SURGICAL TREATMENT OF CARDIAC RUPTURE IN A PATIENT WITH POLYTRAUMA

Batekha V.I., Medvedev N.V., Gumanenko V.V.

Irkutsk Regional Clinical Hospital of the Badge of Honor Order, Irkutsk State Medical University, Irkutsk, Russia

 SURGICAL TREATMENT OF CARDIAC RUPTURE IN A PATIENT WITH POLYTRAUMA

 A cardiac rupture, which is more common for men of working age after blunt chest injury, 91 % of victims die within 30 minutes after road traffic accidents (RTA) [1, 2, 3]. Among patients with blunt chest injury, a cardiac rupture is a single cause of death or promotes a lethal outcome in persons with penetrating chest injury [5, 6, 7].
A cardiac chamber laceration appears as result of high impact load to anterior surface of the chest with heart compression between the sternum and the spine, and fast increase in pressure in its chambers [8, 9]. A Propagation of high hydraulic pressure in the system of inferior vena cava at the moment of injury causes a sudden hypovolemia in the right atrium, especially in the period of late diastole or early systole, when the tricuspid valve is closed [9]. It can explain the most common laceration in the region of the right atrial appendage, when its wall is the thinnest [5, 10].
Traumatic lacerations, which are accompanied by disordered integrity of pericardium, the lethal outcome appears as result of massive blood loss into the pleural cavity or after cardiac entrapment in the pericardium defect [11]. In 70 % of cases, the pericardium remains intact [12]. Therefore, cardiac tamponade is the most common outcome of such injury.
The events of cardiac tamponade can be missed because of multiple associated injuries and insufficient correction of hypovolemia [1, 3, 4]. Echocardiography (EchoCG), computer tomography (CT) and urgent surgery play the main role for prognosis in a patient with suspected cardiac laceration.
Objective – to discuss the essential details of surgical management in the right atrial appendage rupture and cardiac tamponade after a blunt chest injury.
The study was conducted in concordance with ethical standards of Helsinki Declare and the order by Health Ministry of Russia, 1 April 2016, No.200n, “About confirmation of rules for clinical practice”. The patient gave the written consent for publication of the clinical case. 

CLINICAL CASE

The patient N., age of 62, was admitted by the emergency medical team to the admission unit of Irkutsk Regional Clinical Hospital of the Badge of Honor Order. He was admitted one hour after a front collision against an obstacle on 21 July 2018. The patient was unconscious at prehospital stage.
Considering the severity of condition (RTS – 6.171), the patient was urgently transferred to the anti-shock unit. The state was severe, with agitation, the consciousness level – moderate obtundation (GCS – 13). The skin was pale, with high pulsation in jugular veins. Arterial pressure was 90/40 mm Hg, pulse – 100 per min. The respiratory rate was 28 per min. There was a massive subcutaneous hematoma on the anterior surface of the chest. There was a pathologic mobility of sternum body, of the ribs 3-5 to the right and ribs 3-4 to the left. Auscultation showed the weak breathing to the right. The cardiac sounds were muffled. A knee hematoma was to the left. A tear-contused wound was to the right. There were bruises and scratches of facial soft tissues.
Urgent tracheal intubation was conducted. Artificial lung ventilation was initiated. Catheterization of peripheral and central veins and urinary bladder was performed. The gastric probe was installed.
Ultrasonic abdominal, retroperitoneal and pleural examination was carried out, as well as EchoCG. Free fluid was in pleural cavity to the right (up to 2 cm) and in pericardial cavity (up to 1.3 cm) along the contour.
X-ray examination of knee joints showed an intraarticular fragmented fracture of the upper one-third of left shinbones.
CT did not show any abnormalities in the brain, the spine, abdominal organs and the pelvis. Chest CT showed a fragmented fracture of corpus sternum with a displaced fragment towards pericardium, fractures of anterior sections of ribs 4-5 to the left and 3-5 to the right (Fig. 1), a retrosternal hematoma, fluid in pericardial cavity (thickness of 16-20 mm) (Fig. 2).

