A team of surgeons

                                                                                                                                                                                                                                               

Cardiac wounds

Clinical and epidemiological characteristics of the cardiac wound cases treated at the Nap Kenbe hospital.

 

Presented by: Dr Louis Franck Télémaque

   

 

Abstract   

   This is a retrospective , descriptive study carried out on the care of 6 patients admitted and treated at the Nap Kenbe hospital in Tabarre-Medecins Sans Frontieres-Belgium for heart wounds during the period from January to December 2016. Observations have shown how the presence of a suitable technical platform and a well trained healthcare team in a general trauma center have made it possible to obtain very promising results, even in the absence of specific infrastructures of a cardiac surgical department. Among 13 cases of serious chest wounds , including the nine wounds  of the cardiac area, during the year of 2016, six cases are retained for the sturdy. Three of them(50%) survived after pericardial drainage or after direct myocardial repair carried out by general surgeons, in the absence of the availability of an extracorporeal circulation or of a specific resuscitation service to heart surgeries.

 

 

Introduction

   Nap Kenbe hospital of doctors without  border Belgium has been open in the commune of Tabarre, Haiti since February 2012 in support to the Haitian health system following the devastating earthquake of January 12, 2010. From 2016, he only receives orthopedic and general surgery emergencies except burns.

A multidiciplinary team, made up national surgeons, periodically reinforced by national and/or foreign thoracic and vascular surgeons, of national and/or foreign anesthesiologist-resuscitator, an internist, intensive care nurses, trained locally in the institution or internationally and physiotherapists, providing free patient care. Residents from the country’s university hospitals benefit from a 3-month rotation in these two specialties. Nearly 75% of these patients are orthopedic cases, while 25% are cases of visceral surgery. Nearly 85% of injuries are caused by road accidents, the others being by weapon (sharp weapons, firearm) and work accidents. Postoperatively, patients are admitted to the intensive care unit on a regular basis with the possibility of having real-time examinations such as: ultrasound and laboratory tests. Revisions of surgery are done as needed, with efficient support from the local blood transfusion service.

 

 

Methodology

   This is a retrospective study covering the period from January 2016 to January 2017. The hospital Nap Kenbe (doctors without borders Belgium, at Tabarre, Haiti) admissions database was consulted to identify all cases of thoracic and abdominal trauma. Of these cases, the population observed is that with a history of cardiac injury. All trauma patients diagnosed for cardiac damage by cardiac ultrasound will be included in the sturdy. Patients without cardiac damage on ultrasound will be excluded. The variables retained for the analysis are: age, sex, cause of the trauma, place of residency. The data is processed with the excel software. As our study limit, we retain that the sample is small, and that the study takes places over a relatively short period of time for this kind of pathology. In addition, not all of the patients who survived had a follow-up beyond 9 months of completion, as not all of them were not back for follow-ups.

 

 

The results

 

A-     Epidemiology

 

1-Population

   During the periode from January to December 1016,  13,305 cases of trauma were received in the hospital, among of them 49 cases were peripheral vascular wound (0.36%). In the intensive care unit, 13 cases of severe thoracic injury requiring thoracotomy were admitted. Of them, nine had cardiac air lesions. Six of the heart wounds have been confirmed by ultrasound and therefore retained for the study.

 

2- Breakdown by age group

Capture2

Board 1: Age groups 21-30 years and over 40 years have an equal number of cases.

 

 

3- Breakdown according to the sex

Capture 1

Board 2: All patients are male.

 

4- Location of accidents

Capture3

Board: 67% are referrals from doctors without border of Martissant.

 

5- Cause of trauma

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Board 4: The main cause of trauma is the stabbing.

 

6- anatomy of the lesions

The patients were divided into 3 series of two patients.

a-      For the first series of patients (1 and 2nd) having benefited an ultrasound-guided pericardial drainage in the operating room. Their heart wound could not be located.

b-      The series of two other patients (3 and 4th):  the 3th  presents a transfixing lesion of the right atrium and auricle; the 4th a stellar wound of the right ventricle.

c-       The serie of two patients ( 5th and 6th): the 5th  presented an ascending aortic wound not far to the mitral valve; for the 6th patient: two wounds of the anterior and inferior surfaces of the right ventricle was found.

