Presentation for students

1. CARDIAC TRAUMA
DEPARTMENT OF CARDIAC AND VASCULAR SURGERY
MEDICAL UNIVERSITY PLOVDIV
HRISTO RAHMAN

2. CARDIAC TRAUMA
TRAUMATIC AORTIC RUPTURE ( AORTIC
TRANSECTION )
EMERGENCY RESUSCITATIVE
THORACOTOMY
BLUNT CARDIAC TRAUMA
PENETRATING CARDIAC TRAUMA

3. TRAUMATIC AORTIC RUPTURE
(AORTIC TRASECTION)
PAHOPHYSIOLOGY
- OCCURS AFTER A DECELERATION INJURY, WHICH
CAUSES STRAIN AT THE POINTS OF ANATOMICAL
FIXATION OF THE THORACIC AORTA
- AS THE DESCENDING AORTA IS HELD IN PLACE BY
THE INTERCOSTAL ARTERIES AND THE LIGAMENTUM
ARTERIOSUM, AORTIC TRASECTION USUALLY
OCCURS AT THE AORTIC ISTHMUS ( BETWEEN THE
LEFT SUBCLAVIAN ARTERY AND THE LIGAMENTUM
ARTERIOSUM ) IN 80-90% OF CASES WITH THE
REMAINING AT THE ORIGIN OF THE AORTIC ARCH
BRANCHES

4. TRAUMATIC AORTIC RUPTURE
(AORTIC TRASECTION)
PAHOPHYSIOLOGY
THE MAJORITY ( 80-90% ) OF PATIENTS DIE
AT THE SCENE OF INJURY
50% OF SURVIVORS DIE WITHIN THE NEXT 48
HOURS

5. TRAUMATIC AORTIC RUPTURE
(AORTIC TRASECTION)
PAHOPHYSIOLOGY
THE ADVENTITIA AND SURROUNDING FASCIA
OF THE THORACIC AORTA CAN MAINTAIN
LUMINAL CONTINUITY FOLLOWING
TRAUMATIC AORTIC RUPTURE
IN CERTAIN SITUATIONS, IT IS NECESSARY TO
DIAGNOSE AND TREAT OTHER LIFE-
THREATENING INJURIES FIRST AND IF THIS IS
THE CASE THE SYSTOLIC BLOOD PRESSURE
NEEDS TO BE KEPT < 110 mmHG

6. AORTIC TRANSECTION
GRADE
I INTIMAL TEAR
GRADE
II
INTRAMURAL
HAEMATOMA
GRADE
III
PSEUDOANEURYS
M
GRADE
IV RUPTURE
CLASSIFICATION

7. TRAUMATIC AORTIC RUPTURE
(AORTIC TRASECTION)
CLINICAL FEATURES
THE DIAGNOSIS SHOULD BE CONSIDERED IN ALL PATIENTS
HAVING SUSTAINED SEVERE BLUNT CHEST TRAUMA,
ESPECIALLY IN THOSE WITH UPPER RIB ( 1-st - 3-rd ), STERNAL,
SCAPULA FRACTURES
RETROSTERNAL OR INTERSCAPULAR PAIN CAUSED BY
STRETCHING OR DISSECTION OF THE AORTIC ADVENTITIA
HAEMODYNAMIC COMPROMISE PRODUCING TACHYCARDIA,
HYPOTENSION AND OLIGURIA
PERI-AORTIC HAEMATOMA CAUSING COMPRESSION OF
SURROUNDING STRUCTURES RESULTING IN DYSPHAGIA,
STRIDOR, DYSPNOEA OR HOARSENESS

8. TRAUMATIC AORTIC RUPTURE
(AORTIC TRASECTION)
TYPICAL CHEST RADIOGRAPHY
WIDENED ( > 8 cm. ) SUPERIOR MEDIASTINUM
FRACTURES OF SUPERIOR THORACIC CAGE
OBLITERATION OF AORTIC KNOB
LEFT APICAL PLEURAL CAP
LEFT PLEURAL EFFUSION OR HAEMOTHORAX
DEVIATION OF THE OESOPHAGUS ( NASOGASTRIC TUBE ) TO THE RIGHT
DEVIATION OF THE TRACHEA ( ENDOTRACHEAL TUBE ) TO THE RIGHT
DISPLACEMENT OF THE LEFT HILUM DOWNWARDS
WIDENING OF THE PARATRACHEAL AND PARASPINAL STRIPE

