45 year old man, involved in road traffic accident as front seat passenger, restrained, no airbag. Trapped in his car for 40 minutes. Airlifted to hospital.

In resus, no external injuries, Haemodynamically stable, GCS 15 and appropriate, complaining of central chest tenderness. C-spine, pelvis normal. Chest X-Ray, slightly widened mediastinum. Abdo ultrasound - no free fluid. No pericardial fluid.

25 minutes into resus, EMD arrest, which recovered spontaneously, then VF arrest x2, responded to DC shock and adrenaline. Continued to arrest every few minutes, either EMD or VF, despite adrenaline infusion & fluid administration. CVP catheter read 25 cmH2O

Would you go to angio, Spiral CT or open his chest?
If you open his chest, what would you expect to find, and what would you do about it?

_____________________________________
Dr. Karim Brohi BSc FRCS FRCA
Trauma & Critical Care Unit, Royal London Hospital
Mailto:karim@trauma.org
http://www.trauma.org/

A patient like this who arrests in front of you following trauma should have an immediate ER thoracotomy, as the overwhelming likelihood must be that the arrest is from bleeding or pericardial tamponade--the post-traumatic causes of arrest can not be dealt with by external chest compression as medical causes can be, which is why external compression should have NO place in the acute resuscitation of a trauma victim. When an assumption has to be made, it HAS to be the most likely thing (i.e. bleeding, tamponade, tension pneumo, etc), NOT the least likely thing (i.e. MI in a young patient, electrolyte disturbance, etc), and what this patient needs is ATLS, NOT ACLS. The worst thing that could happen to YOU in this case is that the patient came thru with your maneuvers , because that will tend to reinforce to you that you did the right thing rather than that you were incredibly lucky (along with the patient) to have gotten away with an approach that will not work in more than 99 of every hundred post-traumatic arrests. If on opening the chest there is no obvious traumatic cause, you can still resuscitate the heart with open massage(much more effective than closed) while clearly excluding the possibility of having missed something without endless scratching of heads and academic debates. The less automatic this response is, and the more time you take to do it, the less likely will the patient be to survive a potentially recoverable injury.

Eric Frykberg, M.D.
Jacksonville, Fl

Prior to answering the inquiry about cracking the chest in a patient with blunt trauma and vfib, it would be nice to know the blood gas results. This patient may have a coronary artery injury and the equavalent of a heart attack. I would have been considering, with the limited information which we received, the use of an IABP. His high CVP is worrisome.

K

I wound wonder about a bonifide cardiac contusion. I assume that tension PNX was excluded and with a normal echo pericardial tamponade was as well. Were wall motion abnormalities present on US? Without entering the debate about whether the chest should be cracked or not I would make the following observations. This patient may very well have had the 2 episodes of vfib as a result of the epinephrine drip that was started. Although it can be used for hypotension it is very arrhythmogenic and better options are avialable. Secondly, if a decision was made that the chest was not going to be opened immediately then a patient with recurrent v-fib should receive lidocaine prophylaxis.

H. Louzon MD

You do not mention any EKG changes prior to his arrest. Were there PVC's or any ST changes. Could this be an MI vs aortic rupture? If it is an MI, you are screwed if you do a lateral thoracotomy. If it is aortic rupture, you are screwed if you do a median sternotomy.

After arrest, angio takes too long. Spiral CT is no place to run a code. If you open his chest, do a bilateral anterior thoracotomy,prop up the patient's left side, bivalve the chest to get to pericardium and explore. The patient has suffered a myocardial infarction, blunt cardiac injury with contusion severe enough to cause right heart failure, or an aortic rupture. At this point, all of these are probably unsurvivable.

Awww. Come on Ken. Crack the chest. I wanna see whats inside.

Gord

We have to consider what could cause this picture in a presumably healthy patient who was stable for over an hour after the injury, and who suddenly develops EMD, with elevated CVP. The differential diagnosis is rather limited. The two main possiblities are tension pneumothorax and tamponade. I would therefore try bilateral neele applications, followed by chest tubes, and if that fails crack the chest. This could be the odd case where on could find a surgically correctable lesion in a blunt trauma victim.

