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Ann Thorac Surg 1996;61:1244-1245
© 1996 The Society of Thoracic Surgeons

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Case Report

Cardiopulmonary Bypass for Resuscitation After Penetrating Cardiac Trauma

Department of Surgery, University of Alberta Hospitals, Edmonton, Alberta, Canada

Accepted for publication October 16, 1995.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
Cardiopulmonary bypass is only occasionally required acutely in the management of penetrating cardiac injuries, usually to allow coronary grafting. We describe a case of penetrating trauma in which cardiopulmonary bypass was used to resuscitate a patient whose cardiac lacerations were controlled in the emergency department.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
A 44-year-old man presented to the emergency department with a single stab wound at the level of the left nipple. On arrival he rapidly lost detectable vital signs, and an anterolateral thoracotomy was performed. A moderate hemothorax and pericardial tamponade were noted. When the pericardium was opened, two lacerations were noted in the left ventricle, each approximately 2.5 cm long. The wounds were closed with a skin stapler, and compressions resulted in detectable carotid pulsations. The aorta was not occluded.

Because of persistent fibrillation, despite cardioversion, the patient was transferred to the operating room. During this interval, the patient was supported by hyperventilation and cardiac massage alone, the adequacy of the latter being determined by monitoring carotid pulsations. Cardiopulmonary bypass, using a sternotomy, was instituted within 30 minutes of arrival. Additional considerations included the lack of readily available percutaneous femorofemoral bypass and improved exposure of the inferior laceration. Aortic root pressures were maintained at 80 mm Hg. Venting was not required. The initial core temperature was 30°C and arterial pH 7.0. After 30 minutes the patient's core temperature was 38.5°C and arterial pH 7.40. The patient reverted to normal sinus rhythm after one defibrillation. The wounds were re-repaired with pledgeted sutures. The patient made an uneventful recovery, spending 2 days in intensive care, and was discharged on the eighth postoperative day.

	Comment

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There has been a marked increase in the incidence of penetrating chest trauma, and subsequently cardiac trauma, related to the ``drug wars'' [1]. A number of patients with penetrating cardiac injuries will present in extremis but are potentially salvageable. Patients who may benefit from emergency room thoracotomy include those who have detectable vital signs on arrival, have suffered penetrating trauma to the chest only, have a cardiac rhythm, and have an element of tamponade, particularly after stab wounds [2, 3]. Rapid initial control of ventricular lacerations can be obtained by digital pressure, the careful use of a Foley catheter, or skin staplers [4]. Subsequently, careful suture repair with pledgets, avoiding coronary arteries, can be performed in a controlled fashion.

Although it is rarely needed acutely, cardiopulmonary bypass may be appropriate in the 3% to 9% of patients who have suffered penetrating coronary injuries, usually to the left anterior descending artery [2, 5]. The need for bypass in this setting is determined by how proximal the injury is and the subsequent area of myocardium threatened [5]. This case illustrates another potential role for cardiopulmonary bypass, that of resuscitation after control of the injuries. In this case, a degree of tamponade and rapid control of injuries limited blood loss and allowed effective compressions to maintain forward flow. Because of hypothermia and acidosis, the heart remained in intractable fibrillation. Cardiopulmonary bypass allowed correction of the metabolic deficits and recovery. Cardiopulmonary bypass may be appropriate in the following isolated, specific instances: it is available within a short time, the patient presented with isolated cardiac trauma, injuries are easily repaired allowing effective compressions, and there has been no delay in intubation and ventilation.

	Footnotes

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Address reprint requests to Dr Karmy-Jones, Divisions of Trauma and Thoracic Surgery, CFP-4, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI 48202.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Webster DW, Champion HR, Gainer PS, Sykes L. Epidemiologic changes in gunshot wounds in Washington D.C., 1983–1990. Arch Surg 1992;127:694–8.[Abstract/Free Full Text]
2. Knott-Craig CJ, Dalton RP, Rossouw GW, Barnard PM. Penetrating cardiac trauma: management strategy based on 129 surgical emergencies over 2 years. Ann Thorac Surg 1992;53:1006–9.[Abstract/Free Full Text]
3. Buckman RF, Badellino MM, Mauro LH, et al. Penetrating cardiac wounds: prospective study of factors influencing initial resuscitation. J Trauma 1993;34:717–27.[Medline]
4. Macho JR, Markison RE, Schecter WP. Cardiac stapling in the management of penetrating injuries of the heart: rapid control of hemorrhage and decreased risk of personal contamination. J Trauma 1993;34:711–6.[Medline]
5. Reissman P, Rivkind A, Jurim O, Simon D. Case Report: The management of penetrating cardiac trauma with coronary artery injury-is cardiopulmonary bypass essential? J Trauma 1992;33:773–5.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Riyad Karmy-Jones Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Karmy-Jones, R. Articles by Lovoulos, C. Search for Related Content PubMed PubMed Citation Articles by Karmy-Jones, R. Articles by Lovoulos, C.