- Email: [email protected]
Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture
Accepted Manuscript Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture: A case report
Shunsuke Kudo, Keiji Tanaka, Kunihiko Okada, Takahiro Takemura PII: DOI: Reference:
S0735-6757(17)30661-7 doi: 10.1016/j.ajem.2017.08.015 YAJEM 56900
To appear in: Received date: Revised date: Accepted date:
18 July 2017 ###REVISEDDATE### 4 August 2017
Please cite this article as: Shunsuke Kudo, Keiji Tanaka, Kunihiko Okada, Takahiro Takemura , Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture: A case report, (2017), doi: 10.1016/j.ajem.2017.08.015
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 5
Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture: A case report
Shunsuke Kudo, MDa, Keiji Tanaka, MDa, Kunihiko Okada, MDa, and Takahiro Takemura, MDb Department of Emergency and Critical Care Medicine, Saku Central Hospital Advanced Care
PT
a
Department of Cardiovascular Surgery, Saku Central Hospital Advanced Care Center, 3400-28
SC
b
RI
Center, 3400-28 Nakagomi, Saku, Nagano, Japan
NU
Nakagomi, Saku, Nagano, Japan
MA
Corresponding author:
D
Shunsuke Kudo
PT E
Department of Emergency and Critical Care Medicine, Saku Central Hospital Advanced Care Center 3400-28 Nakagomi, Saku, Nagano, Japan
CE
Tel: +81-267-62-8181
AC
Fax: +81-267-88-7354
Email: [email protected]
Acknowledgement: None
ACCEPTED MANUSCRIPT 6
Funding: This case report did not receive any specific grant from funding agencies in the public, commercial,
PT
or not-for-profit sectors.
RI
Presentation history:
SC
This manuscript has not been previously presented at any scientific meeting. Abstract
NU
Extracorporeal cardiopulmonary resuscitation (ECPR) followed by operating room
MA
sternotomy, rather than resuscitative thoracotomy, might be life-saving for patients with blunt cardiac
D
rupture and cardiac arrest who do not have multiple severe traumatic injuries.
PT E
A 49-year-old man was injured in a vehicle crash and transferred to the emergency department. On admission, he was hemodynamically stable, but a plain chest radiograph revealed a
CE
widened mediastinum, and echocardiography revealed hemopericardium. A computed tomography
AC
scan revealed hemopericardium and mediastinal hematoma, without other severe traumatic injuries. However, the patient’s pulse was lost soon after he was transferred to the intensive care unit, and cardiopulmonary resuscitation was initiated. We initiated ECPR using femorofemoral veno-arterial extracorporeal membrane oxygenation (ECMO) with heparin administration, which achieved hemodynamic stability. He was transferred to the operating room for sternotomy and cardiac repair. Right ventricular rupture and pericardial sac laceration were identified intraoperatively, and cardiac
ACCEPTED MANUSCRIPT 7
repair was performed. After repairing the cardiac rupture, the cardiac output recovered spontaneously, and ECMO was discontinued intraoperatively. The patient recovered fully and was discharged from the hospital on postoperative day 7.
PT
In this patient, ECPR rapidly restored brain perfusion and provided enough time to perform
RI
operating room sternotomy, allowing for good surgical exposure of the heart. Moreover, open cardiac
SC
massage was unnecessary. ECPR with sternotomy and cardiac repair is advisable for patients with
NU
blunt cardiac rupture and cardiac arrest who do not have severe multiple traumatic injuries.
MA
Key words
AC
Key words:
CE
PT E
injury, Heart injury, Thoracotomy
D
Extracorporeal membrane oxygenation, Extracorporeal cardiopulmonary resuscitation, Thoracic
Extracorporeal membrane oxygenation, Extracorporeal cardiopulmonary resuscitation, Thoracic injury, Heart injury, Thoracotomy
ACCEPTED MANUSCRIPT 8
Text1 Blunt cardiac rupture rapidly causes cardiac arrest in most cases, and resuscitative thoracotomy could be life-saving. However, the survival rate of both blunt and penetrating cardiac
PT
injury victims who received resuscitative thoracotomy was reported to be only 17.3% [1]. Herein, we
RI
describe a patient with blunt cardiac rupture and cardiac arrest, who was successfully treated for
extracorporeal
cardiopulmonary
resuscitation
SC
blunt cardiac rupture and fully recovered. Instead of resuscitative thoracotomy, we performed (ECPR)
using
femorofemoral
veno-arterial
NU
extracorporeal membrane oxygenation (ECMO) followed by operating room sternotomy and cardiac
MA
repair, though ECPR is rarely considered for patients with post-traumatic cardiac arrest.
