Management of cardiac trauma and penetrating cardiac injuries with severe hemorrhagic shock: a 5-year experience

Article information

J Trauma Inj. 2024;37(4):268-275

Publication date (electronic) : 2024 December 16

doi : https://doi.org/10.20408/jti.2024.0063

Tran Thuc Khang, MD

Department of Cardiovascular and Thoracic Surgery, Tam Anh Hospital, Ho Chi Minh City, Vietnam

Correspondence to Tran Thuc Khang, MD Department of Cardiovascular and Thoracic Surgery, Tam Anh Hospital, 2B Pho Quang St, Tan Binh District, Ho Chi Minh City 700000, Vietnam Tel: +84-28-71026789 Email: khangchircardio@gmail.com

Received 2024 September 25; Revised 2024 October 16; Accepted 2024 October 23.

Abstract

INTRODUCTION

Cardiac injuries present significant challenges in cardiothoracic emergencies, typically resulting from blunt trauma or penetrating wounds [1]. Penetrating cardiac injuries or ruptures of the cardiac cavity often leads to lethal outcomes, potentially causing hemorrhagic shock and cardiac tamponade, which can be fatal if not promptly addressed [2,3]. Hemodynamic stability largely depends on the nature and extent of the trauma, the time taken to transport the patient to a hospital, the amount of intravascular volume lost, and the presence of cardiac tamponade [4]. Immediate emergency surgery to control bleeding is critical, as there is often not enough time for imaging studies. Delays in surgery can lead to increased postoperative mortality due to irreversible multiorgan failure and most patients die at the scene of occurrence without prompt intervention [5,6]. Therefore, an ultra-emergency protocol is essential, which includes directly transferring patients from the field to the operating room, bypassing administrative procedures. This strategy requires flawless coordination between thoracic-cardiovascular surgeons and anesthesiology-resuscitation teams to optimize patient survival.

METHODS

RESULTS

Mechanism of injury

Of the total injuries recorded, closed chest trauma accounted for two cases (9.5%), while there was one case (4.8%) of open chest trauma. Penetrating wounds were the most prevalent mechanism, with 14 cases (66.7%) of stabbing. Additionally, there were four cases (19.0%) of self-inflicted wounds; among these, two patients were on psychiatric medication (Table 1).

Table 1.

Mechanisms of injury (n=21)

Persons accompanying the patient to the hospital

Among the total cases, four individuals (19.0%) were referred from another hospital with a relative. A significant majority, comprising 15 individuals (71.5%), arrived through emergency services (Vietnam emergency medical services 115), witnesses, or police, without accompanying relatives. Only two patients (9.5%) arrived at the hospital with family members (Table 2).

Table 2.

Persons accompanying the patient (n=21)

Patients’ general condition upon arrival

Upon arrival at the hospital, the assessment of patients' conditions varied (Table 3). Four patients (19.0%) were conscious with blood pressure less than 60 mmHg, while six (28.6%) appeared drowsy and were difficult to assess the blood pressure. Five patients (23.8%) were intubated due to their drowsy or unconscious state. Three patients (14.3%) experienced cardiac arrest during transport but were successfully resuscitated. Additionally, three patients (14.3%) presented with bradycardia, exhibiting heart rates below 30 beats per minute. Notably, four patients (19.0%) had dilated pupils with varying light reflexes.

Table 3.

Patients’ general condition upon arrival (n=21)

Intraoperative parameters

The majority of cases utilized a median sternotomy approach (n=17, 80.9%), while one (4.8%) involved right thoracotomy (Table 4). Two intraoperative deaths occurred; one case (4.8%) due to an inability to elevate blood pressure despite complete control of bleeding, and the other (4.8%) due to uncontrollable bleeding. Blood loss varied, with 11 (52.4%) losing 2,000 to 3,000 mL, and 3 (14.3%) exceeding 3,000 mL. Injury locations were predominantly in the right ventricle (n=14, 66.6%). Additionally, 11 patients (52.4%) presented with associated injuries, including liver lacerations, diaphragm perforations, lung injuries, and rib fractures.

Table 4.