 

A-     Management

1-All the patients are sorted according to the SATS systeme (South African Triage System) by a team of nurses and general practitioners trained in emergency medicine (ATLS:Advanced Trauma Life support) and knowing how to effectively perform an emergency ultrasound (Echo fast),[1,2]. The most severe cases (red cases) are admitted directly to the dechocage service for complet evaluation, appropriate emergency actions (thoracic drainage,endotracheal intubation, emergency thoracotomy) and emergency transport to the operating room.

 

2- All these patients had an ultrasound from the emergency room, carried out by the general practitioner on call before even calling the surgeon on call, who resumed the same examination on his arrival. This allows confirmation of the diagnosis of pericardial effusion in correlation with a suggestive clinical condition before further care is provided.

 

3- Preoperative latency: most of the patients arrive aproximatly one hour after the trauma. Only one of them arrived 3 hours after. Treatment begins immediately; the duration varies from one minute to 3 days for the procedures specifically aimed at the cardiac lesions, ranging from an emergency thoracotomy in the shock unit to a pericardial drainage in intensive care on the 3 day of hospitalization in front of a pericardial tamponade table developed by the patient.

 

 

4-Surgery:

a-      Both of patients from the first series (1 and 2) who had benefited from ultrasound-guided pericardial drainage in the operating room evolved well after only the drainage, which was sufficient and definitive.Their heart wound could not be located.

b-      The patient 3 and 4 also had an ultrasound-guided pericardial drainage in the operating room, but had to undergo a thoracotomy. The 3th died after resuming surgery to repair the severely hemorrhagic transfixing lesion of the atrium and right auricle, following a hypertensive surge in the intensive care.  About the 4th patient, faced with the worsening of his clinical condition by severe cardiac tamponade, he underwent a bilateral transverse sternothoracotomy on the 3rd posttraumatic day. The stellate wound of the right ventricle was discovered and sutured. A pericardial drain was replaced for 72 hours. He performed very well in intensive care and was exeated after a week.

c-       The last two patients (5th ans 6th ) had an emergency thoracotomy. The 5th patient died on the oprating table from uncontrollable bleeding from the ascending aorta, near the mitral valve. For the 6th patient, the team of general surgeons saw the patient 3 times to repair a wound of the anterior surface of the right ventricle. However, a fourth operation was necessary with the presence this time of a voluntary national cardiac surgeon, which made it possible to highlight a second wound located on the lower face of the right ventricle. It was repaired, but the patient died on the operating table due to possible myocardial fatigue.

 

Note that for two of these patients (0.33%), an exploratory laparotomy was also performed in a context of multiple trauma with trauma to the abdomen.

 

 

5- postoperatively, patients are systematically admitted to the intensive care unit with the presence of mechanical ventilators, the possibility of resuming in real time the ultrasound, the biological assessements. A multidisciplinary team is made up of national general surgeons, periodically reinforced by national and/or foreign thoracic and vascular surgeons, of national and/or foreign anesthesiologists-resuscitator, an internist, intensive care nurses, physiotherapists. Revisions of surgery are done as needed, with efficient support from the local blood transfusion service, an annex to the laboratory and partner of the national red cross service.

 

 

Evolution

   At one year of evolution, only two of the three survivors were seen at the clinic. One of the two who only benefited a pericardial drainage was refered to a cardiologist for noise added to the cardiac auscultation(valve injury?). The 4th , that of the myocardial repair, remained clinically stable. He did not require a specialized cardiac ultrasound during his one year follow-up and was no longer seen.

 

Capture

Figure 1: Foreign body passing through the breastbone

and causing a right ventricular myocardial injury.

 

Capture5

Figure 2: The 4th patient, on his third postoperative

day, in the intensive care (bilateral thoracotomy).

 

 

Results analysis

1-      Epidemiology

Supported period

We cannot comment on the prehospital phase of the management of our trauma, given the lack of  appropriate data. Patients arrived  at the hospital on average within an hour after the trauma.They started about 10 minutes from their arrival (1 to 20 minutes) compared to that of Avaro and All that was 63 minutes ( 0-180 minutes). [3].

 

a-      Nomber: Diring the year, the institution received the highest rate on record of vascular and thoracic wounds. 13 cases of severe chest injury required thoracotomy, including 9 of cardiac air injury. Only 6 out of 9 have been proven to reach heart level. Two of the 6 patients also required exploratory laparotomy for extrathoracic lsions as reported by Zeglaoui and All.

c- Breakdown by age/gender: 21 to 30 and over 40 years of age  have an equal number of cases, while the Avaro et All study shows and average age of 45.7 years. All patients are male wile Avari and All report 75% male [3].

