E141 Journal Club with Morad Hameed on Cardiac Injuries
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Chad Ball 00:06
Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We're absolutely thrilled on Cold Steel today to have our friend of the podcast and, really, national leader in trauma, critical care and emergency general surgery back, Morad Hameed. Welcome, Morad. Thank you for joining us.
Morad Hameed 00:44
It's so great to be here, Chad and Ameer. Thank you for having me.
Chad Ball 00:47
So we're really excited to launch a new series within the Cold Steel podcast family, and that essentially is a journal club. And first out of the gate, we've chosen your technical review of managing penetrating cardiac trauma. So we're really excited. The topic is certainly close to all of our hearts — pun intended. And, yeah, we're thrilled that you're on, and we're thrilled to go through this content, because I think, you know, discussing it in combination with the review paper in the Canadian Journal of Surgery, it's probably really going to be helpful to a lot of folks. So thank you.
Ameer Farooq 01:21
So, Dr. Hameed, what was the instigating reason for you actually writing this paper in conjunction with Dr. Ball, Alex Lee and Matthew Kominsky.
Morad Hameed 01:31
Yeah, thanks for starting with that Ameer. I wanted to start with this disclaimer that I'm not a cardiac surgeon, nor do I have any specific training in cardiac surgery. I approach this topic with complete humility as a student, somebody who's very interested in the topic, and as a trauma and acute care surgeon trying to write for the audience of surgeons that may not find themselves in this situation, but do have sort of leadership and teamwork skills to coordinate a response in a critical situation and also have the technical skills to at least get the exposure and get initial control. And I wrote with colleagues who do have a lot of experience in cardiac trauma and the technical nuances of this type of operating. That's Matt Kominsky from Chicago and, of course, Chad from Calgary. And a resident, Alex Lee, who devoted a lot of time to doing a big literature review, reviewed hundreds of papers with us. And so, what we wanted to present here is a technical primer on cardiac trauma that's, sort of, well researched and has some basis in evidence. And we know that we might fall short of this, but we didn't want to shy away from those technical nuances of cardiac trauma; like, for example, how to place incisions, or what needles to pick, or how do you actually do a repair, or how do you actually do a, you know, transdiaphragmatic window, things that may seem simple but that sometimes the books may not actually provide the actual technical detail to do this. So in some ways, it would have been great to write almost like a graphic novel or Toronto Video Atlas [of Surgery]-style publication on this to really get those, you know, technical nuances across. We tried to come close to it, and this paper probably fell short, but at least we thought it would be the start of a great discussion on, you know, getting some clarity about what actual technical strategies to use in cardiac trauma.
Chad Ball 04:04
As usual, Morad, you are too humble. So the audience understands, I think, you know, your training extends across not only Canada, but also Miami and South Africa. And, you know, being witness to the videos that you have shown us in the hemorrhage control course here in Canada, you're certainly a very skilled operator and in this environment, so we're going to try and exploit that to the benefit of Ameer and myself and our audience, for sure. Now, this is a review paper on penetrating cardiac injury. So we're gonna put the blunt stuff aside, which is certainly interesting in itself but clearly much, much more rare. So I'm curious, could you start us off, you know, you're on call, you get a level 1 or a grade A, or whatever the terminology is, trauma coming your way. It's going to generally be a stab to the chest, and they come into the trauma bay where you're the attending and the trauma team leader. I'm curious how you frame that initial, immediate interaction with those patients. What's relevant to you, in particular in your assessment? How are you rapidly assessing that patient? And what are the absolute pearls and the absolutely do-nots going through your mind?
Morad Hameed 05:19
Well, like most things in trauma, this starts with a 30,000-foot view and a systems-based response to the injuries. It's a high-acuity, low-occurrence injury, and it requires a system setup and a lot of forethought and planning. And so, sometimes I think the most critical determinant of good outcomes is a good trauma system that can bring that patient to you within minutes of the incident, that can minimize downtime and minimize that period of hypoperfusion. So that planning with EMS is key. Those transport protocols that bring the patient to a hospital that could be ready under ideal circumstances is great. And, sort of, predefined coordination with the emergency physicians, surgeons, nursing, anesthesia is also key. That trauma team response that sometimes includes activation of the operating room, and the blood bank, and so on are also key components of a timely intervention. I think that this injury is obviously so time-dependent, that you have to be primed and ready for it before it comes in. And I think that's one thing that trauma and ACS surgeons are used to thinking about how to be ready for a critical event before it happens. Once the patients arrive, you obviously want to move them quickly to the resuscitation — into the resuscitation room and onto the, onto the stretcher. And you want to make sure that you have predefined roles for the team, including airway management, the right and left chest tube placement, intravenous access, good coordination with nursing, you need to have blood bank ready and the operating room on standby. And then I think some of the initial key clinical priorities are to do a quick primary survey, understand how long the period of rest was, how good the perfusion is, does the patient have pulses? And, and then just proceed from there. It doesn't take that many clinical data points to start to formulate an idea of how sick the patient is and what the next strategies might be.