Intraoperative parameters (n=21)

Postoperative parameters

Complications were common, with 13 patients (61.9%) developing severe acidosis and 3 (14.3%) experiencing acute renal failure. The overall mortality rate was 14.3%, with two intraoperative deaths (9.5%) and one postoperative death (4.8%) (Table 5).

Table 5.

Postoperative parameters (n=21)

DISCUSSION

In this cohort, young male patients were predominantly affected, with a high incidence of cardiac injuries primarily due to stabbings or slashings during conflicts and social disputes (14 out of 21 cases, 66.7%) (Table 1). This trend is consistent with findings from urban trauma centers worldwide. In the review by O’Conner et al., they demonstrated that the victims were predominantly male (86%), knew their assailant (83%), and that assaults occurred more often in the evening during the spring and summer [7]. This is one of the most lethal forms of injury with mortality rate ranging from 3 to 84% and in one large report of 1198 patients with penetrating cardiac trauma in South Africa, only 6% of patients arrived to a hospital [8].

However, a notable discrepancy exists in the rate of self-inflicted injuries. In our study, among the total, four (19.0%) were self-inflicted, including two patients with schizophrenia (Table 1). In contrast, some authors have reported a much lower rate of 1.4% [9]. This difference may stem from variations in the populations studied, as our cohort may have had a higher prevalence of psychiatric disorders, particularly schizophrenia, which is associated with an increased risk of self-harm.

Various authors concur that stab wounds are the leading cause of cardiac injuries, followed by gunshot wounds and traffic accidents [10]. Shoar et al. [11] have reported that cardiac injuries resulting from blunt chest trauma constitute approximately 18.3% of cases in developing countries. In contrast, in the United States, gunshot wounds are twice as common as stab wounds [12]. Although our study confirms that injuries to the right ventricle are the most frequent, the lower mortality rate we observed is in contrast to the higher rates reported in other studies. This difference may be attributed to our rapid surgical protocols and effective emergency management.

Chest injuries or perforating wounds accompanied by severe hemorrhagic shock are often the result of damage to the heart or major vessels within the thoracic cavity. Consequently, when attending to emergency patients or responding to prehospital calls, we immediately consider these injuries, especially those involving wounds in the anterior cardiac triangle accompanied by hemorrhagic shock—criteria that are sufficient for diagnosis and necessitate emergency surgery [5]. According to Rahim Khan et al. [13], only about 6% of victims survive long enough to reach the hospital. Jagelavicius et al. [14] characterize penetrating cardiac injuries as a dramatic and often fatal form of trauma that primarily affects young individuals, with most victims dying before they can receive hospital care. The key to saving these patients lies in the rapid identification of injuries and a race against time. Conversely, patients quickly succumb to acute blood loss, cardiac tamponade, heart failure, or complications such as irreversible brain damage and multiorgan failure [5,15].

In this group, all cases experienced hemorrhagic shock (100%), and six (28.6%) were either in cardiac arrest or on the verge of it prior to thoracotomy. Notably, these patients were taken directly to the operating room from the emergency reception, bypassing all administrative procedures. Although surgery typically requires consent from the patient and family, only two (9.5%) had family members present (Table 2). Strict adherence to these consent regulations could potentially delay treatment. To address this issue, our emergency department has established a dedicated team responsible for completing the necessary documentation with witnesses, the individual who brought the patient, or local police to confirm the patient's condition. This allows the surgeon to concentrate solely on the surgical procedure. Consequently, the survival rate observed in this study is relatively high. Our findings underscore the critical importance of immediate surgical intervention for cardiac injuries and the necessity of protocols that ensure swift access to surgery while effectively addressing legal and logistical challenges.

In this group, four patients (19.0%) presented with dilated bilateral pupils upon entering the operating room; however, all of these cases recovered without postoperative brain damage (Table 3). Therefore, we do not consider these factors when deciding whether to proceed with surgery. As a result, all of these cases were taken directly to the operating room, where chest opening and resuscitation were performed simultaneously.

An emergency median sternotomy is the preferred approach because it allows rapid access, facilitates the management of cardiac injuries regardless of their location, and enables the establishment of extracorporeal circulation if required [5,16]. We perform a median sternotomy in 20 patients (95.2%), with the exception of one case (4.8%) involving extensive open chest wounds (Table 4).

