Thoracic compartment syndrome after penetrating heart and lung injury

iprs000133 10.3205/iprs000133 urn:nbn:de:0183-iprs0001336 Case Report Thoracic compartment syndrome after penetrating heart and lung injury Thorakales Kompartmentsyndrom nach penetrierender Herz- und Lungenverletzung Rupprecht Rupprecht Holger H Prof. MD, PhD

Surgical Department 1, Clinical Center Fürth, Germany

author Dormann Dormann Harald H Prof. MD, PhD

Emergency Department, Clinical Center Fürth, Germany

author Gaab Gaab Katharina K Dr. med.

Surgical Department 1, Clinical Center Fürth, Jakob-Henle-Straße 1, 90766 Fürth, Germany, Phone: 0049/911/7580 1201, Fax: 0049/911/7580 1890Surgical Department 1, Clinical Center Fürth, Germany

katharina@gaab-web.de author German Medical Science GMS Publishing House

Düsseldorf

610 penetrating heart and lung injury compartment syndrome myocardial and lung edema packing bogota bag 20190404 engl This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). 2193-8091 8 GMS Interdisciplinary Plastic and Reconstructive Surgery DGPW GMS Interdiscip Plast Reconstr Surg DGPW 07 Thorakale Verletzungen sind die tödlichsten penetrierenden Verletzungen.Zwei Patienten wurden nach einem Suizidversuch mit einer penetrierenden Thoraxverletzung in unsere Notaufnahme eingeliefert. Während der CT-Untersuchung kam es zu einer Kreislaufdekompensation, so dass die notfallmäßige Thorakotomie erfolgen musste. In beiden Fällen fand sich eine Perforation im linken Ventrikel neben multiplen Lungenparenchym- und Gefäßverletzungen. Nach Versorgung der verschiedenen Läsionen verhinderte ein massives Ödem des Herzens und der Lunge einen Primärverschluss des Thorax, wobei wegen diffuser Blutung noch ein „Packing“ der Thoraxhöhle notwendig wurde. Zur Prävention eines Kompartmentsyndroms blieb der knöcherne Thorax offen und es wurde nur die Haut mit einer Plastikfolie verschlossen. Aufgrund der Kombination des offen belassenen Thorax und des Austamponierens der Thoraxhöhle kann die Mehrzahl der Patienten mit einem Herz-Lungen-Ödem nach penetrierender Verletzung gerettet werden.Fallstricke der präklinischen und klinischen Behandlung sowie Aspekte der Diagnostik und Operation werden diskutiert. Thoracic injuries are the most lethal penetrating injuries. After attempting suicide, two patients with a penetrating thoracic wound were admitted to our emergency department. During CT scan they became hemodynamically unstable, which is why we had to perform an emergency thoracotomy.In both cases, a perforation in the left ventricle as well as multiple lesions of the lung parenchyma and vessel injuries were found. After the treatment of the different injuries, a massive edema of the heart and lung prevented a primary closure of the thorax. Due to massive diffuse bleeding, a “packing“ of the pleural cavity became necessary. To prevent a thoracic compartment syndrome, the thoracic wall was left open and the skin was closed with a plastic sheet. Due to the “open chest” procedure combined with “packing” of the thoracic cavity, the majority of patients with an edema of the heart and lung after a penetrating chest injury can be saved. Pitfalls of preclinical and clinical treatment, aspects of diagnostics and surgery are discussed. IntroductionMost patients with blunt and penetrating chest trauma die at the accident site . Knowledge of the mechanism of injury, precise clinical anamnesis and examination as well as the appropriate use of diagnostic tools will help to choose the right surgical access and to realize the lethal complications related to cardiac injury. Case descriptionsTwo patients (42- and 49-year-old) were admitted to our emergency department after a suicide attempt. In the first case, the patient stabbed himself in the left chest with a letter opener. In the second case, the 49-year-old man shot himself with a 45-magnum-revolver into the anterior left chest wall. The clinical examination showed rarely bleeding thoracic wounds (Figure 1 , Figure 2 ). The patients were responsive, completely oriented (GCS=15) and hemodynamically stable. The abdominal sonography (FAST) showed no free fluid. Due to unclear injury patterns, a CT scan was performed. Shortly after the completion of the investigation, the patients became hemodyn</PlainText></TextGroup>amically unstable