Chad Ball 08:01
I think that's well said, Morad. As you know, there's a few pearls in there, too, that that are sort of always dancing around our heads. You know, the first, at least for me, is, you know, we might argue, especially in these scenarios, nevermind penetrating trauma in general, that, you know, the ABC of ATLS maybe is not exactly how we practice. And there's certainly been a number of nice papers written about C being first, maybe even E being first, meaning exposure. And so I think it's probably — I don't know if you agree — but you know, critical when these penetrating trauma patients roll in; the exposure component. In other words, stripping them down and looking at every element of their skin, from their axilla, to their gluteal cleft, to everywhere for those additional holes so you can start to work on trajectory in general, is important. And then the second part for me is the ultrasound, the extended fast examination immediately. And obviously, we're always going to start at the cardiac window, no matter if it's blunt or penetrating, because I think as you'll probably go into in the context of when and when not to do an emergency department thoracotomy, that's really the window that's going to change what we do in real time immediately. I'm curious how you, sort of, look at exposure and the ultrasound in particular.
Morad Hameed 09:21
Oh, yeah. I absolutely agree with you about exposure, and sometimes we forget to do the complete primary survey. The primary survey from A to E should, you know we should be able to do that within 30 seconds and we don't have to always start interventions, but it's key to get good situational awareness with the full primary survey, including exposure. 100% agree. And the ultrasound has really sharpened our diagnostic abilities. I think of several occasions where the probe goes on almost immediately. As you're beginning the primary survey, and you'll have that information right away. And so I think that the ultrasound has become an indispensable part of this assessment, and it can govern your next moves, most definitely. There's some, there's some limitations of ultrasound. It is still operator-dependent, it could be dependent on body habitus, it could be restricted by the presence of subcutaneous emphysema. But most of the time, it's going to give you fantastic information about fluid in the pericardium.
Ameer Farooq 10:33
Let's walk it back, for the humble colorectal surgeon in the room. And can you talk a little bit about the anatomy for cardiac injuries? And so I actually have pulled up on the screen — and for all the listeners out there, head over to our YouTube channel to check out the accompanying video that we have with this, and we actually have the paper pulled up as well. So can you talk to us a little bit about this, Dr. Hameed and Dr. Ball, about what is the anatomy that you care about when thinking about cardiac injuries? Dr. Hameed, why don't you go first?
Morad Hameed 11:04
Yeah. Thanks, Ameer. We tried to put this — the box — the classic box on this image of a patient, and I think that the box, which is bounded by the clavicles above and the mid-clavicular line, [inaudible] nipples laterally and then a line connecting the costal margins and the mid-clavicula lies at the inferior margin of the box. I think, sort of, the classic teaching is that any penetrating wound in the box — and that box extends, too, to the back as well — is a cardiac injury until proven otherwise. And so it does require some ultrasonography, potentially echocardiography or even CT to really definitively exclude a cardiac injury. So anything in the box is a cardiac injury until proven otherwise. But as Chad points out in the paper that entries originating from outside the box can also cause cardiac injuries. So it doesn't it — we still have to have vigilance and a high degree of suspicion about injuries coming from outside the box that still could cause penetrating cardiac trauma. But the box does give you sort of a guide and can heighten your suspicion when the injury is in that location. The other thing about the box — and Chad and Ameer, I wonder if you agree — is I sometimes think that if an injury originates outside the box, there are likely associated injuries like, for example, injuries to the lung, or injury to the pulmonary hilum or injury to the diaphragm. And so, for those types of injuries, if the patients are somewhat stable and you have a bit of luxury of time, it may affect your choice of incision. And inbox injury is likely to be, especially if it's an anterior injury, and add to your cardiac injury, which is well exposed by median sternotomy. So if you have time, you can go to the OR and do median sternotomy and get really good exposure. And outside the box, injury might require an anterolateral thoracotomy to get exposure to associated injuries as well as to cardiac injuries. Chad, we never really talked about that specifically, but what do you think of that?