There were two intraoperative deaths (9.5%). In one case, a right ventricular perforation occurred; although the bleeding was controlled, prolonged cardiac arrest ultimately led to unsuccessful resuscitation. The other case involved a perforation at the left ventricular apex, which resulted in ragged wounds that exposed the papillary muscle of the left ventricle. Lacking extracorporeal circulation, the patient succumbed to uncontrollable bleeding (Table 4). Mortality rates in other studies have been reported to range from 16% to 44% [8]. The causes of death following penetrating cardiac wounds include cardiac tamponade, exsanguination, coronary artery laceration, valvular disturbances, disruption of conduction pathways, or other severe injuries such as major mediastinal vascular injury [17]. In our cohort, an additional cause of death was diffuse cerebral edema in a patient suffering from multiorgan failure, where resuscitation proved ineffective; this patient passed away on postoperative day 11. This lower mortality rate, compared to some reports, underscores the vital importance of immediate emergency surgery in preventing massive hemorrhage.

Regarding cardiac injury location, wounds to the right ventricle are most common, accounting for 14 cases (66.7%) (Table 4). Based on our practical experience, immediate consideration of cardiac injury is essential for stab wounds to the chest that are located between the midclavicular lines, especially if accompanied by hemodynamic instability or undetectable blood pressure. All instances of cardiac perforation in this cohort were managed according to clinical criteria. Future research should aim to include larger cohorts to confirm our findings and to assess the effectiveness of various preoperative resuscitation strategies. Additionally, studying the long-term outcomes of patients with severe cardiac injuries could yield important insights into their recovery and rehabilitation processes. In these cases, diagnostic imaging modalities only serve to delay emergency surgery; thus, we do not extensively discuss diagnostic tools here.

In cases of penetrating cardiac trauma, the right ventricle alone is involved in 35% of patients reaching the hospital [18]. This prevalence is supported by various studies that attribute it to the anatomical characteristics of the heart. Barbero et al. [18] corroborate this finding, pointing out that the right ventricle's location and relative exposure make it particularly vulnerable to chest trauma. This finding is consistent with reports by Majeed et al. [19], who also identified a higher frequency of right ventricular injuries in their studies, followed by the left ventricle. The anatomical position of the right ventricle, being more exposed and closer to the chest wall, contributes to its higher susceptibility to injury compared to other cardiac structures.

Based on our experience, immediate consideration of cardiac injury is essential for stab wounds that penetrate the chest, especially when the wound is located between the midclavicular lines and is accompanied by hemodynamic instability or undetectable blood pressure. Williams et al. [20] support this approach. They stated that injury to this area is anatomically significant for predicting cardiac injury, with survival largely depending on minimizing the time from injury to operative repair. They emphasize that significant hemodynamic instability should prompt immediate exploration for potential cardiac injuries. Their research supports our practice of prioritizing clinical assessment over diagnostic imaging in these critical situations. In our cohort, all instances of cardiac perforation were managed according to clinical criteria, aligning with the approach advocated by Lee et al. [2], who argue that in emergent settings, clinical judgment should guide initial management decisions, as reliance on diagnostic imaging can delay critical emergency interventions. While diagnostic imaging can be valuable, it may postpone necessary emergency surgery, which is why it is not the primary focus of discussion here. Estrera and Schreiber [21] argue that in cases of acute trauma, the primary focus should be on immediate surgical intervention rather than on delaying treatment for imaging, which is consistent with our approach.

Closed chest trauma that results in cardiac chamber rupture is uncommon, with an incidence of approximately 0.2% to 0.5% of cases. Of these, only about 10% of survivors make it to the hospital [22]. In our cohort, this rate was 9.5%, which may be attributed to the small sample size. Diagnosing this type of injury is challenging, as it can be mistaken for other conditions. In cases of blunt chest trauma accompanied by signs of hemorrhagic shock and clinical evidence of cardiac tamponade, we exercise caution in diagnosing cardiac injuries. Bedside echocardiography plays a crucial role in this diagnostic process [5].

