|Year : 2007 | Volume
| Issue : 2 | Page : 131
Emergency anaesthetic management of cardio-thoracic & abdominal injury
Vishal Panchamia1, Neelam Thaker2, Chetana Jadeja2, BJ Shah3
1 P.G. Student, Department of anesthesiology, B. J. Medical College, Ahmedabad, India
2 M.D., D.A., Asst. Prof., Department of anesthesiology, B. J. Medical College, Ahmedabad, India
3 M.D., D.A., Prof., Department of anesthesiology, B. J. Medical College, Ahmedabad, India
|Date of Acceptance||20-Feb-2007|
|Date of Web Publication||20-Mar-2010|
C-503, Vardan Tower, Nr. Pragati Nagar, Ahmedabad - 380063
Source of Support: None, Conflict of Interest: None
A 40 years old male presented with multiple stab injuries over left side of chest& abdomen with unstable hemodynamic status was taken for emergency exploratory laprotomy. Anesthetic management of this patient is discussed here.
Keywords: Stab Injury, ventricular trauma, ICD
|How to cite this article:|
Panchamia V, Thaker N, Jadeja C, Shah B J. Emergency anaesthetic management of cardio-thoracic & abdominal injury. Indian J Anaesth 2007;51:131
|How to cite this URL:|
Panchamia V, Thaker N, Jadeja C, Shah B J. Emergency anaesthetic management of cardio-thoracic & abdominal injury. Indian J Anaesth [serial online] 2007 [cited 2020 Feb 19];51:131. Available from: http://www.ijaweb.org/text.asp?2007/51/2/131/61128
| Introduction|| |
Patients presenting with major and multiple injuries requiring emergency surgery are a great challenge to the anaesthesiologist. The anaesthesiologist is ideally suited & trained to deal these problems.
Despite, increasing sophistications of emergency medical services and rapid transportation to the hospitals 60-80% of thoracic injuries cause mortality at the site before arrival at trauma facility. ,
The patients with thoraco-abdominal trauma frequently present to the operating room in an urgent manner. There is generally little time to fully evaluate the patient. Here we are presenting a case of thoraco-abdominal injury in which the patient was taken for laprotomy as thoracic wounds were not seemingly needed exploration. Later, after induction, it was found to have some major thoracic vessel injury and on thoracotomy right ventricular tear was found.
| Case report|| |
A 40 years old male presented in causality with history of multiple stab injury in the left side of chest and abdomen three hrs back. No complaints of breathlessness, hemoptysis, hematemesis. There was no other significant history present.
On examination patient was conscious, oriented and followed commands. Periphery was cold and pallor was present. Pulse was 130/min, regular and blood pressure was 80/60 mm of Hg. RS examination showed no crepitus over
chest, bilateral air entry present but decreased in left lower zone. CVS examination showed tachycardia and S1-2 normal. On abdominal examination omentum was coming out from the wound. Primary sutures were present on chest and there was no oozing. U/O was 100 ml.
| Investigations Showed|| |
No abnormal finding in chest x-ray and ECG showed sinus tachycardia. All other investigations were within normal limits.
Patient was taken inside the operation theatre. Two I.V. lines were taken and SPO2 & ECG monitor applied. SpO2 was 100% on air. Injection hemacele started and 100% O2 started by mask. Blood pressure was 80/60 mm of Hg. Patient was given Inj. Glyco pyrollate 0.2mg. Then patient was induced with Inj. Ketamine 100mg & Inj. Succinyle Chloride 100 mg. Sudden gush of blood started from upper chest wound with projectile flow. Airway was secured with proper sized endotracheal tube and IPPV with 100% O2 started. SBP was 90 mm of Hg. Bleeding was not controlled on pressure with mops and ICD was inserted at same time in 5th left intercostals space in mid axillary line. About 300ml of blood came from ICD. SBP started falling to 50mm of Hg at brachial artery. Radial pulse was not palpable inj. dopamine at the rate of a 0.7mg/minute started.
Chest wound was opened by surgeon but bleeding could not be controlled so would was packed with mops and cardiothoracic surgeon was called. SBP was 40 mm of Hg. Inj. dobutamine drip started at the rate of 5-6 micro gm/ minute. Patient was ventilated with 100% O2.As spontaneous respiration was present Inj. Atracurium was given for muscle relaxation. Heart rate was remained between 150 to 160 per minutes and SBP 40-42 mm of Hg till cardiothoracic surgeon opened the pericardium through the left thoracotomy incision. Immediately after that, radial pulse was palpable and SBP was 90 mm of Hg at radial artery.
On exploration, there was massive blood loss and which was collected for autologus blood transfusion. 5 such autologus blood transfusions were given.