Chad Ball 13:23
Yeah, I think there's a few really important pearls there. And you know, they're almost as always, really come from some of the titans in the history of trauma surgery that write a lot of this initially. And, you know, your comment about injury outside of the box being possible with regard to the hardest is critical, of course comes from Dr. Andy Nicol in Cape Town in South Africa in his PhD. He's shown that very, very nicely. The other thing, maybe to comment, just to back up a little bit, for me anyway, is that, you know, most of the initial manuscripts that looked at test performance, sensitivity and specificity of the extended fast exam and the cardiac view, published things that, really that indicated it was a perfect test. And, you know, you pointed out a couple of scenarios, maybe in particular subcutaneous emphysema that limit that investigation. It's important, I think, to also keep in mind that you can get a false negative in one rare circumstance and that's really surrounds what you're mentioning, which is sometimes a, typically a stab wound, often to the right side of the heart that comes from quite a peripheral distance and and goes through and tears the pericardium. So you have a hole in the right side of the heart, which is generally reasonably low pressure, you have a hole in the pericardium, and you have a hole in the pleura. And so these patients can be very stable, but they have a persistent, again, usually right-sided hemothorax and so for — I think I saw, all in the trauma bay, if that patient gets a chest tube in their right chest as an initial maneuver and the follow-up chest X-ray post-insertion shows a residual hemothorax, you need to rule that out. And, you know, as we've shown in a couple of manuscripts, when you and I were in the US, the reality is, you know, ultrasonography is probably not going to do it, whether that's a formal echo[cardiogram] or whether that is, you know, a bedside E-FAST examination. So there is other things we talk about in terms of trying to rule that out. But, and I think we'll get to it in terms of pericardial window, but it is a way that that can be burned. Yeah, like, the rest of your comments, of course, I totally agree with. Yeah.
Morad Hameed 15:44
Yeah. Yeah, that's such a great point, Chad. And I think, just to underline that, if there is an associated hemothorax, that should make us even more worried and more definitive about ruling out a [inaudible]. Can you just, in case that hemopericardium is decompressed into the pericardial space, you won't see it as prominently, and that could, yeah, definitely create a false negative echo[cardiogram].
Chad Ball 16:08
I think your other comment about incision choices is important too, because it — certainly upfront when you're learning this stuff, or when you don't deal with it a lot, it can be very confusing. I also think we both recognize, actually that, you know, certain well-known colleagues in various places around the world have really strong opinions. I don't know how you approach it, but my overall, sort of, pathway in my brain is always that a median sternotomy is probably reserved almost exclusively for a precardial stab wound in a relatively stable patient. And, you know, part of that is, as I think as you insinuated, you need time to do a sternotomy, which you don't need to do a thoracotomy, which obviously, it's very quick. So the stability physiology component to it's important, but your ability, you know, again, as published by Andy Nicol and others, to access some of the posterior mediastinal spaces or the back of the heart is possible through median sternotomy, and in the build of most, you know, typically males but, but not always. And so for patients that are unstable, that need cardiac decompression immediately, where you're not sure, and in particular gunshot wounds, those things tend to be a little bit more helpful with regard to an emergency department or operative suite thoracotomy. I agree.
Ameer Farooq 17:39
Can you just talk a little bit about what sort of things you have to have in your equipment, in your thoracotomy tray. So I love this picture that you guys have in the paper of the set. And it's interesting; like, I remember going to — on a, sort of, more community rotation, and surprisingly having to or being involved in a thoracotomy, and the tray that came down was this humongous, like, you know, cardiac surgery tray, and it had instruments I had never seen before, and the instruments that we needed were like, buried somewhere deep in the tray. So can you talk a little bit about, Dr. Hameed, a little bit about what are the things that you need to have in your tray? And I think, you know, here's someone who's a systems-based guy who probably has thought a lot about this. So you can talk a little bit about one of the things you need and one of the things you probably don't need in your emergency department tray?