with upper venous congestion. The patients were immediately transported to the operating room. In both cases, the computed-assisted tomography verified a massive left hematothorax and a pericardial tamponade (Figure 3 <ImgLink imgNo="3" imgType="figure"/>, Figure 4 <ImgLink imgNo="4" imgType="figure"/>). In the case of the 42-year-old patient, a sternotomy was performed initially, followed by an anterolateral thoracotomy to supply the intercostal vessels more sufficiently. The second patient was treated with a left anterolateral thoracotomy. In both cases, a blood-filled pleural cavity, a lesion of the left ventricle as due to the pericardial tamponade and extracardiac <TextGroup><PlainText>inj</PlainText></TextGroup>ur<TextGroup><PlainText>ies</PlainText></TextGroup> were found (Table 1 <ImgLink imgNo="1" imgType="table"/>). </Pgraph><Pgraph>Due to the massive bleeding, the situs was initially unclear. Therefore, the lung hilum was primarily disconnected for bleeding control and after the continuous suction of the pleural cavity with the cell saver, the specific disconnection of the ruptured parts of the lung was performed.</Pgraph><Pgraph>The damaged vessels were supplied with non-absorbable sutures and the destroyed lung parenchyma was resected atypically using a stapler devise. The perforation channel of the lung perforations was treated by tractotomy with the help of a linear cutter. The bronchial tubes and vessels were supplied with sufficient seam <TextLink reference="2"></TextLink>. </Pgraph><Pgraph>Case 1: After the pericardiotomy and the evacuation of the blood clots, a “chemical asystole” was induced through the administration of adenosine (Adrekar<Superscript>®</Superscript>) to close the lesion in the left ventricle more easily. </Pgraph><Pgraph>Case 2: The blast wave of the projectile led to a myocardial contusion with secondary delayed rupture of the left ventricle. Initially, the massive bleeding from the 2 cm intraventricular defect was only manageable through the insertion of a blocked Fogarty catheter. With non-absorbable sutures sheathed with teflon plates (Prolene 2-0) the defect was closed and the leackage of the stitches was sealed sufficiently with two fibrin fleeces (Tachosil<Superscript>®</Superscript>) (Figure 5 <ImgLink imgNo="5" imgType="figure"/>, Figure 6 <ImgLink imgNo="6" imgType="figure"/>).</Pgraph><Pgraph>The shock related ischemia led to a massive myocardial and non-cardiac lung edema. A closure of the pericardium was not possible as otherwise it would have resulted in an “iatrogenic” tamponade. Because of that, an “extension plastic” with a Vicryl mesh (Case 1) and a bovine patch (Tutomesh<Superscript>®</Superscript>) (Case 2) was sewed into the pericardium (Figure 7 <ImgLink imgNo="7" imgType="figure"/>).</Pgraph><Pgraph>The massive swollen lung also prevented a primary closure of the thorax. The first attempt resulted in a systemic drop in blood pressure and a massive increase of the ventilation pressure. At this time, a so-called “lethal triad” was present (acidosis, hypothermia, coagulopathy). The result was a diffuse bleeding, which was only manageable through “packing” of the pleural cavity. As a consequence, the “expansion room” of the lung was reduced more and the thoracic wall was left open. An ordinary plastic sheet which is sewed into the skin (Figure 8 <ImgLink imgNo="8" imgType="figure"/>) helps the e<TextGroup><PlainText>de</PlainText></TextGroup>matous lung to expand. After stabilization on the intensive care unit (normothermia, correction of the acid-base equilibrium), the tamponades could be removed and the thorax was closed definitely after 24 hours. The wounds healed per primam under antibiotic covering. After ambulant psychiatric care, the patients are fully restored without physically afflictions.