outcome for a severely injured trauma patient with injuries previouslyconsidered non-survivable.# 2008 Elsevier Ltd. All rights reserved.

Case

A 54 male was the driver of a small motor car whichwas struck by a truck at high speed. The paramedicsfirst at scene noted the patient was conscious andconversant with a nonrecordable blood pressure.There was an entrapment time of 67 min. A duallyresponded Mobile Intensive Care (MICA) paramedic

* Corresponding author at: Emergency & Trauma Centre, Emer-gency Department, The Alfred Hospital, Commercial Road, Mel-bourne, VIC 3350, Australia. Tel.: +61 392762000;fax: +61 392762699.

E-mail address: m.fitzgerald@alfred.org.au (M. Fitzgerald).

0020–1383/$ — see front matter # 2008 Elsevier Ltd. All rights resedoi:10.1016/j.injury.2008.04.024

staffed rotary wing aircraft attended the scene. TheMICA paramedic noted left sided rib fractures and aleft flail chest. The patient was paralysed, intu-bated and mechanically ventilated using Midazolam3.5 mg, Suxamethonium 125 mg and Pancuronium8 mg intravenously (i.v.). Bilateral Arrow Pneumo-cathTM catheters were placed and a Laerdal Stiff-neckTM cervical collar and SAM slingTM pelvic binderapplied. 5500 ml of 0.9% NaCl was administered i.v.en route and the patient arrived at the AlfredTrauma Centre 80 min after the accident.

On arrival at the Trauma Centre the patient had asystolic BP of 60 mmHg and a heart rate of 115 bpm.Pupils were 2 mm and equal and reactive.

rved.

1090 M. Fitzgerald et al.

Figure 2 Procedure.

The patient was noted to have thoracic subcuta-neous emphysema and left sided rib fractures. Thepleura were decompressed bilaterally and 32 Fr TycoArgyleTM pleural catheters were placed prior tosupine chest X-ray. The initial chest radiographdemonstrated a lobulated prominence of the super-ior mediastinum and was suspicious for mediastinalinjury–—although heart size was within normal lim-its.

Despite fluid resuscitation with crystalloids andblood products (4 units of red packed cells and 2units of fresh plasma via a Level 1TM infuser in thefirst minutes of resuscitation) systolic blood pres-sure did not increase. During this time a right sub-clavian Arrow Multi Access CatheterTM and a rightCookTM femoral arterial line were inserted. Thepatient was hypothermic (T 30 8C), coagulopathic(INR 2.4), with a pH of 6.97, PaO2 84 mmHg andserum lactate 8.4 mmol/l. At 18 min postarrival theintra-arterial systolic blood pressure was 57 mmHg.Focused assessment with sonography for trauma(FAST) demonstrated free fluid in Morrison’s pouchand around the spleen with a haemoperitoneumestimated to be <1000 ml. Cardiac views demon-strated haemopericardium with cardiac tamponadeand right ventricular collapse, as well as extensiveclot over the right ventricle (Fig. 1).

An emergency left anterolateral thoracotomywas performed. A left haemothorax and laceratedlower lobe of the left lung was noted. There was atense haemopericardium which was decompressed.Following pericardial decompression the arterialsystolic BP rose from 57 to 157 mmHg. A 3 cmlaceration to the anterior aspect of the left ven-tricle was noted. The most inferior aspect of thelaceration was full thickness with pulsatile haemor-rhage that was controlled with digital pressure. Thethoracotomy incision was extended through thesternum and the left internal mammary arterywas clamped. The left ventricular wound was heldwith gentle traction and Vicryl 2.0 interruptedsutures with SurgicelTM pledgets were placed. Dur-ing the ventricular wound repair substantial bleed-ing suddenly occurred from the superior and

Figure 1 FAST scan demonstrating haemopericardium.

posterior aspect of the heart. A torn left atrialappendage was identified and digitally controlleduntil the left ventricular wound was repaired(Fig. 2). A Satinsky clamp was then applied to theleft atrial appendage and the patient was trans-ferred to the Operating Room. The patient wassupine in Trendelenburg’s position during the pro-cedure. During the resuscitation a total of 0.6 mg ofadrenaline had been administered intravenously.

Definitive management of cardiac, pulmonaryand abdominal injuries was performed in the oper-ating theatre. The left atrium was repaired. A fulltrauma laparotomy with splenectomy and liverpacking was performed. The BIS score on arrivalin the operating theatre was between 30 and 40.It was low for very short periods of time when theheart was handled to facilitate the atrial repair andthe patient became hypotensive. A postoperativetrans-thoracic echocardiograph showed no asso-ciated valvular injury and no hypokineticmyocardialareas. The postoperative course was complicated bypersistent chest infection and a pleural collectiontreated with surgical drainage and prolonged anti-biotic therapy. The patients injuries are listed inFig.3. Atlanto-occiptal instability was treated withhalo fixation. The patient was discharged to a reha-bilitation facility on postoperative day 39 indepen-dent.

Information for this case report was derived fromthe Alfred Trauma NetTM trauma registry, thepatient record and the Trauma Reception and Resus-citation ProjectTM which captures real-time visual,physiological, procedural and diagnostic data.6 Thismethodology has the prior approval of the AlfredEthics and Research Committee.

Resuscitative thoracotomy for LV and LA rupture 1091

Figure 3 Anatomical diagnoses.