One other possiblity is traumatic aortic dissection which occludes the coronaries. This is a bit far fetched, but would be something to mention in a CPC.

Avi

===============================================================
Aviel Roy-Shapira, M.D.
Ben-Gurion University Medical School
Dept. of Surgery A.
POB 151, Beer Sheva, Israel
avir@bgumail.bgu.ac.il

A few more observations about this case. I mentioned the possibilty of cardiac contusion. Right ventricular contusion is actually about twice as common as is LV contusion and can mimic the signs of pericardial tamponade. Like RV infarction in the setting of inferior wall MI it can be associated with hypotension, elevated JVP and clear lungs. My choice in this case would be to push fluids, stop epinephrine, and start dobutamine and lidocaine.

This is a situation that seems almost tailor made for transesophageal echo both to exclude the possibility of aortic disruption and to detect the presence of RV infarction. TEE has been shown in numerous studies to be superior to TTE for these indications.

Of course the question arises of what is going to be done once the chest is opened. The problem here does not appear to be an inability to resusitate but rather of recurrent arrest. What is the yield of ED thoracotomy in blunt chest trauma? My understanding is that it is negligible.

H. Louzon MD

I am curious to know if this patient with blunt chest trauma had more than one ultrasound in the minutes before his arrest. Were serial ultrasounds of the abdomen or pericardium performed? After he arrested did anyone take another look at the pericardium? Just out of curiousity--who performed the ultrasound eval?

Evelyn Cardenas,MD

"CARDIAC CONTUSION" IS A TERM WHICH IS A MISNOMER AND SHOULD NEVER AGAIN BE USED IN THE TRAUMA NOMENCLATURE!! IT IS MEANINGLESS, MISLEADING, AND OVERLY MONITORED.....

K

>Awww. Come on Ken. Crack the chest. I wanna see whats inside.

Come on now, this patient would NOT profit from an unnecessary thoracotomy, and could be harmed. The survival from ED thoracotomy following blunt trauma is very low. Your aggressiveness might just be a personal ego trip. I have no objection if you have some real anatomic presumption which you think you may reverse. Just to look inside because you want to see what is inside is foolish, costly, and unethical.

k

Sorry, I missed his ECG results :

Initially (prior to arrest) his ECG showed T wave inversion in the anterior chest leads. His ECG after his first arrest when back in sinus rhythm was normal, with no T wave abnormality.

Initial blood gases were normal both for oxygenation and acid-base status.

The ultrasound was performed by a trauma radiologist. The probe is not accurrate enough to do a TTE and look at wall motion etc, but can determine if there is pericardial fluid (usually).

__________________________________________________
Dr. Karim Brohi BSc FRCS FRCA
Trauma & Critical Care Unit, Royal London Hospital
Mailto:karim@trauma.org
http://www.trauma.org/

Oh, please. Save it for Oprah.

To suggest, as you have, that this entity does not exist is to blithely ignore anatomic (1) and physiologic evidence (2) that it does. If it doesn't exist then your surgical collegues are apparantly unaware of this fact as they continue to publish research on the topic (3,4,5,6,7,8).

That this entity is overdiagnosed or that, even if present, if often not the cause of death in patients with blunt chest trauma is not subject to dispute (8). Nevertheless many cases have been described in the surgical literature complicated by ventricular and supraventricular arrhymias and even cardiogenic shock requiring IABP (9,10).

On the other hand, if you agree that it does indeed exist, but find fault with my reasoning in this particular case then please point it out rather than making inane overgeneralizations.

By the Dr. Mattox, your Caps Lock key is stuck in the on position.