9. TYPICAL CXR
WIDENED SUPERIOR MEDIASTINUM ( > 8 cm. )
MOST TRAUMA CXR ARE ANTERIOR-POSTERIOR IN PROJECTION, WHICH ARTIFICIALLY ENLARGES THE
MEDIASTINAL SILHOUETTE

10. TRAUMATIC AORTIC RUPTURE
(AORTIC TRASECTION)
TYPICAL CT SCAN
DISRUPTION OF THE AORTIC LUMEN
EXTRAVASATION OF RADIO-OPAQUE
CONTRAST
PERI-AORTIC HEMATOMA

11. TYPICAL CT SCAN
DISRUPTION OF THE AORTIC LUMEN
EXTRAVASATION OF RADIO-OPAQUE CONTRAST
PERI-AORTIC HEMATOMA
EXTRAVASATION OF RADIO-OPAQUE
CONTRAST
DISRUPTION OF THE AORTIC
LUMEN
PERI-AORTIC HEMATOMA
PERI-AORTIC HEMATOMA

12. TRAUMATIC AORTIC RUPTURE
(AORTIC TRASECTION)
OPTIONS FOR AORTIC
TRANSECTION TREATMENT
1. SURGERY
2. ENDOVASCULAR
STENTING ( EVAR/TEVAR )

13. TRAUMATIC AORTIC RUPTURE
(AORTIC TRASECTION)
TREATMENT RECOMMENDATINS FOR TRAUMATIC
AORTIC RUPTURE
AORTIC
TRANSECTION
TREATME
NT
GRAD
E I INTIMAL TEAR
MEDICAL
THERAPY
GRAD
E II
INTRAMURAL
HAEMATOMA
TEVAR / OR
GRAD
E III
PSEUDOANEUR
YSM
TEVAR / OR
GRAD
E IV RUPTURE
TEVAR / OR
Emergency

14. TRAUMATIC AORTIC RUPTURE
(AORTIC TRASECTION)
SURGERY
LEFT THORACOTOMY
THE AORTIC ISTHMUS IS CAREFULLY DISSECTED
CLAMPING OF THE AORTIC ARCH BETWEEN THE LEFT
SUBCLAVIAN AND LEFT COMMON CAROTID ARTERY/ LEFT
SUBCLAVIAN ARTERY AND DISTAL DESCENDING THORACIC
AORTA
AN INTERPOSITION TUBULAR VASCULAR GRAFT IS
ANASTOMOSED TO THE THORACIC AORTA, USING A
NUMBER OF DIFFERENT ADJUNCT TECHNIQUES

15. TRAUMATIC AORTIC RUPTURE
(AORTIC TRASECTION)
SURGICAL TECHNIQUES
CLAMP AND SEW: NO CPB; NO SYSTEMIC HEPARINISATION, BUT
ASSOCIATED WITH INCREASED RISK OF PARAPLEGIA IF THE CLAMP
TIME EXCEEDS 30 MIN.
GOTT SHUNT: HEPARIN-BONDED TUBING BYPASSING THE AREA OF
THE AORTA UNDERGOING SURGERY, FROM THE ASCENDING AORTA OR
LV APEX TO THE DESCENDING AORTA OR FEMORAL ARTERY
LEFT HEART BYPASS: HEPARIN-BONDED TUBING BETWEEN THE LA
APPENDAGE AND LEFT FEMORAL ARTERY WITH CENTRIFUGAL PUMP AT
2 L/MIN.; NO OXYGENATOR; NO SYSTEMIC HEPARINISATION
CARDIOPULMONARY BYPASS: PERIPHERAL CANNULATION;
BETTER CONTROL OF COLLATERAL FLOW WITH IMPROVED SURGICAL
VISUALISATION

16. Gott shunt: heparin-
bonded tubing to bypass
the area of aorta
undergoing surgery, from
the ascending aorta or
left ventricular apex to the
descending aorta or
femoral artery
Vincent Lynn
Gott

17. EMERGENCY RESUSCITATIVE
THORACOTOMY
ACCORDING TO ADVANCED TRAUMA LIFE SUPPORT ( ATLS )
GUIDELINES, FOLLOWING PENETRATING TRAUMA ( NOT BLUNT
TRAUMA ) WITHIN 10 MINUTES OF PULSELESS ELECTRICAL
ACTIVITY ( PEA )
PERFORMED BY LEFT ANTEROLATERAL THORACOTOMY
THROUGH THE 4th INTERCOSTAL SPACE
THROUGH THIS ACCESS, THE THERAPEUTIC OPTIONS INCLUDE:
- 1. EVACUATION OF THE PERICARDIUM;
- 2. OPEN CARDIAC MASSAGE;
- 3. CLAMPING OF THE DESCENDING THORACIC AORTA
( TO STOP DISTAL BLEEDING AND INCREASE CORONARY AND
CEREBRAL PERFUSION )