Morad Hameed 18:37
Oh, yeah. Thanks, Ameer. I'm so glad that you liked that picture and the whole idea about the tray. We, like, this begins, sort of, the technical aspect of this and I think that if you decided to do a resuscitative thoracotomy, particularly an ED thoracotomy, I think it's very important to be, to try to control the situation and to be as deliberate as possible. And that makes me think that sometimes there's a surgeon that's going to make the call to do this ED thoracotomy usually, or maybe it's an emergency physician, but the point is, as your focus narrows to the technical exercise and doing the ED thoracotomy, you want to make sure that someone else has overall control of the resuscitation. So this is like the classic example about how leadership in the trauma bay is dynamic. The TTL might be the one who enters to do the resuscitative — or, the ED thoracotomy, but that person will have to pass the overall supervision of the resuscitation, and that includes airway control, IV access, the byproduct resuscitation and all of the, really, the nuances of this resuscitation will have to pass to someone else — when to give calcium, magnesium and bicarb, and so on. And so as you start to focus on this, you want to make sure that you position your patient well and you set up almost as if you were doing this in the operating room. You know, my preference is to, at least to square off the patient, and then to open that set. And you didn't ask me all, Ameer, but, um, but I think that that context is, is important. And I'm sorry for the digression. But then as you open up this tray, you want to make sure that — I mean, it's much nicer if it has only the equipment you need and no equipment that you don't need. And so, the steps of the procedure, which include making an incision and surprisingly, sometimes, it's not easy to find a knife, and we tape a 10 scalpel to the top of our set so that it's the first thing that comes into your hand while you're making the anterolateral thoracotomy incision. An assistant can open up the set and start to lay it out in sequence. So the knife cut goes down to the chest wall. And then I find that curved Mayo scissors are the second thing that you would reach for. You punch those in above the rib in the fifth intercostal space, and cut the intercostals off the top of the rib and enter into the pleural space. Then the next thing you want is the rib spreader. To get the finish [inaudible] in allows you access to that pleural space. And once the finish [inaudible] spread, you might find that you could gain a few more centimetres of exposure by cutting the intercostal muscles forward, right to the lateral edge of the sternum. And those few extra centimetres can provide you a lot more exposure, especially in a dimly lit setting. And they can also set you up for a sternal incision if you're wanting to clam shell. So the next thing you might need, especially if you intend to clam shell right off the bat is [inaudible]. So once you've finished with your current Mayo scissors, you move to the left [inaudible] to open the sternum and then really get great exposure of the chest. And then, usually the first move is to open the pericardium; that's often done either by grasping the pericardium between long Allises anterior to the phrenic nerve, and then cutting the pericardium between the Allis clamps. Sometimes the pericardium is too tense and you might have to freehand inside the pericardium again, anterior to the phrenic nerve and parallel to the phrenic nerve, a few centimetres in front of the phrenic nerve, to preserve that structure. So you'd need to get the Allis clamps followed by a knife, and then the Metzenbaum scissors to extend the pericardial incision. And so it's not a lot of instruments that you need, really, to get that exposure down to the heart and to deliver it. And so it's fun to sort of think through the steps of an ED thoracotomy and then just align your instruments that way. And we actually go over our, the composition of our set every few years and keep, we keep trying to make it more and more parsimonious.
Ameer Farooq 23:43
Dr. Ball, can you comment a little bit on what are some of the pearls that you have, when, obviously when doing this, the instrument tray, and perhaps, hopefully you can talk a little bit about your triggers for when you would be doing this.
Chad Ball 23:58
You know, going back to the ultrasound of your heart, you should have some sense as to how much fluid is in that pericardial space. And so if there's, you know, 2 cm or an inch of fluid, then that patient's in [inaudible] or full arrest, then honestly you don't have to pick up the pericardium at all, as Dr. Hameed points out; just grab your scalpel and make a little hole in it, and then cut it anterior–posterior. In theory, paying attention to the nerve, which is not insignificant and it is important but, you know, often forgotten for sure, in the heat of the moment, but you know, it's a little bit like putting a chest tube into a large pneumothorax. You don't have to worry so much about injuring the lungs; it's far away and the heart can, relatively speaking, be sort of the same. You hear a lot of debate, I think, over the years about what you can do through a left-sided anterolateral thoracotomy, and that's an interesting discussion. And I think what's often lost in it, as to whether you need to extend over to the other side, is a couple of things. One is patient anatomy. So I think we've all fixed multiple hearts and cardiac injuries through the left chest alone, not having clam-shelled these patients. But in other patients, you'll open them and you realize there's no anatomical or possible way to do that. And so it's really a case-by-case scenario. I think if you're not here a lot, which is really the intended target audience of our general surgical colleagues, then you should plan to come across the sternum if you need it at all. Away you go; clamshell the patient. Don't try and be super pretty about it. If you are going to do work through the left chest, though, you also have to keep in mind that when we move the heart around, in particular, you know in the context of a median sternotomy or bilateral anterolateral thoracotomy or clamshell, that when you raise it up, when you lift it up towards their head, you automatically change the inflow in particular, and the outflow to some extent, as well. In other words, you kink the heart, and so you will arrest that patient. The same exact thing, and we talk about it a little bit in terms of classic maneuvers, like digital or hand-based maneuvers. But if you kink that heart out into the left pleural space of the left chest, it can also arrest the patient. Sometimes you use that to your advantage to repair an injury in the back of the heart or in a challenging location. But you do have to be able to, you have to think about that in terms of where your hole in the heart is. And then of course, as I was mentioning, the anatomy or the size and the geometry, really, of a patient, which can certainly vary. I think at the end of the day, again, for me, as I mentioned, if the patient's in cardiac arrest or close to it and you've made a decision in particular that you have to do this thoracotomy right now (i.e., in an emergency department), your threshold for coming across the sternum should be very, very low.