In cases of open chest trauma with cardiac injury, the prognosis is significantly worse, and management becomes complex due to factors such as foreign bodies, wound contamination, high infection risk, and associated chest wall injuries or defects. Some studies indicate that cardiac injuries may be overlooked in complex multitrauma scenarios involving the chest [23]. Lee et al. [2] pointed out that in such multitrauma situations, cardiac injuries may not be immediately evident, leading to delayed diagnosis and management. This suggests that the likelihood of missing cardiac injuries can adversely affect prognosis and treatment outcomes, underscoring the importance of comprehensive assessment in multitrauma cases. Hattori et al. [24] observe that managing cardiac injuries in these scenarios is challenging due to complications that can rapidly worsen respiratory status and overall health. This is consistent with our study’s findings, where open chest wounds with cardiac injury led to severe complications, including shock and cardiac arrest. The management of open chest wounds is complicated by the presence of foreign bodies and contamination, which increase the risk of infection and complicate surgical intervention with poor prognosis. In such cases, cardiac damage is difficult to detect; therefore, caution is required. In our cohort, one case (4.8%) involved open chest wounds that exposed the right atrium, a defect in the anterior chest wall, multiple fractured ribs, and gasoline contamination. We extended the thoracic wounds to rapidly address the cardiac injury while mitigating the risk of sternal osteomyelitis through a median sternotomy approach. The chest wall was reconstructed using plate fixation and a local muscle flap to cover the defect and maintain respiratory function. The choice of surgical approach and concurrent management of cardiac injury and chest wall reconstruction is critical in such cases. However, this approach should only be considered in very specific cases, such as those outlined in the author’s research. As previously mentioned, in all other circumstances, an emergency median sternotomy remains the most effective option for ensuring rapid access to cardiac wounds.

Our study indicates that blood loss during surgery ranged from 1,000 to 3,000 mL in 16 cases (76.2%) and exceeded 3,000 mL in 3 (14.3%) (Table 4). Given that our institution lacks a cell saver system, there is often a requirement for substantial blood transfusions, which increases the risk of intraoperative and postoperative complications. This significant level of blood loss underscores the necessity for prompt and adequate blood resuscitation, a strategy endorsed by Ingraham and Sperry [25]. They emphasize that substantial blood loss can lead to coagulopathy and severe acid-base disturbances, conditions commonly observed in trauma patients. Consequently, multiple methods for temporary control and subsequent definitive repair of penetrating cardiac injuries have been documented to manage bleeding as quickly as possible. The authors often utilize digital control as a temporizing measure, simultaneously performing definitive repair, typically with a non-absorbable suture on an atraumatic needle in a horizontal mattress fashion.

Postoperative complications frequently stem from prolonged hypovolemic shock, which can precipitate renal failure and multiple organ dysfunction, as demonstrated in our study. Acute renal failure ranks as the most prevalent postoperative complication. Our observations revealed that three patients (14.3%) needed immediate dialysis in the intensive care unit. Of these, two patients regained renal function within the first week, whereas one patient died due to multiorgan failure and septic shock on postoperative day 11 (Table 5).

Associated injuries significantly worsen prognosis by exacerbating blood loss and precipitating early shock. In our study, 11 cases (52.4%) involved associated injuries (Table 4). This finding aligns with results from various other studies. Tran et al. [26] observed that associated injuries, especially those affecting major organs and vessels, markedly deteriorate the prognosis due to increased blood loss and shock. Conversely, Goldstein and Soffer [27] reported that the impact of associated injuries on prognosis varies based on the timeliness and effectiveness of medical interventions, indicating that prompt and effective treatment could alleviate some of the severe outcomes. In our research, cases involving concurrent injuries to the liver, internal mammary artery, or intercostal artery led to severe shock and were frequently associated with cardiac arrest episodes.

One case in our study experienced delayed death on the 11th postoperative day, consistent with findings by Isaza-Restrepo et al. [28], who observed delayed mortality due to complications from severe trauma. However, other authors have noted that delayed death can also stem from inadequate initial management or secondary complications, not just the severity of the injuries [6]. This suggests that factors beyond the immediate severity of associated injuries might contribute to delayed mortality.

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