CASE 6---2015: Penetrating Biventricular Cardiac Injury in a Trauma Patient: Heart Versus Machete

NJURIES TO THE HEART and great vessels can occur by almost any mechanism in patients who have sustained trauma. These injuries can be categorized into injuries that are so devastating that patients die at the scene and injuries that are stable enough for patients to arrive at the hospital. In the hospital setting, several factors affect the management of patients who sustain cardiac or great vessel injuries, including the mechanism of injury (penetrating v blunt), patient stability (unstable v stable), and injury location (cardiac v great vessels). When a patient presents with an obvious cardiac injury, the anesthesiology team should be prepared to initiate several key interventions immediately. These interventions include airway management, obtaining intravenous access, and determining which patients are candidates for extreme lifesaving maneuvers. The anesthetic management in the operating room (OR) includes supporting the circulation, providing maneuvers that aid surgical repair, and identifying the extent of cardiac injury. Postoperatively, it is important to ensure adequate resuscitation and continue close monitoring. The following case highlights various issues that need to be considered when managing a patient who presents with a significant cardiac injury. CASE REPORT A 31-year-old man (height 175 cm, weight 77 kg) was brought to the trauma center after sustaining stab wounds with a machete. One wound was to the left shoulder, and a second wound was to the left anterior chest. He arrived without vital signs and receiving cardiopulmonary resuscitation (CPR). The total time without vital signs was reported by prehospital personnel to be o10 minutes. The patient underwent immediate tracheal intubation, intravenous access was obtained, and an anterolateral resuscitative thoracotomy was performed in the emergency department (ED). Because of cardiac tamponade, a decision was made to open the pericardium. A large amount of blood clot was evacuated from the pericardial space. Two large lacerations were identified involving both left and right ventricles. These lacerations were closed emergently with staples. After continued CPR and administration of crystalloids and blood, the heart began exhibiting unorganized electrical activity. The heart was defibrillated with internal paddles, and organized cardiac activity was obtained. The patient was rushed to the OR. In the OR, the patient was placed in the supine position. A 9F central venous catheter was inserted in the right internal jugular vein. A right radial arterial catheter also was placed. The trauma center’s massive transfusion protocol was initiated, and the patient’s intravenous access was connected to a rapid infusion device. Scopolamine, 0.4 mg, rocuronium, 80 mg, fentanyl, 250 μg (in divided doses), and cefazolin, 2 g, were administered. Sevoflurane was used for anesthetic maintenance as tolerated by the patient’s blood pressure. Careful attention was given to avoid large fluctuations in blood pressure because of concern that severe hypertension would increase bleeding or disrupt the initial repair. The goal was to maintain the patient’s systolic blood pressure (SBP) at 80 to 90 mmHg. An initial dose of epinephrine, 100 μg, was administered owing to severe hypotension. After incision, a median sternotomy was performed, and the pericardium was reopened. The laceration at the apex of the right ventricle, which had been closed temporarily with staples, was oversewn with a 3-0 polypropylene (Prolene) suture and pledgets in a running fashion. The injury to the left ventricle was repaired in a similar fashion via the anterolateral thoracotomy wound. When the cardiac injuries were closed, a left lung injury was sutured, and bleeding was controlled. Two left-sided chest tubes, one right-sided chest tube, and a mediastinal chest tube were placed, and the sternotomy was closed with sternal wires. Skin incisions were closed with staples. The patient’s initial pH and base excess in the OR were 6.8 and � 16.5, respectively. Fluid totals for the case were 8 L of crystalloid, 17 units of packed red blood cells, 7 units of fresh frozen plasma, and 10 units of platelets. The estimated blood loss was 8,500 mL, and urine output was 405 mL. On leaving the OR, the pH was 7.3, and base excess was � 5.9. The patient was transported intubated to the trauma intensive care unit