D
A 49-year-old man with a history of stimulant abuse was injured in a vehicle crash and
PT E
transferred to the emergency department. On admission, his heart rate was 90 beats per minute, and blood pressure was 103/75 mmHg. The oxygen saturation was 100% while breathing oxygen at a
CE
flow rate of 10 liter per minute via a face mask. Although there was no chest wall bruising, plain
AC
chest radiography revealed widened mediastinum (Fig. 1), and echocardiography revealed hemopericardium that was not compressing the right ventricle. A computed tomography (CT) scan revealed hemopericardium and mediastinal hematoma (Fig. 2), but no injuries were found in other parts of the body, including brain, great vessels, abdomen, and pelvis. Although the patient was transferred to the intensive care unit for optimal monitoring, his blood pressure suddenly dropped.
1
Abbreviations: ECPR; extracorporeal cardiopulmonary resuscitation; ECMO: extracorporeal membrane oxygenation; CT: computed tomography
ACCEPTED MANUSCRIPT 9
Echocardiography revealed progression of hemopericardium, which was compressing the right ventricle and resulting in cardiac tamponade. We performed pericardiocentesis, but the patient’s pulse was lost, and cardiopulmonary resuscitation was initiated. Because the initial CT revealed no
PT
great vessel or abdomino-pelvic injuries, we inserted a draining cannula into his right atrium through
RI
the right femoral vein and a return cannula into the left femoral artery to institute veno-arterial
SC
ECMO, with heparin administration. Within 20 minutes from the initiation of cardiopulmonary resuscitation, the patient became hemodynamically stable. He was transferred to the operating room.
NU
After performing median sternotomy and pericardiotomy, the large hemopericardium was evacuated.
MA
Active bleeding from a laceration, approximately 1 cm in length, in the right ventricle was identified.
D
Furthermore, we observed a laceration in the pericardial sac, which caused left hemothorax. After the
PT E
right ventricular rupture was repaired, the patient’s cardiac output recovered spontaneously, and ECMO was successfully discontinued intraoperatively. He was extubated on postoperative day 3. He
AC
day 7.
CE
fully recovered without any neurological deficits, and was discharged from hospital on postoperative
In our case, ECPR might be more advantageous to rapid, full recovery than resuscitative thoracotomy. First, because we could initiate ECPR using veno-arterial ECMO immediately after cardiac arrest, veno-arterial ECMO rapidly restored brain perfusion before release of cardiac tamponade and cardiac repair, and reduced the risk of the hypoxic brain injury. Second, we were able to transfer the patient with hemodynamic stability to the operating room to perform sternotomy,
ACCEPTED MANUSCRIPT 10
which allowed good surgical exposure of the heart and ascending aorta. Although lateral thoracotomy is preferred for resuscitation because it is accomplished more rapidly than sternotomy, surgical exposure of the heart is limited. Therefore, sternotomy is reliable for cardiac repair. ECPR
PT
provided enough time to perform sternotomy in the operating room. Third, veno-arterial ECMO
RI
support was continued intraoperatively; therefore, open intraoperative cardiac massage was not
SC
needed.
In our case, veno-arterial ECMO could satisfactory maintain sufficient blood flow to the
NU
vital organs and did not cause any complications because the patient did not have severe multiple
MA
traumatic injuries, apart from the cardiac injury. As with our case, only one case of blunt cardiac
D
rupture and cardiac arrest, who did not have other severe traumatic injuries, was treated with ECPR
PT E
using veno-arterial ECMO and discharged with minor stroke [2]. However, ECPR should not be considered for patients with cardiac arrest who have severe multiple traumatic injuries, because
CE
vascular access cannot be obtained in patients with great vessel injury, and sufficient venous drainage
AC
cannot be obtained due to hypovolemia in patients with hemorrhagic shock. The survival of patients with severe multiple traumatic injuries might deteriorate due to the hemorrhagic complications of ECPR, especially when heparin is administered to prevent blood coagulation in ECMO circuit. Moreover, if ECPR can restore brain perfusion, the neurological outcome cannot be improved in patients with severe traumatic brain injury. A previous study reported that among 30 patients with polytrauma who were considered for ECMO, ECMO could not be started or maintained in 16
ACCEPTED MANUSCRIPT 11
patients, mainly because of massive bleeding. Among 11 patients with post-traumatic cardiac arrest due to polytrauma who received ECPR, only 2 patients survived and the neurological outcomes were not reported [3].