18. BLUNT CARDIAC TRAUMA
PRINCIPLES OF TREATMENT
PATIENTS ARE MANAGED AS PER THE ATLS GUIDELINES WITH PARTICULAR
ATTENTION TO CARDIAC DYSRHYTHMIAS, TAMPONADE AND MYOCARDIAL
CONTUSION
PATIENTS SHOULD BE MONITORED IN A HIGH DEPENDENCY AREA WITH SERIAL
ECGS, ECHOCARDIOGRAMS, CARDIAC ENZYMES, CHEST RADIOGRAPHS AND CT
SCANS
BCT MAY RESULT IN:
- 1. LEFT PLEUROPERICARDIAL TEARS;
- 2. RIGHT ATRIAL DISRUPTION AT THE CAVAL JUNCTIONS;
- 3. ATRIAL OR VENTRICULAR SEPTAL DEFECTS;
- 4. AORTIC REGURGITATION

19. PENETRATING CARDIAC TRAUMA
PRINCIPLES OF TREATMENT
PROMPT DIAGNOSIS OF CARDIAC TAMPONADE IS ESSENTIAL BY
ECHOCARDIOGRAPHY AND CLINICAL SIGNS:
- 1. HAEMODYNAMIC COMPROMISE;
- 2. BECK’S TRIAD;
- 3. KUSSMAUL’S SIGN;
- 4. PULSUS PARADOXUS
PROMPT DECOMPRESSION BY PARAXIPHOID PERICARDIOCENTESIS AND
THEN OPERATIVE CLOSURE OF THE PENETRATING CARDIAC WOUND

20. PENETRATING CARDIAC TRAUMA

21. NAIL GUN PENETRATING INJURY TO THE HEART
CT images obtained at different levels show two nails: One traverses the free wall of the right ventricle, with the tip appearing lodged in the inter ventricular
septum ( black arrow in a and b ); the second nail ( white arrow in a and b ) is less seen bur according to the patient’s history entered through the anterior chest,
penetrating the left ventricular apex and possible involving a portion of the inferior septum. The tip appears to exit via the free wall of the posteroinferior left
ventricle (b). The tip appears to exit via the free wall of the posteroinferior left ventricle (b). Haemopericardium is also present

22. PENETRATING CARDIAC TRAUMA
PRINCIPLES OF TREATMENT
ACCESS TO THE HEART IS OBTAINED BY:
- 1. LEFT ANTEROLATERAL THORACOTOMY IN EMERGENCY
SITUATIONS;
- 2. CLAMSHELL THORACOTOMY IN EMERGENCY SITUATIONS;
- 3. MEDIAN STERNOTOMY PROVIDES BETTER ACCESS TO THE
PERICARDIUM AND GREAT VESSELS IF TIME PERMITS
ONCE THE MEDISTINUM IS ACCESSED, THE PERICARDIUM IS
OPENED, ANY CLOTS OR LIQUID EVACUATED, OPEN CARDIAC
MASSAGE PERFORMED AND ANY BLEEDING POINT OCCLUDED

23. EMERGENCY LEFT ANTEROLATERAL
THORACOTOMY

24. EMERGENCY LIFE-SAVING
CLAMSHELL THORACOTOMY

25. EMERGENCY CLAMSHELL THORACOTOMY

26. PENETRATING CARDIAC TRAUMA
PRINCIPLES OF TREATMENT
ATRIAL AND VENTRICULAR
LACERATIONS - DIRECT SUTURE AND MAY
BE BUTTRESSED BY TEFLON STRIPS
CORONARY ARTERY LACERATIONS -
LIGATION AND BYPASS GRAFTING
POSTERIOR CARDIAC INJURY - AVOID AIR
EMBOLISM WHEN LIFTING THE HEART

27. ATRIAL AND VENTRICULAR LACERATIONS
ATRIAL LACERATION - DIRECT SUTURE
VENTRICULAR LACERATION - DIRECT SUTURE BUTTRESSED BY TEFLON
STRIPS
ATRIAL
LACERATION
REPAIR
VENTRICULAR
LACERATION
REPAIR

28. CORONARY ARTERY LACERATIONS
LIGATION +
SAPHENOUS VEIN GRAFTING