</Pgraph></TextBlock> <TextBlock linked="yes" name="Discussion"> <MainHeadline>Discussion</MainHeadline><Pgraph>Patients with a pericardial tamponade can stay hemod<TextGroup><PlainText>yn</PlainText></TextGroup>amically stable for a longer time. Clinical symptoms vary or can be completely missing until the intrapericardial pressure exceeds the diastolic pressure, which leads to a circulatory collapse <TextLink reference="3"></TextLink>, <TextLink reference="4"></TextLink>, <TextLink reference="5"></TextLink>. Because of that, penetrating thoracic traumata must be considered as “worst case scenarios” until the contrary is proven. Aggressive diagnostics and therapy are required. The “time factor” plays an important role for prognosis <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink>, <TextLink reference="7"></TextLink>, <TextLink reference="8"></TextLink>. </Pgraph><Pgraph>In the cases of our patients, two fatal mistakes could have led to a lethal outcome. Both patients were transported seated by private persons. Normally, an emergency team has to be alerted. Unfortunately, not in all cases a preclinical big lumen thoracic drainage (28 Ch.) is inserted, although in most of the cases additional intrathoracic <TextGroup><PlainText>inj</PlainText></TextGroup>ur<TextGroup><PlainText>ies</PlainText></TextGroup> are present <TextLink reference="9"></TextLink>. Especially in cases of a long transportation time, it is fatal not to place a thoracic drainage on the injured site. Most patients with this injury pattern die of a tension pneumothorax, for example, on the way to the hospital. They do not primarily die of a myocardial lesion <TextLink reference="5"></TextLink>.</Pgraph><Pgraph>The second “pitfall” concerns the clinical diagnostics in the trauma room. The detection of a pericardial hematoma during FAST of the pericarium and the thorax is enough for emergency thoracotomy in cases of a penetrating thoracic trauma. The detection of hematothorax indicates immediate thoracic drainage <TextLink reference="3"></TextLink>, <TextLink reference="10"></TextLink>, <TextLink reference="11"></TextLink>.</Pgraph><Pgraph>In cases of an acute blood loss of 1,000 ml over the drainage or continuous blood loss of 200–300 ml over 3 hours, an emergency thoracotomy is necessary <TextLink reference="5"></TextLink>, <TextLink reference="12"></TextLink>, <TextLink reference="13"></TextLink>.</Pgraph><Pgraph>A primary hemodynamical stable patient and a normal ECG (electrocardiogram) can create a false sense of security <TextLink reference="3"></TextLink>, <TextLink reference="6"></TextLink>. </Pgraph><Pgraph>If the stabilization of the patient is not possible after the rapid infusion of 2 liters <TextLink reference="6"></TextLink>, <TextLink reference="11"></TextLink> or a cardiopulmonal reanimation has already become necessary, a trauma-room thoracotomy should be performed <TextLink reference="2"></TextLink>, <TextLink reference="14"></TextLink>, <TextLink reference="15"></TextLink>. </Pgraph><Pgraph>Standard access is the lateral thoracotomy, which allows the disconnection of the lung hilum (also for prevention of an air embolism), the pericardiotomy and the direct heart massage <TextLink reference="4"></TextLink>, <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink>, <TextLink reference="7"></TextLink>, <TextLink reference="8"></TextLink>, <TextLink reference="13"></TextLink>, <TextLink reference="16"></TextLink>, <TextLink reference="17"></TextLink>. The left lateral thoracotomy also allows the disconnection of the descending aorta over the diaphragm to improve the blood circulation of the coronary arteries retrogradely <TextLink reference="4"></TextLink>.</Pgraph><Pgraph>The “clemshell thoracotomy” (transverse sternotomy) or the median sternotomy allows the inspection of the mediastinum and of both pleural cavities <TextLink reference="4"></TextLink>, <TextLink reference="7"></TextLink>, <TextLink reference="8"></TextLink>, <TextLink reference="16"></TextLink>.</Pgraph><Pgraph>In cases of emergency thoracotomy in the trauma roomm the clemshell technique should be preferred due to of an easier handling. After opening the thorax, the lung hilum should be disconnected <TextLink reference="4"></TextLink>, <TextLink reference="17"></TextLink> to detect the reason for the bleeding after the suction with the cell saver <TextLink reference="5"></TextLink>, <TextLink reference="8"></TextLink>. A longer central disconnection may lead to acute right heart failure <TextLink reference="18"></TextLink>. After pericardiotomy, smaller perforations in the heart wall should be manually compressed and can be sewed with non-absorbable stitches <TextLink reference="4"></TextLink>, <TextLink reference="5"></TextLink>, <TextLink reference="19"></TextLink>.