Ameer Farooq 26:59
Just to back up for 1 second, again, as someone who, you know, covers call but is not a trauma surgeon. Is there ever a role for CT scan? You know, obviously, we're talking with a stable patient here, but is there ever a role for a cardiac CT in helping you make a decision about whether this patient has a cardiac injury, Dr. Hameed?
Morad Hameed 27:21
I think you said it perfectly. If a patient is in any way unstable from a respiratory or hemodynamic standpoint, of course, you would never want to take that patient to CT. You have a lot of diagnostic adjuncts at your disposal in the trauma bay or in the operating room, including X-ray, echocardiogram — even anterolateral thoracotomy could be considered to be diagnostic strategy. So there's a lot that you can do to figure out what's happening in the emergency department trauma bay or in the operating room and sort of bypass the CT. I think, occasionally patients are so stable, and our CT scanners are steps away, that you could do a CT chest, abdomen, pelvis. We do CT so often to guide our operative strategy, even if we know we're going to be operating, that I would say that a CT could have a role in operative planning. But certainly, it's usually — the CT usually shows you an unexpected finding and that you've already gone through everything you can in the trauma bay in this situation. As I mentioned, a thorough exam, like Chad said, a good full exposure, chest X-ray, a good fast with good views. And if you're still — if all these things are nondiagnostic and the patient's stable, then certainly I think a CT chest can help you establish trajectory and inventory of all the injuries.
Chad Ball 29:03
I mean, I would certainly agree, Morad, for sure. I think certainly the reality is that, you know, for gunshot wounds and the patient that — the unusual patient that shows up alive with a concurrent or synchronous cardiac injury as a result of a portion of a missile or a missile, CT is clearly very helpful. And then, of course, for the unusual scenario of [inaudible] cardiac rupture that's contained and controlled with, again, an alive patient, which is also relatively uncommon. You know, that's often where you diagnose it, to be quite honest with you. Yeah, there's no doubt. I wanted to just switch gears here a little bit and talk about some of the nuances of something you and I love, which is the pericardial window. You know, I think with the framing of it, that a pericardial window is probably underutilized in a lot of places in the world. It's a very powerful test that can be performed in the emergency department under local anesthetic, it can be performed in the ICU in intubated patients, and of course in the operating theatre. What are some of your technical pearls with regard to a window and performing it, in particular?
Morad Hameed 30:19
I think that's such a fascinating point, Chad. Like, you know, sometimes we think that the pericardial window has been supplanted by the fast ultrasound, like, kind of like the DPL; like, we never use the DPL because we have abdominal FAST. But I think there are important indications for the subsequent pericardial window, just like you said. Like, if I mean for one, if the FAST is nondiagnostic, but secondly, also, if there's an associated hemothorax, like we talked about before, you might need to increase the sensitivity of your test; [inaudible] window is good for that. And then a third, very important option is with an established hemopericardium, which you're not sure if it stopped bleeding yet or not. And sometimes like — and I'm sure, Chad, you'll talk about Andy's paper that you were instrumental on — sometimes, even with an establishing of pericardium, the subsequent pericardial window has an important role. And so there are very — it is still a very relevant procedure. I've never done it in the ED or under local [anesthetic], but I know it can be done. For our patients, usually, where I've seen it done and where we've done it, we've done it in the operating room. Careful general endotracheal anesthesia; obviously, initiating positive pressure ventilation in a patient with an established hemopericardium is risky, and you want to make sure that that patient is pretty well resuscitated, with good access and good blood products standing by. You prep the chest, you make sure that you're ready for anything. So it's basically a full prep from neck to thighs into the bed bilaterally, so that you're ready to extend this to a median sternotomy, to a laparotomy, to a thoracotomy, but the actual incision for the subsequent pericardial window is about a 6–7-centimetre incision centred on his xiphoid. And that carried down with cautery. These are stable patients, so you have time to use cautery and get set up properly. I usually excised the xiphoid. So just kind of, it's a sort of a triangle, an upside-down triangle, at the bottom of the sternum. So I usually just kind of skeletonize it with the cautery and then try to amputate it high to get under the sternum, and then creating some space under the sternum and sometimes you, and then you have to divide the linea alba as you're getting access into that retrosternal space. Keep taking care not to get into the peritoneal cavity. And then that's when the, sort of, finicky part starts. You have to sort of clear away the fat, you might have to divide some fibres of the central tendon, the diaphragm, to get up to the pericardium and it's a, it's often a deep hole under the sternum. You can actually kind of push down on the diaphragm to try to bring that pericardium down towards you a little bit better. And when it's, kind of, in range, you grasp the pericardium with Allises to the left and right of midline and then feathered through that with a scalpel to get to the pericardium. And sometimes I find, it's maybe not the slickest, but there's sometimes a few false starts, you know? You have tissue up in your Allises that you think might be diaphragm, but might be pericardium, but it might be diaphragm. And so you sort of deepen that vertical incision between the Allises until you finally do arrive at the pericardium. And when you do, it's pretty clear because you have a, sort of, a grip on it that's a firm definite grip. It's really important to make sure the field is dry because you don't want the blood, any blood, in the field to mix with the fluid that's going to come out of the pericardium, which will sort of contaminate the diagnosis. And then you, when you're on the pericardium, you incise it vertically, and it's one of the most I don't know, I find it's been the most thrilling and gratifying things in surgery when you see that clear pericardial fluid come through and, you know, that you have a negative subxiphoid pericardial window.