H. Louzon MD

(1)
Scorpio RJ, Wesson DE, Smith CR, Hu X, Spence LJ
Blunt cardiac injuries in children: a postmortem study.
J Trauma 1996 Aug;41(2):306-9

(2)
Diebel LN, Tagett MG, Wilson RF
Right ventricular response after myocardial contusion and hemorrhagic shock.
Surgery 1993 Oct;114(4):788-92; discussion 793

(3)
Christensen MA, Sutton KR
Myocardial contusion: new concepts in diagnosis and management.
Am J Crit Care 1993 Jan;2(1):28-34

(4)
Biffl WL, Moore FA, Moore EE, Sauaia A, Read RA, Burch JM
Cardiac enzymes are irrelevant in the patient with suspected myocardial contusion.
Am J Surg 1994 Dec;168(6):523-7; discussion 527-8

(5)
Paone RF, Peacock JB, Smith DL
Diagnosis of myocardial contusion.
South Med J 1993 Aug;86(8):867-70

(6)
Adams JE 3rd, Davila-Roman VG, Bessey PQ, Blake DP, Ladenson JH, Jaffe AS
Improved detection of cardiac contusion with cardiac troponin I.
Am Heart J 1996 Feb;131(2):308-12

(7)
Diebel LN, Tagett MG, Wilson RF
Right ventricular response after myocardial contusion and hemorrhagic shock.
Surgery 1993 Oct;114(4):788-92; discussion 793

(8)
Fildes JJ, Betlej TM, Manglano R, Martin M, Rogers F, Barrett JA
Limiting cardiac evaluation in patients with suspected myocardial contusion.
Am Surg 1995 Sep;61(9):832-5

(9)
Orlando R 3d, Drezner AD
Intra-aortic balloon counterpulsation in blunt cardiac injury.
J Trauma 1983 May;23(5):424-7

(10)
Snow N, Lucas AE, Richardson JD
Intra-aortic balloon counterpulsation for cardiogenic shock from cardiac contusion.
J Trauma 1982 May;22(5):426-9

The righting of previously inverted T waves is a well known phenomenon called 'pseudonormalization' and is not uncommonly seen in infarction. There is no reason to believe that it cannot also be seen with myocardial contusion (or whatever else it is called in Houston).

The fundamental feature in this case which has heretofore defied explanation is the presence of impaired right ventricular compliance manifested by the elevated JVP. What makes this case unique, of course, is that the two most common causes of this syndrome, namely pericardial tamponade and tension PNX appeared to have been ruled out. I say 'appeared' because I am not sure how carefully the ECHO was done and whether other signs of tamponade such as diastolic chamber collapse were looked for.

The syndrome of impairment of RV compliance represents the final common manifestation of diverse processes. I.e., RV contusion, right coronary artery thrombosis, pseudoaneurysm and dissection can all result in this finding. Likewise these diagnoses are not mutually exclusive in the sense that aortic dissection may occlude the coronary ostia as well and present in a similar fashion.

Although less common, cases of traumtic VSD or tricuspid valve rupture have been described after blunt trauma and would result in overload of the right ventricle.

When placed in this perspective it is clear that simple hypovolemia does not explain this case. Uncomplicated aortic dissection does not explain this case. Disruption of hilar vessels does not explain this case. So unless some information has been with-held, such as the presence of tension on repeat exam or inadvertantly discovered on CXR, something else is going on here.

The abject refusal of surgeons to consider any diagnosis that is not immediately remediable with a scalpal or 14 guage needle is tunnel vision and represents the best example to date of why surgeons should not be allowed to run truma codes unassisted by emergency medicine physicians and other specialists who can formulate a more compreshensive differential diagnosis.

Of course when I suggest excluding truama surgeons from the early management of trauma codes I am half kidding.

But only half.

H. Louzon MD

Here is the reference.....check it out.

Blunt cardiac injury : J Trauma 1994 Mar;36(3):462-3
Mattox-KL; Flint-LM; Carrico-CJ; Grover-F; Meredith-J; Morris-J; Rice-C; Richardson-D; Rodriquez-A; Trunkey-DD
J-Trauma. 1992 Nov; 33(5): 649-50