</Pgraph><Pgraph>Bigger defects can be occluded primarily with the help of a Fogarty or urinary catheter to prevent bleeding to death <TextLink reference="4"></TextLink>, <TextLink reference="16"></TextLink>, <TextLink reference="20"></TextLink>. The urinary catheter also allows an intracardial fluid resuscitation <TextLink reference="16"></TextLink>. With a 16 Charrière urinary catheter up to 250 ml/minute can be administrated. The intravenous administration of adenosine (Adrekar<Superscript>®</Superscript>: 0,15–0,30 mg/kg KG) leads, through to a short block of the AV (atrioventricular) node, to an asystole, which simplifies the treatment of heart injuries <TextLink reference="19"></TextLink>, <TextLink reference="21"></TextLink>.</Pgraph><Pgraph>The shock related ischemia and hypothermia lead to a massive edema of the myocardium and the lung parenchyma <TextLink reference="7"></TextLink>, <TextLink reference="11"></TextLink>, <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="22"></TextLink> and to a coagulation disorder. The massive diffuse bleeding is not manageable with transfusion of fresh frozen plasma (FFP) and blood reserves alone <TextLink reference="23"></TextLink>. Only the tamponade of the pleural cavity (“packing”) is able to prevent a lethal outcome <TextLink reference="11"></TextLink>, <TextLink reference="17"></TextLink>, <TextLink reference="23"></TextLink>, <TextLink reference="24"></TextLink>. This method which was first used in cases of massive intraabdominal bleeding (e.g. rupture of the liver) <TextLink reference="25"></TextLink>, <TextLink reference="26"></TextLink> was later used in thoracic surgeries <TextLink reference="7"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="27"></TextLink> and after successful application in cardiac surgeries <TextLink reference="28"></TextLink>, <TextLink reference="29"></TextLink>. The tamponade of the pleural cavity can impede the diastolic filling of the heart as well as the expansion of the lung <TextLink reference="11"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="27"></TextLink>. This can be prevented through the “open chest” procedure <TextLink reference="4"></TextLink>, <TextLink reference="11"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="23"></TextLink>, <TextLink reference="30"></TextLink>, <TextLink reference="31"></TextLink>. A massive non-cardiac edema of the lung leads to a thoracic compartment syndrome in case of primary thoracic closure <TextLink reference="7"></TextLink>, <TextLink reference="11"></TextLink>, <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="31"></TextLink>, <TextLink reference="32"></TextLink>. Warning signs can be an increase in ventilation pressure and a drop of blood pressure <TextLink reference="7"></TextLink>, <TextLink reference="11"></TextLink>, <TextLink reference="32"></TextLink>, which can lead to cardiac arrest. To prevent this fatal complication, the thoracic wall <TextLink reference="7"></TextLink>, <TextLink reference="11"></TextLink>, <TextLink reference="31"></TextLink>, <TextLink reference="32"></TextLink> and muscles are left open and only an ordinary plastic sheet should be sewed into the skin (modified “Bogota bag”). This easy, cheap and always applicable method has proven its worth in septic abdominal surgery <TextLink reference="33"></TextLink>. Through expansion of the pleural cavity, even a massive edematous lung is able to expand after packing without affecting intrathoracic organs <TextLink reference="23"></TextLink>.</Pgraph><Pgraph>Furthermore, due to the myocardial edema the pericardium cannot be closed during shock. Trying to primarily close the pericardium under tension leads to an iatrogenic tamponade with a drop of the cardiac output.</Pgraph><Pgraph>Through a pericardial patch plastic with bovine pericardium (Tutomesh<Superscript>®</Superscript>) or with alloplastic materials (Goretex<Superscript>®</Superscript>), this complication can be avoided <TextLink reference="5"></TextLink>, <TextLink reference="34"></TextLink>.