Chad Ball 34:45
Yeah, I agree. That's a beautiful description. You know, you touched on a lot of things that are really critical. Your lighting down that, what can be a deep hole, and you know, in particular, a middle-aged male is critical. And obviously, if you're outside of the operating room, the lighting becomes even more of a challenge. So you have to set that up upfront. And, you know, I would re-emphasize your comment about having a non-bloody field before you actually violate the pericardium with your Metzenbaum scissors. The confusion, if there's rundown from your, you know, removal of your xiphoid or the tissues around it becomes very confusing. And so for me anyway, I always put fresh white sponges all the way around, so that blood is very, very obvious. Everything, I think, that Andy Nicol in South Africa taught both of us was to employ a sponge-on-a-stick technique in sort of a corkscrew way down that hole to try and move the pericardial fat side to side, [inaudible] your relatively small direct line to the heart. That's a very, very helpful tool.
Morad Hameed 35:56
Yeah, that's a great move.
Chad Ball 35:58
You know, his name keeps coming up, of course, as we both mentioned it now, and South Africa and Cape Town group did do a randomized control trial that looked at, very directly, if you have a positive window and a stable patient that has had a cardiac stab, do you really have to proceed with classic sternotomy looking for heart injuries that are repairable or need to be repaired, because there's certainly a lot of those patients that may have scratches on their heart that, really, you don't need to be there for. That's a nuance I think we'll probably, we'll leave behind, and we'll have a link to that Annals of Surgery paper. But you know, the classic obviously, scenario of a positive pericardial window, we then proceed to a sternotomy for full evaluation of the heart, I think probably stands in most circumstances. If we switch gears here again, and you know, we've gone through, you've gone through beautifully the presentation of these patients, the physiology of them, the diagnostic workup, and then the exposure, the incisions. So now you have a hole in the heart; ideally, it's in your hand. How do you control that hemorrhage, either in the short term, setting up for a repair, or maybe in the long term, while you're waiting for help from your cardiac surgery colleagues if the repair is foreign to you or it's extremely complex; for example, coronary artery or something that requires maybe bypass or something like that? How do you control that initial hemorrhage? What are your options and tools in the toolbox?
Morad Hameed 37:37
Yeah, Chad, we talked a little bit about the exposure. So I agree, I didn't, I forgot to mention, but I totally agree with the idea of starting with a wide exposure and having a really low threshold to doing the sternal incision for an anterolateral thoracotomy. You're almost doing like clamshell, and that can get you down onto that pericardium. And that first move is to open the pericardium. And I think the best thing to do once that pericardium is widely opened and you evacuate the clot from the heart, from around the heart, and release that tamponade, sometimes, if you're lucky, the heart begins to fill, and you'll start to get perfusion back. And once you see, once you release the tamponade and you get that cardiac filling and you get, you start to get some perfusion, you kind of know that things are on the right track. And you don't have to do anything aggressive at that point. You've done the biggest thing, which is to decompress the cardiac taponade, allow the heart to fill, check in with the resuscitation team to make sure that volume's going in. And then just digital control of the laceration is a key move. And I think there's so much to be said for just patient, calm, gentle, digital control of that laceration; that gives you time to re-establish your exposure. It even gives time to change your venue and go up to the operating room or where you'll have access to good lighting, good sterile field, good equipment, the right sutures that you want, pledgets, and a team of nurses and anesthesiologists that will really increase the power and capability of this repair. So I guess it's a long way of saying I think digital control is a very good opening move. Would you agree?
Chad Ball 39:47
I think it should always be your default. You know, our hands are magical, intuitive instruments, and you know, as you're implying, it doesn't mean putting your finger in the hole; it just means covering it and supporting that immediate hemostatic move. You know, in the manuscript there's a beautiful picture of a Foley catheter, which is oft talked about, but certainly comes with risks. What do you think of putting Foleys in hearts and when do you do or not do that?
