Rescue extracorporeal membrane oxygenation in a young man with a stab wound in the chest

Rescue extracorporeal membrane oxygenation in a young man with a stab wound in the chest

Injury, Int. J. Care Injured 45 (2014) 1509–1511 Contents lists available at ScienceDirect Injury journal homepage: www.elsevier.com/locate/injury ...

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Injury, Int. J. Care Injured 45 (2014) 1509–1511

Contents lists available at ScienceDirect

Injury journal homepage: www.elsevier.com/locate/injury

Case Report

Rescue extracorporeal membrane oxygenation in a young man with a stab wound in the chest Giuseppe Gatti a,*, Gabriella Forti a, Alessandro Bologna a, Gianfranco Sagrati a, Gianfranco Gustin a, Renata Korcova b, Elisabetta Benci c, Luca Visintin d a

Department of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy Department of Cardiology, Ospedali Riuniti, Trieste, Italy Department of Thoracic Surgery, Ospedali Riuniti, Trieste, Italy d Department of Emergency, Ospedali Riuniti, Trieste, Italy b c

A R T I C L E I N F O

A B S T R A C T

Article history: Accepted 7 June 2014

A 27-year-old man with haemorrhagic shock and acute cardiac tamponade due to a stab in the chest underwent successful resuscitation and surgical repair of the right ventricular perforation thanks to the use of extracorporeal membrane oxygenation (ECMO) in the emergency department. To the best of the authors’ knowledge, this is the first report around the use of ECMO to rescue a victim of a penetrating cardiac trauma. The physicians who have portable ECMO device should be aware of this option when a life-threatening internal bleeding in haemodynamically unstable patients could be quickly controlled by surgery, even if performed in ill-suited settings. ß 2014 Elsevier Ltd. All rights reserved.

Keywords: Chest Extracorporeal membrane oxygenation Myocardial injury Resuscitation Trauma Penetrating

The use of extracorporeal life support in trauma casualties is limited by concerns regarding the increased risk of bleeding due to the need for heparin administration, being the risk very high particularly in the case of penetrating trauma of the chest [1,2]. In the present report, extracorporeal membrane oxygenation (ECMO) was used in emergency department to rescue a young victim of a penetrating cardiac trauma. Case report A 27-year-old man with a stab in the chest was admitted to the emergency department of the present authors’ institution. He was conscious (Glasgow Coma Score, 13), in sinus tachycardia (140 heart beats per minute), with hypotension (mean artery pressure, 60 mmHg) and tachypnea (30 breaths per minute). At physical examination, there was a 4-cm-wide wound in the fifth left intercostal space, just anterior to the middle axillary line. The focused assessment with sonography for trauma exam [4], performed during the primary survey of the advanced trauma life support protocol, identified both a massive left haemothorax, which was managed with placement of a chest tube, and a

* Corresponding author at: Department of Cardiac Surgery, Ospedale di Cattinara, via P. Valdoni, 7, 34148 Trieste, Italy. Tel.: +39 040 3994103; fax: +39 040 3994995. E-mail address: [email protected] (G. Gatti). http://dx.doi.org/10.1016/j.injury.2014.06.008 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.

developing pericardial effusion (Fig. 1). The intention to treat the cardiac injury in the operative room was abandoned due to the rapid clinical decompensation of the patient resulting in cardiac arrest (pulseless electrical activity). Cardiopulmonary resuscitation was initiated promptly and performed according to the advanced cardiac life support (ACLS) guidelines. The decision was made to place the patient on venoarterial ECMO in the emergency department as the only viable way to achieve adequate blood oxygenation and tissue perfusion until the bleeding was controlled and the cardiac function restored. A 21-Fr cannula was placed percutaneously into the patient’s left femoral vein to provide inflow to the ECMO device, and a 17-Fr cannula was placed percutaneously into the right femoral artery in order to provide outflow from the ECMO device to the patient (Fig. 2). Thus, after 42 min of ACLS cardiopulmonary resuscitation, the patient was placed on venoarterial ECMO at a flow rate of 4.5– 5.0 L/min. Following median sternotomy, the pericardial effusion was drained with recovery of a good cardiac function, the right ventricular free wall injury and the adjacent lesion of a small coronary vessel pertaining to the right coronary artery were repaired by using, respectively, a pericardial patch and a 7-0 polypropylene suture, the fifth left intercostal artery and the chest wound were sutured, and some small bleeding lesions of the parietal pleura corresponding to rib fractures (external cardiac massage) were repaired. There were no injuries to the left lung.

