Mallikarjuna Uppara, Gwent Centre for Digestive Diseases, Division of Upper GI Surgery, Royal Gwent Hospital, Newport,
Wales, UK, E-mail:
Thoracotomy in elective lung resections is itself a morbid procedure that carries a reported morbidity rate of 23-43.6% and a mortality rate of 1.2-11.3%. These are significantly higher morbidity and mortality rates than in similar procedures that are performed thoracoscopically, pointing out the morbidity of the thoracotomy approach itself. These rates trend up as age of the patient increases, with one study of thoracotomy in octogenarians reporting a complication rate of 63% (4-8). It follows that thoracotomies performed in the emergency department, often with haste and with poor sterile technique, carry even higher morbidity and mortality rates; notwithstanding the initial traumatic insult that led to the need for such an intervention.
We present the case of an 87 year-old man who underwent an emergent resuscitative thoracotomy for cardiac tamponade and survived. The tamponade was caused by a cardiac injury from chest tube placement for hemo-pneumothorax.
On initial trauma re-evaluation his blood pressure was 118/71, heart rate was 74, and his oxygen saturation was 100% on assist-control ventilation. An endotracheal tube was in place, but the patient was alert and interactive with eyes open, responding to questions appropriately with head nods. His cardiac exam was significant for a rub and his lung exam was notable for decreased breath sounds on the left side, where a chest tube was sutured in place with approximately one liter of blood in the canister. A repeat chest x-ray upon transfer demonstrated near-complete opacification of the left hemithorax as well as a left chest tube that terminated at the lung apex. A focused-assessment with sonography for trauma (FAST) exam was performed which was positive for a notable pericardial effusion. While undergoing the remainder of the trauma evaluation, the patient's blood pressure dropped from normal range to barely palpable. Emergent left thoracotomy was performed at the bedside. This allowed visualization of a tense, purple pericardium that was immediately opened in a cephalad-caudad direction and large amounts of blood clot were evacuated from around the heart. No obvious source of bleeding was identified at this time. Initially the heart was stagnant, but almost immediately returned rhythm after removal of the surrounding clot. Blood pressure returned with systolics in the 80's. The patient was then brought to the operating room where exploration of the left chest and heart revealed a contusion and 1 cm laceration to the left ventricle that was not actively bleeding. This was repaired with a plegetted 4-0 prolene suture. All superficial chest wall muscular bleeding was controlled, the left chest cavity was thoroughly irrigated, and 3 chest tubes were placed and put to suction. The patient remained intubated and was subsequently transferred to the Surgical Intensive Care Unit.
Initially the patient required fluid and pressor support with norepinephrine which was weaned off over hospital days 2 through 4. He was continued on broad-spectrum prophylactic antibiotics (pipercillin-tazobactam) for 8 days given concern for poor sterility of his initial surgical procedure. He underwent daily spontaneous breathing trials and was extubated on hospital day 7. His chest tubes were removed on hospital day 8 and hospital day 13. Postoperatively he developed atrial fibrillation but this reversed to sinus rhythm with aggressive electrolyte repletion. He was discharge to a short-term rehabilitation center on hospital day 15.
Thoracotomy is a particularly morbid procedure in the elderly, and resuscitative thoracotomy is known to be an innately morbid procedure. Despite this, in the patient with acute tamponade with hemodynamic compromise it should be considered, regardless of age. This is especially true in patients with a singular 'stab' wound to the heart as it was in this case, and as it has been reported previously in a considerably younger patient population.
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