Morad Hameed 40:21
I've been sort of conditioned not to use it. I'm so worried that the Foley will pull out. But I do like it as an option. And especially for, maybe, a larger wound and you can sort of hyper-inflate that balloon. It has to be — you have to be very careful and [inaudible] to be very, very gentle with it. I think a little bit of leak from around a fingertip, around a Foley, is totally fine, and it's certainly better than the possibility of pulling that Foley, too. So just, sort of, very gently placing the Foley and inflating the balloon in a larger wound, I think, would make sense. But, Chad, certainly I would love to know what you think about that.
Chad Ball 41:02
Yeah, no, I concur. I mean, I've sort of been called secondarily to look at heart wounds where the Foley catheter, I think like we've all seen, quite honestly, has pulled through the heart and taken a difficult situation and made it effectively impossible, with subsequent patient demise. So you have to be, as you say, very, very careful with that catheter. A standard Foley is typically what we use, if we are going to use it. And honestly, that means you don't hand that job over to the medical student to, you know, or even maybe the junior resident; that somebody probably is at the faculty level or experience level that needs to be holding that, because you're going to use a combination of digital, sort of, ceiling pressure and stabilization of that Foley. But yeah, certainly bad things can happen. And you know, the other thing is, of course, that I think we all think about but probably don't use very often is, if your heart really is quite empty or reasonably empty, you can put clamps on it, too — like, big, vascular Satinsky clamps, right? Angled clamps — like, that can work very well, as well. Obviously, if you clamp a coronary, particularly a critical one, you're going to have the ischemic problems with it, but hopefully it's not on there very long.
Morad Hameed 42:23
Yeah, absolutely. In this picture, in this — this is a still from a video. It looks like there's a little too much tension on that full lead. Do you do agree?
Chad Ball 42:34
Well, I don't know. It's hard to know. It looks like it's working in the video. So, you know, it's okay.
Ameer Farooq 42:44
So can I ask, Dr. Hameed, when you're in the operating room — so let's say, you know, this is now your setup, you've managed to control the hemorrhage enough to the point that the patient is now in the operating room either with the left anterolateral thoracotomy or sternotomy; if you had that luxury of time, what are some of the principles of actually repairing these injuries? You know, you sort of intimated about how delicate the heart can be. Can talk to us a little bit about, you know, like some very specific things that you actually talked about in the paper, like what sutures do you use? How do you go about putting those, placing those sutures in? Do you use budgets? Can you talk to us just a little bit about that?
Morad Hameed 43:27
Yeah, Ameer. Great point. And these are some of the technical details in the paper that we want to make sure we included. And, like Chad said at the beginning, I'm sure many people have different strategies or different tactics in this situation. So what we're saying might not be the only way to do it, but it's one of the ways. So I think, again, you know, taking sort of a more global view, you want to coordinate carefully with anesthesia. Once you've got digital control, let your anesthesiologist know what you're seeing, coordinate with them. How is the airway being managed? How's the resuscitation as to patient hemodynamics, which you can see directly also [inaudible] communicate to them. I think that certain adjuncts to the resuscitation, like a little bit of volume and calcium, are helpful. Calcium is so important, I've learned over the years, for myocardial contractility, but also for that vasomotor tone and also port hemostasis. So yeah; how's the resuscitation going, and that communication. In terms of the question you asked, Ameer, about repairing the myocardial injury, if it's a simple stab wound, it's just a matter of closing the hole, and there's any style you can use for it. You can use simple interrupted, you could use [inaudible], you could use horizontal mattress, you could use running; all of these will have their pluses and minuses. My preference is to use a 3-0 Prolene with an MH needle. The MH needle has a good curve and it's big enough to arc through. So that's my preferred needle and suture choice. I think in the paper, we say a 3-0 or a 4-0 Prolene and an MH. If you're suturing on ventricle, the idea is to maintain digital control on the laceration, and then pass that needle below your finger. The heart's going to rock and, sort of, twist away from you occasionally, and so you have to, sort of, mimic its motion, account for the motion, and then create an arcing below the fingertip and pass it to and through the laceration. With the horizontal mattress, the nice thing is if you have a double-armed Prolene, you can take the second needle and also pass that under your finger, and now, suddenly, you have like a horizontal mattress suture that's spanning the laceration. And I think Chad points this out so beautifully in the paper, that to use the curve of the needle is very important. It's a key point to pronate the wrist, and as you arc the needles through, the more — the way you use the curve, there's so many benefits, in that it catches a little bit more tissue in your bite, and so it's less likely to pull through. And also with that pronation effect, the needle will stably come through the tissue so that when the tip emerges on the other side, it won't retract back. And this is a key point that we always talk about with the residents is, if you've appropriately used the curve of the needle, that needle tip will be stable when it comes to you. You can actually let go with your driver and pick it up on the other side and arc it through on the other side. There are a few nuances, which maybe I'll hand over to Chad, about when to use pledgets and what to do around the coronary arteries.