PT
In conclusion, ECPR followed by operating room sternotomy and cardiac repair can be a
RI
reliable tool to treat a patient with blunt cardiac rupture and cardiac arrest who do not have multiple
SC
severe traumatic injuries. References
NU
[1] Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu WC, Dente CJ, et al. An
MA
evidence-based approach to patient selection for emergency department thoracotomy: A practice
D
management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care
PT E
Surg 2015;79:159-73.
[2] Kim SH, Song S, Kim YD, Cho JS, Lee CW, Lee JG. Application of percutaneous
CE
cardiopulmonary support for cardiac tamponade following blunt chest trauma: two case reports.
AC
Korean J Thorac Cardiovasc Surg 2012;45:334-7. [3] Bonacchi M, Spina R, Torracchi L, Harmelin G, Sani G, Peris A. Extracorporeal life support in patients with severe trauma: an advanced treatment strategy for refractory clinical settings. J Thorac Cardiovasc Surg 2013;145:1617-26.
ACCEPTED MANUSCRIPT
D
MA
NU
SC
RI
PT
12
AC
CE
PT E
Fig. 1
ACCEPTED MANUSCRIPT
MA
NU
SC
RI
PT
13
AC
CE
PT E
D
Fig. 2
ACCEPTED MANUSCRIPT 14
Figure legends Figure 1 A plain chest radiograph showing widened mediastinum. Pneumothorax, hemothorax, and rib
RI
PT
fractures were not observed.
SC
Figure 2
A computed tomography scan showing hemopericardium and mediastinal hematoma. Sternal fracture,
NU
rib fracture, pneumothorax, hemothorax, and obvious great vessel injuries were not observed. In
AC
CE
PT E
D
MA
addition, there were no other traumatic injuries, including brain, abdominal, and pelvic injuries.
Shunsuke Kudo, Keiji Tanaka, Kunihiko Okada, Takahiro Takemura PII: DOI: Reference:
S0735-6757(17)30661-7 doi: 10.1016/j.ajem.2017.08.015 YAJEM 56900
To appear in: Received date: Revised date: Accepted date:
18 July 2017 ###REVISEDDATE### 4 August 2017
Please cite this article as: Shunsuke Kudo, Keiji Tanaka, Kunihiko Okada, Takahiro Takemura , Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture: A case report, (2017), doi: 10.1016/j.ajem.2017.08.015
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 5
Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture: A case report
Shunsuke Kudo, MDa, Keiji Tanaka, MDa, Kunihiko Okada, MDa, and Takahiro Takemura, MDb Department of Emergency and Critical Care Medicine, Saku Central Hospital Advanced Care
PT
a
Department of Cardiovascular Surgery, Saku Central Hospital Advanced Care Center, 3400-28
SC
b
RI
Center, 3400-28 Nakagomi, Saku, Nagano, Japan
NU
Nakagomi, Saku, Nagano, Japan
MA
Corresponding author:
D
Shunsuke Kudo
PT E
Department of Emergency and Critical Care Medicine, Saku Central Hospital Advanced Care Center 3400-28 Nakagomi, Saku, Nagano, Japan
CE
Tel: +81-267-62-8181
AC
Fax: +81-267-88-7354
Email: [email protected]
Acknowledgement: None
ACCEPTED MANUSCRIPT 6
Funding: This case report did not receive any specific grant from funding agencies in the public, commercial,
PT
or not-for-profit sectors.
RI
Presentation history:
SC
This manuscript has not been previously presented at any scientific meeting. Abstract
NU
Extracorporeal cardiopulmonary resuscitation (ECPR) followed by operating room
MA
sternotomy, rather than resuscitative thoracotomy, might be life-saving for patients with blunt cardiac
D
rupture and cardiac arrest who do not have multiple severe traumatic injuries.