Figure 1. A sternum fracture with displaced fragments and fractures of anterior parts of ribs III-V to the right. Volumetric 3D reconstruction of chest CT



Figure 2. Chest CT: sagittal and transverse views. A sternum fracture with a displaced fragment. Retrosternal hematoma. Hemopericardium. Hemothorax to the right

The diagnosis was confirmed: “Hemopericardium with high probability of cardiac laceration”. The patient was transferred to the surgery room. Central venous pressure was 14 mm Hg, arterial pressure – 90/40 mm Hg, sinus tachycardia – 120 per min.
Longitudinal midline sternotomy (Batekha V.I., Medvedev N.V.) was carried out. The sternum was fragmented, with significant displacement of fragments. After mobilization of retrosternal hematoma, the pericardium was exposed. The pericardium was tense and of cyanotic color. It was opened in T-shape. 300 ml of liquid blood with clots were collected one-time. It immediately increased systolic pressure to 150 mm Hg and decreased central venous pressure to 6-8 mm Hg. The hemorrhage source was found – a laceration in the right atrium (8 × 10 mm, incorrect shape). Hemostasis was realized with Satinsky clamp (Fig. 3). The wound was sutured with continuous one-row twisted suture with Prolen 4-0 with teflon layings. After removal of the clamp, hemostasis was obvious (Fig. 4). 200 ml of liquid blood was removed from the pleural cavity. The pericardium was sutured with rare sutures. Anterior mediastinum and right pleural cavity were drained. Osteosynthesis was realized with application of Z-shaped sutures onto the sternum with use of synthetic and wire materials. The traumatologists (Gumanenko V.V.) performed the closed extrafocal osteosynthesis of the tibial bone fracture with use of the external fixation apparatus “leg – hip”.
The postsurgical period was without complication. The patient was discharged from the hospital on the day 15. His condition was satisfactory.

Figure 3. Temporary hemostasis with application of Satinsky clamp to the right atrial appendage. Traumatic rupture of the right atrial appendage (8 × 10 mm)



Figure 4. Final hemostasis of traumatic rupture of the right atrial appendage

DISCUSSION

The obvious clinical signs of cardiac tamponade (acute compression triad) in severe chest injury (fractures of the sternum and rib cage) can be missed, especially in patients with associated abdominal, spinal and cerebral injuries.
One of the most informative studies for identification of cardiac injuries is EchoCG, which provides the visualization of heart anatomy and contents of pericardial cavity. In the presented case, EchoCG explained the cause of hypotonia, tachycardia and high central venous pressure. A substantiated suspicion of cardiac tamponade in combination with EchoCG data allowed the timely surgical treatment.
Considering the relative stability of condition, CT was conducted for exclusion of penetrating pattern of cardiac wound caused by a sternum fragment. It could determine the indications for urgent initiation of artificial blood circulation device.
It is possible to perform a pericardial cavity puncture for unstable patients. It allows removing the blood and giving temporary improvement in hemodynamic values at the stage of transfer to the surgery room [4]. Not all authors agree with it, taking into the account the fact that all patients should receive sternotomy regardless of severity of condition [3].
Midline sternotomy is the optimal approach for patients with suspected cardiac rupture. It provides the sufficient exposure as opposed to lateral thoracotomy. It can be extended along the middle abdominal line for abdominal cavity surgery. Moreover, this approach simplifies the realization of open-chest cardiac massage and creates the favorable conditions for initiation of the artificial blood circulation device and for extracorporeal support in complex cases. It is necessary to consider that sternotomy provides the realization of sternum fixation. 

CONCLUSION

It is advisable to consider the possible traumatic cardiac laceration in patients with sternum fracture after blunt chest injury.
Implementation of EchoCG and CT into diagnostic protocols allows fast identification of a cause of severe condition of the patient with an associated injury, and finding out a life-threatening injury (cardiac laceration and tamponade).
The preferable surgical approach for revision and suturing of a cardiac wound is midline sternotomy. Final hemostasis can be achieved without use of secondary techniques of blood circulation. 

Information on financing and conflict of interests

The study was conducted without sponsorship.
The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.

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