Discussion

Blunt trauma patients with no signs of life at thetime of hospital arrival have been shown to haveconsistently poor outcome–—despite resuscitativethoracotomy performed in the Trauma Centre/Emergency Department.14 Resuscitative thoracot-omy is reserved for those with deteriorating phy-siology and proven cardiac tamponade or forunstable patients in extremis.8

Improvements in pre-hospital care and the con-tinuing development of integrated Trauma Systemshave streamlined access for the severely injured tosophisticated, specialist Trauma Centre receptionand resuscitation.1 There has been an associatedincrease in survival for those patients sufferingmajor trauma.2,11,12 As regional trauma systemsevolve, patients with severe, but potentially survi-vable cardiac injury are surviving to reach hospital.7

A theme of Australasian Trauma Systems is thespecialist Trauma Teams that receive seriouslyinjured patients. These multidisciplinary teamsemploy a broad range of resuscitative, diagnosticand surgical skills and have been shown to improveoutcomes in the trauma patient.9 With this case ofseverecardiac injurytheoutcomewasgoodasaresultof this multidisciplinary approach, rapid assessment,intensive monitoring and prompt treatment.

Cardiac chamber rupture has an incidence of 0.3—0.9% of major trauma cases.17 Survivors of blunt orpenetrating cardiac injury usually present with vitalsigns4,10 and the main pathophysiological determi-nant for most survivors is acute pericardial tampo-nade.13,16 This requires a prompt diagnosis and apotentially good outcome if acted on immediately.

In this case ultrasound played a vital role in earlydiagnosis of pericardial tamponade and triggeredemergency resuscitative thoracotomy. Ultrasound isan important triage tool in determining the pre-

sence of cardiac tamponade. Its widespread avail-ability has made part of the blanket argumentagainst resuscitative thoracotomy for blunt traumapatients redundant.3 Immediate use of ultrasono-graphy can establish the diagnosis of haemopericar-dium–—and prompt repair of the injury may improveoverall survival.15 For patients with severe hypoten-sion or in extremis the treatment of choice is resus-citative thoracotomy and direct control of thecardiac injury.5,7

This case demonstrates the importance of anintegrated trauma system for the reception andmanagement of patients with severe multi-trauma.Patients with injuries previously considered nonsur-vivable may now achieve good outcomes withprompt diagnoses and management in appropriatespecialist centres.

Conflict of interest

There are no conflicts of interest associated with thepublication of this article.

Acknowledgement

The authors acknowledge the contribution of thestaff from the Trauma Registry, Department ofTrauma Surgery in the provision of data for thismanuscript.

References

1. Atkin C, Freedman I, Rosenfeld JV, et al. The evolution of anintegrated state trauma system in Victoria, Australia. Injury2005;36(November):1277—87.

1092 M. Fitzgerald et al.

2. Barquist E, Pizzutiello M, Tian L, et al. Effect of traumasystem maturation on mortality rates in patients with bluntinjuries in the Finger Lakes Region of New York State. JTrauma 2000;49(July):63—9.

3. Bodai BI, Smith JP, Blaisdell FW. The role of emergency thor-acotomy in blunt trauma. J Trauma 1982;22(June):487—91.

4. Brathwaite CE, Rodriguez A, Turney SZ, et al. Blunt traumaticcardiac rupture. A 5 year experience. Ann Surg 1990;212(December):701—4.

5. Feliciano DV, Rozycki GS. Advances in the diagnosis andtreatment of thoracic trauma. Surg Clin N Am 1999;79(December):1417—29.

6. Fitzgerald M, Bystrzycki A, Farrow N, et al. Trauma receptionand resuscitation. ANZ J Surg. 2006;76:725—8.

7. Fitzgerald M, Spencer J, Johnson F, et al. The definitivemanagement of cardiac rupture and tamponade secondaryto blunt trauma. Emerg Med Australasia 2005;17:494—9.

8. Hunt PA, Greaves I, Owens WA. Emergency thoracotomy inthoracic trauma–—a review. Injury 2006;37:1—19.

9. Lee G, Farrow N, Fitzgerald M, et al. Innovative technology toimprove trauma patient outcomes–—the trauma receptionand resuscitation project. Australasian Emerg Nurs J2005;8:122—3.

10. Martin TD, Flynn TC, Rowlands BJ, et al. Blunt cardiacrupture. J Trauma 1984;24(April):287—90.

11. Mullins RJ, Mann NC, Hedges JR, et al. Preferential benefit ofimplementation of a statewide trauma system in one of twoadjacent states. J Trauma 1998;44(April):609—16.

12. Mullins RJ, Veum-Stone J, Hedges JR, et al. Influence of astatewide trauma system on location of hospitalisation andoutcome of injured patients. J Trauma 1996;40(April):536—45.

13. Rhee PM, Foy H, Kaufmann C, et al. Penetrating cardiacinjuries: a population based study. J Trauma 1998;45(August):336—70.

14. Shimazu S, Shatney CH. Outcomes of trauma patients with novital signs on hospital admission. J Trauma 1983;23:213—6.

15. Sybrandy KC, Cramer MJM, Burgersdijk C. Diagnosing cardiaccontusion: old wisdom and new insights. Heart 2003;89(May):485—9.

16. Tyburski JG, Astra L, Wilson RF, et al. Factors affectingprognosis with penetrating wounds of the heart. J Trauma2000;48(April):587—91.

17. Wintermark M, Delabays A, Bettex D, Schnyder P. Blunttrauma of the heart: pattern of atrial appendage ruptures.Eur Radiol 2001;11:113—6.