PT E
A 49-year-old man was injured in a vehicle crash and transferred to the emergency department. On admission, he was hemodynamically stable, but a plain chest radiograph revealed a
CE
widened mediastinum, and echocardiography revealed hemopericardium. A computed tomography
AC
scan revealed hemopericardium and mediastinal hematoma, without other severe traumatic injuries. However, the patient’s pulse was lost soon after he was transferred to the intensive care unit, and cardiopulmonary resuscitation was initiated. We initiated ECPR using femorofemoral veno-arterial extracorporeal membrane oxygenation (ECMO) with heparin administration, which achieved hemodynamic stability. He was transferred to the operating room for sternotomy and cardiac repair. Right ventricular rupture and pericardial sac laceration were identified intraoperatively, and cardiac
ACCEPTED MANUSCRIPT 7
repair was performed. After repairing the cardiac rupture, the cardiac output recovered spontaneously, and ECMO was discontinued intraoperatively. The patient recovered fully and was discharged from the hospital on postoperative day 7.
PT
In this patient, ECPR rapidly restored brain perfusion and provided enough time to perform
RI
operating room sternotomy, allowing for good surgical exposure of the heart. Moreover, open cardiac
SC
massage was unnecessary. ECPR with sternotomy and cardiac repair is advisable for patients with
NU
blunt cardiac rupture and cardiac arrest who do not have severe multiple traumatic injuries.
MA
Key words
AC
Key words:
CE
PT E
injury, Heart injury, Thoracotomy
D
Extracorporeal membrane oxygenation, Extracorporeal cardiopulmonary resuscitation, Thoracic
Extracorporeal membrane oxygenation, Extracorporeal cardiopulmonary resuscitation, Thoracic injury, Heart injury, Thoracotomy
ACCEPTED MANUSCRIPT 8
Text1 Blunt cardiac rupture rapidly causes cardiac arrest in most cases, and resuscitative thoracotomy could be life-saving. However, the survival rate of both blunt and penetrating cardiac
PT
injury victims who received resuscitative thoracotomy was reported to be only 17.3% [1]. Herein, we
RI
describe a patient with blunt cardiac rupture and cardiac arrest, who was successfully treated for
extracorporeal
cardiopulmonary
resuscitation
SC
blunt cardiac rupture and fully recovered. Instead of resuscitative thoracotomy, we performed (ECPR)
using
femorofemoral
veno-arterial
NU
extracorporeal membrane oxygenation (ECMO) followed by operating room sternotomy and cardiac
MA
repair, though ECPR is rarely considered for patients with post-traumatic cardiac arrest.
D
A 49-year-old man with a history of stimulant abuse was injured in a vehicle crash and
PT E
transferred to the emergency department. On admission, his heart rate was 90 beats per minute, and blood pressure was 103/75 mmHg. The oxygen saturation was 100% while breathing oxygen at a
CE
flow rate of 10 liter per minute via a face mask. Although there was no chest wall bruising, plain
AC
chest radiography revealed widened mediastinum (Fig. 1), and echocardiography revealed hemopericardium that was not compressing the right ventricle. A computed tomography (CT) scan revealed hemopericardium and mediastinal hematoma (Fig. 2), but no injuries were found in other parts of the body, including brain, great vessels, abdomen, and pelvis. Although the patient was transferred to the intensive care unit for optimal monitoring, his blood pressure suddenly dropped.
1
Abbreviations: ECPR; extracorporeal cardiopulmonary resuscitation; ECMO: extracorporeal membrane oxygenation; CT: computed tomography
ACCEPTED MANUSCRIPT 9
Echocardiography revealed progression of hemopericardium, which was compressing the right ventricle and resulting in cardiac tamponade. We performed pericardiocentesis, but the patient’s pulse was lost, and cardiopulmonary resuscitation was initiated. Because the initial CT revealed no
PT
great vessel or abdomino-pelvic injuries, we inserted a draining cannula into his right atrium through
RI
the right femoral vein and a return cannula into the left femoral artery to institute veno-arterial
SC
ECMO, with heparin administration. Within 20 minutes from the initiation of cardiopulmonary resuscitation, the patient became hemodynamically stable. He was transferred to the operating room.
NU
After performing median sternotomy and pericardiotomy, the large hemopericardium was evacuated.
MA
Active bleeding from a laceration, approximately 1 cm in length, in the right ventricle was identified.