 

d- Cause: Stabbing is responsible for 67% of penetrating wounds with cardiac involvement, compared to 56.25% in Alvaro and All [3].

 

e- Localization-anatomy of lesions: 69.23% of patients with chest wounds with indication for thoracotomy had cardiac area involvement. The left anterior thoracic seat was the preferred region for injuries as was right ventricular involvement (50% of injuries repaired) as noted in several publications[3,5,6].

 

2- Management

Paraclinique: echo fast has been routinely used and is called stethoscope of the “21st century”. This examination made it possible to diagnose the hemopericardium and to proceed to the pericardial drainage. The echofast is proven as the pivotal examination carried out at the admission for the management of the wounded suspects of cardiac damage by the demonstration of a hemopericardium which must seek an underlying heart wound by surgical exploration according to Vignon.

 

b.         In 33% of cases the drainage was sufficient and the patients were not thoracotomized. Rhazaloviith 2015 reports the potential benefit of the examination in the indication or not of a rescue thoracotomy, by the discover or not of a pericardial effusion [2]. However, one wonders what are the heart damage that can stop bleeding after drainage?

 

 

c. Technique: 66% of patients underwent thoracotomy. 3 patients underwent a left anterolateral thoracotomy and the other, a transverse bilateral sternothoracotomy. Thoracothomy is justified by the fact that it remouves the hemopericardium, allows hemostasis of heart wound and restoration of hemodynamics [2,4,8].

 

With beating heart, we performed a repair of a transfixing wound of the atrium and the right auricle, two reparations of the right ventricular muscle and an attempt to repair the ascending aorta. Myoraphia without intracardiac procedure or associated coronary surgery is the technique used by Avaro, El Kouache and all [3,5]

 

d. reintervention: one reoperation was performed for the patient with the right atrium and the right auricle wound, and 3 reoperations for the patient with the right ventricular wound.

 

e. extracorporeal circulation: This procedure was not available in the institution.It was not essential for myoraphia, but would be if we had to perform intracardiac procedures such as coronary artery surgery and that of the large heart vessels as presented in the sturdies of Avaro, All and El kouache [3,5].

 

 

3-      Death:

a.       Three patients  among six died on the operating table during surgery. Among the main causes of these deaths are a lack of infrastructure such as the absence of the device for cardiopulmonary bypass and the lack of experience of the staff in thoracic surgery resulting in untimely revivals to try to repair the lesions.

b.      Out of a total of 16 patients, Avaro J.P and all found a mortality of 12.5% The main cause was a long delay bfore treatment. Benoi was only able to see 7-10% of those with chest injuries, as 60-90% of them died on the spot survival would bee 75% if they had arrived at the hospital alive.

 

 

Conclusion

   The number of cardiac wounds received was limited. The latency period, the speed of resuscitation, the ultrasound diagnosis, an early admission to the operating room, the pericardiocenthesis, the thoracic drainage, the site of the lesions and their association  with other traumas; each have an impact on mortality and morbidity of cardiac lesions.

Three patients were able to survive. This result indicates that it is possible to save such cases when the ideal conditions are met, especially when the department has a device for cardiopulmonary bypass.

 

The basic requirements are the presence of general surgeons trained in thoracic surgery, the availability of a technical platform making it possible to confirm the diagnostic, to allow specific resuscitation procedures, to produce basic examinations, to dispose an adequate amount of blood to transfuse, to quickly have the operating room and an intensive care unit.

 

The hospital nap kenbe of tabarre doctors withour borders Belgium met these conditions, which greatly facilitated the management of theses patients. However it was still crucial to have a cardiac surgery department with cardiopulmonary bypass. The increasing number of gunshot and stab wounds increases the chances of potenctially salvageable chest and heart trauma.

 

Reference:

lavaudnicodeme@yahoo.fr     https://www.linkedin.com/in/nicodeme-lavaud-391104167

edme1609@yahoo.fr

tlmq15@yahoo.com

emiledams@yahoo.com

infochir@gmail.com   http://infochir.wordpress.com/contact/

Schwartz'principles of surgery,10th   https://www.linkedin.com/in/gary-schwartz-md-68179212

 

 

 

Date de dernière mise à jour : 11/07/2021