GSW L. Chest - Forum

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Thorax

GSW L. Chest - Ärzteforum

Post#1 »

Here's an interesting trauma case (a real one). Put it up for discussion, then I'll let you know the actual outcome.

1 AM. 18 yo male with GSW L. chest arrived ER in extremis. P-160, BP 65/40, tachypneic. Entrance wound L. chest 7th ICS just anterior to mid-axillary line. No exit wound found. Neck veins distended.

Excellent ER physician in attendance with no diagnostic tests other than brief physical, intubated him, got fluids going, placed a L. large bore chest tube (returned 200cc blood with moderate air leak). When this resulted in no significant improvement, made correct diagnosis of pericardial tamponade. One of our senior general surgeons was in house. Together in ER the did a subxyphoid pericardotomy and placed a soft catheter which returned lots of blood. Immediately BP rose to 110/60. (They clearly saved his life.) I was called for GSW to heart. With blood and fluids running, he was fairly stable.

He was stable enough for us to get him to OR, do a good skin prep, and call in the perfusionists. Did sternotomy and drained more blood on opening pericardium. It was obvious fresh blood was coming from posterior or inferior surface of heart, but every time I tried to tip the heart to see the injury, he would crash. So, put him on the pump to have a good look.

There was a clear tract of the bullet path across the diaphragmatic surface of the heart--looked like someone had pulled a spade across freshly cultivated soil - but no evidence that ventricle had been punctured. The distal posterior descending branches of the right coronary artery and vein had been transected, and the artery was pumping. The transection was far too distal to consider bypassing, so the artery and vein were suture ligated. At this point he had good cardiac function, and clearly would come off bypass with no problem. Chest tube still had small air leak, but draining very little. Before discontinuing bypass my general surgeon colleague and I considered what more, if anything, we should do.

How would you proceed from here?


Hans

Re: GSW L. Chest - Ärzteforum

Post#2 »

I would not do anything more than described in this interesting case, although here in Germany we are not that experienced in treating gunshot wounds of the heart. I assume, that his diaphragm was intact, which could be a possible source of major bleeding.

John Dissector

Re: GSW L. Chest - Ärzteforum

Post#3 »

An interesting and gratifying case. You don't mention where the bullet is or what direction its track went, and I assume at this point there is no further bleeding. A celiotomy should be done to exclude intraperitoneal injury. If the bullet went posteriorly thru the posterior pericardium, the esophagus and descending aorta are at risk. I see no reason at this point to not come off bypass as the heart seeems to be fixed - any missed injuries there will be evident as the circulation is restored. In cases like this, I'll always gert a quick chest and abdomen x-ray before taking patient to O.R. or even in the O.R. after stabilizing to be certain of where the bullet is so as not to miss an injury. If it went posteriorly and the patient is stable, your options are to either close and do aortography and esophagram or proceed now with a lateral thoracotomy to inspect--all has to do with your suspicion and condition of patient. I don't see any way of avoiding a celiotomy, however, which can be done very easily and quickly from where you are.

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A Doctor

Re: GSW L. Chest - Ärzteforum

Post#4 »

Regarding GSW to the left chest, I think the patient was lucky not to have died after time was wasted doing a subxyphoid pericardial window. The patient was lucky enough to come to a place capable of performing chest surgery. If he had been taken somewhere else he would have died. He needed the obvious GSW to the heart addressed whether it was through a left thoracotomy or a median sternotomy. They both have advantages and disadvantages. The left thoracotomy is a quicker route to the heart and posterior mediastinum in this patient who had a blood pressure of 60. It is not as easy to put him on bypass via a left thoracotomy. The median sternotomy makes bypass easier, but it is much harder to address the other potential injuries. If he would have had a large penetration of his ventricle, he would likely have died shortly after the subxyphoid window was performed.

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Surgeon

Re: GSW L. Chest - Ärzteforum

Post#5 »

Cardiovascular and Thoracic Surgery (retired)open the left (and possibly the right) pleural space while you're there, and explore the chest.

Wired

Re: GSW L. Chest - Ärzteforum

Post#6 »

An interesting case. Would definitely obtain x-rays to look for the bullet; It may have wandered into the R chest and/or the belly; I would perform a laparotomy. A thorough evaluation of the other thoracic organs is mandated, however, I think if you have good visualization of the Aorta and Esophagus I would not pursue the A-gram or Esophogram. As an aside, I would have favored an immediate L Lateral thoracotomy in the ER; both because I would have better visualization of the heart at that time, better access to the L pulmonary hilum, and prefer that incision for the formal thoracotomy. I also would have attempted the repair without bypass, figuring that by the time my perfusionist got in and had things set up, too much time would have elapsed.

Pet

Re: GSW L. Chest - Ärzteforum

Post#7 »

I would open the L and R pleura and have a look then see if I could figure out where the bullet went. Is it possible it's in the belly, after bypass you could consider a laparotomy.

Thorax

Re: GSW L. Chest - Ärzteforum

Post#8 »

With transection of distal posterior descending R. coronary artery and vein treated and having ruled out any other cardiac injury, we considered our further priorities to be:

1) Explore abdomen (mandatory). For the bullet to have entered the L. 7th ICS and injure the distal RCA on the diaghragmatic surface of the heart in the midline, it had to have passed through the diaphragm and through the upper abdomen en route.

2) Explore L. chest. We were there, and could easily be done through the sternotomy - although less than optimal as you cannot adequately get at hilum, descending aorta, or esophagus.

3) Explore R. chest. We were not sure this would be needed, but decided to make final decision after doing 1) and 2). With the sternotomy exposure we could see the R. lung moving nicely through the intact pleura, and there was no evidence on this inspection of pneumothorax.

Actually we looked in L. chest first with him still on bypass feeling that we might have to press on or manipulate the heart to get good exposure. There was a large hematoma in the inferolateral aspect of LLL. We may have been able to leave this to resolve, but I elected to remove the injured portion of the lung with a fair sized wedge resection using staplers. The hematoma may not have become as large had we not had to heparinize him for bypass. Then he was weaned from bypass and heparin reversed.

Extended midline incision down to umbilicus. As the linea alba was cut, just inferior to xyphoid, the bullet literally popped out. The spleen was badly fractured. Bullet had entered fundus of stomach posterolaterally and exited anteriorly, then had also caused a shattering injury of L. lobe of liver. We did a splenectomy, closed the two holes in the stomach, and resected the distal L. lobe of the liver. We did not explore R. chest given our visual findings through the sternal incision and where we found the bullet. He made a good recovery.

This case has been used as an oral board question (as I presented here) both for general and thoracic surgery by some friends whom I've told about it - the obvious point being to stress the importance of thinking about associated abdominal injury with penetrating (or blunt) injury low in the chest. We become accustomed to thinking of the position of the diaphragm as being as we see it on routine full inspiration chest films. The dome of the diaphragm can ride as high as T5 (I'm told - anyhow quite high) on full expiration.

Tom mentioned that the tube pericardiotomy as done may have been less than optimal - a good point. The people involved tried a needle tap first, didn't get an adequate responce, so did what they had to do. A technique I've used for chronic pericardial effusion which rapidly reaccumulates (such as malignant), is to enter the pericardium with a large needle, then thread in a soft catheter. This can be rigged to a stopcock, and fluid drained incrementally as necessary, until definitive treatment can be undertaken. I have not tried this in trauma cases, and certainly not in a cardiac chamber injury case, but it could be something to consider when one has to buy time.

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