D
Furthermore, we observed a laceration in the pericardial sac, which caused left hemothorax. After the
PT E
right ventricular rupture was repaired, the patient’s cardiac output recovered spontaneously, and ECMO was successfully discontinued intraoperatively. He was extubated on postoperative day 3. He
AC
day 7.
CE
fully recovered without any neurological deficits, and was discharged from hospital on postoperative
In our case, ECPR might be more advantageous to rapid, full recovery than resuscitative thoracotomy. First, because we could initiate ECPR using veno-arterial ECMO immediately after cardiac arrest, veno-arterial ECMO rapidly restored brain perfusion before release of cardiac tamponade and cardiac repair, and reduced the risk of the hypoxic brain injury. Second, we were able to transfer the patient with hemodynamic stability to the operating room to perform sternotomy,
ACCEPTED MANUSCRIPT 10
which allowed good surgical exposure of the heart and ascending aorta. Although lateral thoracotomy is preferred for resuscitation because it is accomplished more rapidly than sternotomy, surgical exposure of the heart is limited. Therefore, sternotomy is reliable for cardiac repair. ECPR
PT
provided enough time to perform sternotomy in the operating room. Third, veno-arterial ECMO
RI
support was continued intraoperatively; therefore, open intraoperative cardiac massage was not
SC
needed.
In our case, veno-arterial ECMO could satisfactory maintain sufficient blood flow to the
NU
vital organs and did not cause any complications because the patient did not have severe multiple
MA
traumatic injuries, apart from the cardiac injury. As with our case, only one case of blunt cardiac
D
rupture and cardiac arrest, who did not have other severe traumatic injuries, was treated with ECPR
PT E
using veno-arterial ECMO and discharged with minor stroke [2]. However, ECPR should not be considered for patients with cardiac arrest who have severe multiple traumatic injuries, because
CE
vascular access cannot be obtained in patients with great vessel injury, and sufficient venous drainage
AC
cannot be obtained due to hypovolemia in patients with hemorrhagic shock. The survival of patients with severe multiple traumatic injuries might deteriorate due to the hemorrhagic complications of ECPR, especially when heparin is administered to prevent blood coagulation in ECMO circuit. Moreover, if ECPR can restore brain perfusion, the neurological outcome cannot be improved in patients with severe traumatic brain injury. A previous study reported that among 30 patients with polytrauma who were considered for ECMO, ECMO could not be started or maintained in 16
ACCEPTED MANUSCRIPT 11
patients, mainly because of massive bleeding. Among 11 patients with post-traumatic cardiac arrest due to polytrauma who received ECPR, only 2 patients survived and the neurological outcomes were not reported [3].
PT
In conclusion, ECPR followed by operating room sternotomy and cardiac repair can be a
RI
reliable tool to treat a patient with blunt cardiac rupture and cardiac arrest who do not have multiple
SC
severe traumatic injuries. References
NU
[1] Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu WC, Dente CJ, et al. An
MA
evidence-based approach to patient selection for emergency department thoracotomy: A practice
D
management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care
PT E
Surg 2015;79:159-73.
[2] Kim SH, Song S, Kim YD, Cho JS, Lee CW, Lee JG. Application of percutaneous
CE
cardiopulmonary support for cardiac tamponade following blunt chest trauma: two case reports.
AC
Korean J Thorac Cardiovasc Surg 2012;45:334-7. [3] Bonacchi M, Spina R, Torracchi L, Harmelin G, Sani G, Peris A. Extracorporeal life support in patients with severe trauma: an advanced treatment strategy for refractory clinical settings. J Thorac Cardiovasc Surg 2013;145:1617-26.
ACCEPTED MANUSCRIPT
D
MA
NU
SC
RI
PT
12
AC
CE
PT E
Fig. 1
ACCEPTED MANUSCRIPT
MA
NU
SC
RI
PT
13
AC
CE
PT E
D
Fig. 2
ACCEPTED MANUSCRIPT 14
Figure legends Figure 1 A plain chest radiograph showing widened mediastinum. Pneumothorax, hemothorax, and rib
RI
PT
fractures were not observed.
SC
Figure 2
A computed tomography scan showing hemopericardium and mediastinal hematoma. Sternal fracture,
NU
rib fracture, pneumothorax, hemothorax, and obvious great vessel injuries were not observed. In
AC
CE
PT E
D
MA
addition, there were no other traumatic injuries, including brain, abdominal, and pelvic injuries.