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postpericardiotomy syndrome and a posttraumatic stress disorder. The 30-day follow-up echocardiography assessment showed neither right ventricular dysfunction nor pericardial effusion. Discussion

Fig. 1. The pericardial effusion at the focused assessment with sonography for trauma exam.

After 116 min of cardiopulmonary bypass, the ECMO was discontinued, the sternum reconstructed, and the femoral cannulas surgically removed. A total of 350 U/kg of heparin were given to the patient. The 2000 ml of blood that were aspirated from the surgical field with a standard high-power sucker were processed through a blood salvage system and readily returned to the patient. However, a generous homologous blood transfusion was needed, and a total of 22 U of packed red blood cells, four units of fresh frozen plasma, and five pools of platelets were used. The patient was taken to the intensive care unit of the department of cardiac surgery, where he woke 10 h later without neurological dysfunctions. He was moved to the ward in postoperative day two and discharged home after 11 days from operation. Cefotaxime (1000 mg) and vancomycin (1000 mg) have been intravenously used for perioperative prophylaxis of septic complications. Vancomycin (2000 mg every 24 h) and gentamicin (300 mg every 24 h) were continued until discharge. No signs of infection developed. The patient was treated for a mild

The clinical presentation of penetrating cardiac injuries covers the spectrum from haemodynamic stability to cardiac arrest [1–3]. Stable patients can benefit from examination with chest radiography, transoesophageal echocardiography, or computed tomography, and undergo surgical repair through a median sternotomy in operative rooms with cardiothoracic team and equipment. Conversely, the optimal management of haemodynamically unstable patients is a controversial issue. For patients admitted in extremis to emergency department, most of the authors perform an immediate thoracotomy, even in the course of cardiac massage [3,5]. However, a few of authors believe that taking the patient to the nearest operative room with cardiothoracic expertise may, all things considered, increase his/her chances of survival [6]. Indeed, although thoracotomy provides a rapid access to the chest without the need of especial instruments like the sternal saw, median sternotomy provides superior surgical exposure to the mediastinum as well as to both thoracic cavities. Thus, even complex repairs can be performed using cardiopulmonary bypass if necessary [7], and late complications such as vascular and ventricular pseudoaneurysms can be avoided [8]. In the present report, portable ECMO device was successfully used to rescue a young man with a stab wound in the chest. After the cardiac arrest, adequate blood oxygenation and tissue perfusion of the patient were restored following ECMO institution, his unloaded right ventricle was repaired through a median sternotomy by an expert surgical team, and the blood was recovered from the surgical field. Even more complex cardiac lesions or lung injuries could have been repaired. Although the operation was performed not in operative but in emergency room inevitably with poor sterility conditions, no infection developed.

Fig. 2. (A) The DLP1 femoral cannulae and insertion kit (Medtronic Inc., Minneapolis, MN, USA). (B) The portable extracorporeal membrane oxygenation device: centrifugal pump (ROTAFLOW1; Maquet Getinge Group, Rastatt, Germany), oxygenator (QUADROX-i1 Adult; Maquet Getinge Group, Rastatt, Germany), and circuit (SOFTLINE1 Coating; Maquet Getinge Group, Rastatt, Germany).

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The patient’s hospital course was uneventful, and his early outcome good. Actually, there was a substantial delay between the onset of cardiac arrest and the start of cardiopulmonary bypass with ECMO. This was mainly due to the distance at the authors’ institution between the department of cardiac surgery, where the ECMO device and the dedicated team are located, and the emergency department. Unfortunately, these two departments are in separate and poorly connected buildings. To the best of the authors’ knowledge, this is the first report around the use of ECMO in emergency department for victims of penetrating cardiac trauma. When a life-threatening internal bleeding in haemodynamically unstable patients could be quickly controlled by surgery, portable ECMO device (if available) should be kept in mind as a life support option, even in ill-suited settings [9].

Conflict of interest There are no conflicts of interest for the authors of the present report.

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