</Pgraph><Pgraph>After “damage control” the patient should be stabilized on the ICU (intensive care unit) for example through the regulation of temperature and correction of the acid-base-balance <TextLink reference="35"></TextLink>, <TextLink reference="36"></TextLink>. Cardiac diagnostics such as echocardography (transthoracal or transesophageal) should be performed in this phase to exclude intracardial lesions, e.g. ventricular septal defect <TextLink reference="14"></TextLink>, <TextLink reference="37"></TextLink>.</Pgraph><Pgraph>Usually 24–36 hours after stabilization, the tamponades can be removed and the thorax can be closed after the insertion of big lumen thoracic drainages <TextLink reference="38"></TextLink>.</Pgraph></TextBlock> <TextBlock linked="yes" name="Conclusion"> <MainHeadline>Conclusion</MainHeadline><Pgraph>In cases of penetrating heart and lung injuries, not only a massive edema of the intrathoracic organs <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink> results due to the shock but also a massive coagulation disorder with consecutive diffuse bleeding is visible. </Pgraph><Pgraph>This primarily leads to a thoracic compartment syndrome <TextLink reference="7"></TextLink>, <TextLink reference="11"></TextLink>, <TextLink reference="32"></TextLink> and at last to a cardiac arrest and bleeding to death. The massive diffuse bleeding is not manageable with transfusion of fresh frozen plasma (FFP) and blood reserves alone. Only the ”packing” of the pleural cavity <TextLink reference="23"></TextLink>, <TextLink reference="24"></TextLink> and the “open chest” procedure <TextLink reference="5"></TextLink>, <TextLink reference="11"></TextLink>, <TextLink reference="31"></TextLink> with a so called “Bogota bag” <TextLink reference="33"></TextLink> can save the life of patients with such injury patterns.</Pgraph></TextBlock> <TextBlock linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Competing interests</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Salehian O</RefAuthor> <RefAuthor>Teoh K</RefAuthor> <RefAuthor>Mulji A</RefAuthor> <RefTitle>Blunt and penetrating cardiac trauma: a review</RefTitle> <RefYear>2003</RefYear> <RefJournal>Can J Cardiol</RefJournal> <RefPage>1054-9</RefPage> <RefTotal>Salehian O, Teoh K, Mulji A. Blunt and penetrating cardiac trauma: a review. 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DOI: 10.1097/CCM.0b013e31817da7dc</RefTotal> <RefLink>http://dx.doi.org/10.1097/CCM.0b013e31817da7dc</RefLink> </Reference> </References> <Media> <Tables> <Table format="png"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Table 1: Extracardiac injuries</Mark1></Pgraph></Caption> </Table> <NoOfTables>1</NoOfTables> </Tables> <Figures> <Figure format="png" height="432" width="521"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Figure 1: Entry wound of 45-Magnum-revolver</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="432" width="557"> <MediaNo>2</MediaNo> <MediaID>2</MediaID> <Caption><Pgraph><Mark1>Figure 2: Thoracic wound of the letter opener</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="432" width="563"> <MediaNo>3</MediaNo> <MediaID>3</MediaID> <Caption><Pgraph><Mark1>Figure 3: Computer-assisted tomography: hematothorax</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="352" width="430"> <MediaNo>4</MediaNo> <MediaID>4</MediaID> <Caption><Pgraph><Mark1>Figure 4: Computer-assisted tomography: pericardial tamponade</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="431" width="389"> <MediaNo>5</MediaNo> <MediaID>5</MediaID> <Caption><Pgraph><Mark1>Figure 5: Left ventricle with non-absorbable sutures sheathed with teflon plates (Prolene 2-0)</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="422" width="576"> <MediaNo>6</MediaNo> <MediaID>6</MediaID> <Caption><Pgraph><Mark1>Figure 6: Left ventricle sealed with fibrin fleeces (Tachosil</Mark1><Mark1><Superscript>®</Superscript></Mark1><Mark1>)</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="432" width="573"> <MediaNo>7</MediaNo> <MediaID>7</MediaID> <Caption><Pgraph><Mark1>Figure 7: Pericardium with bovine patch (Tutomesh</Mark1><Mark1><Superscript>®</Superscript></Mark1><Mark1>)</Mark1> </Pgraph></Caption> </Figure> <Figure format="png" height="432" width="575"> <MediaNo>8</MediaNo> <MediaID>8</MediaID> <Caption><Pgraph><Mark1>Figure 8: Thoracic “Bogota bag”</Mark1></Pgraph></Caption> </Figure> <NoOfPictures>8</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <NoOfAttachments>0</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>