On exploration there was tear in right ventricle, which was primarily repaired. Left internal memory artery was also torn and was also ligated. After thoracic would closure laparotomy was done. No injury was found to abdominal structures. Intra-operative steroids, inj. calcium Gluconate 2 ampule, inj. soda bicarb 100 ml were given. Total fluid during surgery was given in form of 5 pints of autologus blood, 3 pints of homologus blood, 1 liter of colloid and 2 liters of crystalloids. U/O was 200 ml. After completion of surgery, neuromuscular blockade was revered with inj. neostigmine and inj. glycopyrrolate. Inj. diclofenac sodium 75 mg intramuscular was given for pain relief. Patient was extubated after achievement of adequate tidal volume. Patient was conscious and followed commands and was maintaining saturation 99% on air. ICD column movement was present. Air entry was decreased on left lower zone. Pulse rate was 120/minute regular and BP was 100/70mm of Hg without ionotropic support. The patient was shifted to surgical ICU for observation. Patient was stable and there were no complications in postoperative period. Patient was discharged on 8th postoperative day.
| Discussion|| |
According to Naughton and Colleagues penetrating cardiac injuries occur most often in the home (70%), by a known assistant (83%) and are domestic or social disputes (73%). Victims are predominantly male.  In the majority of patients (more than 80%) of stab wound of the heart cardiac teamponade occurs. 
Trauma is a disease of the young and is the leading cause of death in the first three decades of the life. Trauma is third leading cause of death after cancer and atherosclerosis in all age group. In US, thoracic trauma accounts for one quarter of all trauma deaths. 
Here we are, presenting a case of multiple stab wounds in the chest and abdomen. As the patient had no symptoms/signs of lung injury like breathlessness, wheezing, subcutaneous emphysema, sucking of chest wound, SpO2 100% on air, lung injury was less likely. There were no signs of cardiac injury like muffled heart sounds, distended neck veins. However, this classic signs are almost universally absent in traumatic cardiac tamponade. 
As ECG and X-ray chest were normal and omentum was lying outside abdominal wound and patient was taken for laparotomy. When patient was first received at causality his SBP was 70 mm Hg which was brought up to 90mm Hg by giving 500 ml of colloids and 1 liter of crystalloids. Considering the hypovolamic status, it was decided to induce the patient with inj. ketamine. Accordingly to Karim Broli,  induction of anesthesia may lead to a dramatic loss of blood pressure and care should be taken with the choice of induction agent Ketamine and/or and Opiate (such as fentanyl / alfentanyl) may be preferable to the standard intravenous agents. Muscle relaxation was maintained throughout. So, Induction with Ketamine was justified.
After intubation, as the haemodynamic status has improved because of Ketamine sudden jet of projectile flow of blood was started coming out from upper thoracic wound. At this time, cardiac or a major vessel injury was suspected. On wound explorations, it was more likely that cardiac injury was there. While, waiting for cardiothoracic surgeon wound was packed and ICD was put. As SBP was 50 mm of Hg, only muscle relaxant (Atracurium) was sufficient to maintain anesthesia. These patients need 100% O2 delivery to the tissues until hemoglobin can be replaced.  In literature , it is suggested that large volume fluid therapy should be avoided prior to hemorrhage control. Once it is controlled, patients will need rapid correction of hypovolemia to refill the heart and restore perfusion to nonvital organ systems. Patients will be cold and profoundly coagulopathic. Blood and component therapy should be warmed and administered rapidly after hemorrhage is controlled.  So, here, we maintained the patient with two I.V. lines on crystalloids till tear was repaired.
As hemorrhage was massive from thorax, autologus transfusion was done which was life saving in this case, as homologus blood was not adequate considering the rapidity of the blood loss. This is in accordance with Kenneth L. Mattox & Matthew J. Wall.  who say that auto transfusion is now a safe effective means of recycling shed blood in the patient who has undergone thoracic trauma. In their experience with more than 5000 patients, auto transfusion was most effective when applied in those with blood loss due to injury to intrathoracic great vessels.
The use of adrenaline or ionotropes is contra indicated in the presence of hypovolemia. Ionotropes may be required after control of hemorrhage and cardiac repaired.  The patient recovered and was discharged home on 8th postoperative day.
| Conclusion|| |
Thoracic trauma needs a high index of suspicion to detect cardiac injury as sings/symptoms may be misleading & investigations are limited in the emergency situation. Maintenance of optimal blood volume, autologus blood transfusions and judiciary use of ionotropes may be life saving.
| References|| |
|1.||Symbas PN. Cardiothoracic trauma, Philadelphia, W.B. Saunders 1989: 23. |
|2.||Trinkle JK. Penetrating heart wounds: difficulty in evaluating clinical series. Ann Thorac Surg 1984; 38: 181. [PUBMED] |
|3.||Naughton, M.J. Brissie, R.M. Bessey, P.Q., McEachern. Demography of penetrating cardiac trauma, Ann Surg 1989;209: 676. |
|4.||Fred A. Crawford, Jr(M.D.). penetrating cardiac injuries, Sabiston Textbook of Surgery, 15 th Ed. W.B. Saunders 1997:1956-60. |
|5.||J.Fhigh Devitt, MD, FRCPC. Blunt Thoracic Trauma, Assessment, management& Anaesthesia, Winterluke 95-Blunt thoracic trauma 1-9. |
|6.||Karim Brohil : Thoracic trauma, Truama.org 6:6, June 2001: 1-3. |
|7.||Anasethesia for Trauma, Johan K.Stene, Cristopher M. Gande, Anaesthesia 4th Ed. Chirchill Livingston 1994: 2157-2173. |
|8.||Kenneth L. Mattox, Matthew J. Wall. Management of trauma to thoracic great vessels, Mastery of surgery 4th Edition, Ed: Robert J. Baker, Losef E. Fischer, Publisher : Lippincott Williams and Wilkins 2001: 2033-40. |