Chad Ball 47:21
Yeah, I think those are all pearls. You know, there's a whole set of principles, I think like we all know, surrounding sewing soft things. Obviously, in my daily job, that's liver and pancreas, but the heart, although it's easier to sew than those 2 structures, the muscle still is certainly applicable to that domain. As you pointed out, you know, using the curve of the needle is not only suggested, it's essential, because if you pull that needle through like you can, and get away with easily, in bowel surgery, you will make that hole bigger and worsen and potentially, like the Foley catheter, go from challenging to catastrophic. So, really good suturing technique and those basic fundamental principles that we're taught from, you know, intern on really do need to apply despite the excitement, probably, that you feel at the time. You know, in HPB surgery we use 4-0's, more commonly 5- and 6-0's on RB-1 needles, and again, I would re-emphasize that that is not the workhorse needle or suture for most cardiac injuries. The, as you point out, the 3-0 on an MH needle, in particular, is the way to go for most scenarios. When we start to talk about those more fine sutures, though, you're right; it's more about, sometimes, closing scratches in the heart or working, you know, back and forth and under and around coronary arteries. I think the truth is that if you're in a location where you don't have access to cardiac surgery, then it is what it is. But if you do and you believe that the laceration extends into a coronary, you should probably ask for help. More often than not, those patients will go on bypass and they will get an extensive and very nuanced repair that is beyond the capabilities of most of us. The other thing to keep in mind, as this picture shows, is that it's sort of a setup, obviously, for an atrial appendage injury here with a clamp, but we can use staplers, and particularly atrial appendages — a TX or a TL or TA, depending on the company you choose. Linear stapler is absolutely superb, very much like the lung, and works very well. It works to the extent that you don't have to oversew that staple line, almost ever. So I think that the take-home message is that that 3-0 Prolene, MH needle is your workhorse and you should get that out early. Sorry, Morad, I lost you there.
Morad Hameed 50:01
Sorry, Chad, I just wanted to ask you, is that a stapler with vascular load or a blue load? Is it, does it depend on the thickness of the structure you're stapling?
Chad Ball 50:11
Yeah, great point. Always depends on what you're trying to accomplish in terms of the anatomy and the thickness. But in general, that's going to be a vascular state where, you betcha. So sometimes that's got the V on it. Sometimes that's an X. Again, it depends on the company that you're pulling from. You know, Morad, I wanted to switch gears maybe one 1 last time here again and ask, in particular, a couple of very directed questions. One is: Do you close, in your practice, the pericardium on the way out? And if so, why so? And if not, why not?
Morad Hameed 50:52
I like to close the pericardium. Just, it's just a preference to restore anatomy, when possible. I know that there are different views on this. For enclosing an anterolateral thoracotomy, I do like to close it, because I find that the heart really swings back into position. You know, it kind of herniates to the left when you have the pericardium open on the left. So if you can put a few interrupted [inaudible] or 2 [inaudible] in the pericardium, just the act of closing down the pericardium a little bit will swing that heart back into its anatomic position for the anterolateral thoracotomy. You still leave gaps in the pericardium in case there's a little bit of pleural fluid or residual blood, so that it can leak out to the chest into the pleural space to be evacuated by a chest tube. With a median sternotomy, I think it's probably not as essential, in terms of cardiac herniation, to close it. I still do like to close it, to create that sort of smooth barrier towards the cardium under the sternum. And if someone has to ever have a re-do sternotomy, you'll still have that plane preserved there. And in the paper, we describe, sort of, T-ing off the bottom of the pericardial incision when you do a median sternotomy. So you do this long, vertical pericardial incision, but you T off the bottom, and you can leave that bottom part of the T open, again, for the entry of chest tubes and for drainage of any residual fluid or blood after the procedure. So my answer would be that my preference is to close the pericardium, if possible. I do know that sometimes it's not technically feasible to close, particularly if the heart is really swollen after a big resuscitation. And occasionally, that might be in a damage control situation, where you just actually, overall, you're just temporarily closing the chest, taking the patient to ICU and you can return. Hopefully, at that time, if the swelling is down, you might have a second shot to try to re-approximate the pericardium, but that's totally open to discussion about that.
Chad Ball 53:17
Yeah, no, I think you've hit all the relevant factors that, at least in my mind, go into that decision to close or not to close, and my preference, my bias, is, of course, the same as yours. It probably shouldn't surprise us given our similar training. The next question, then, would be about drains. What cavities do you drain? Do you do the pericardium? Did you do the pleural spaces, and if so, why? And what goes into that decision? Yeah, and I'd love to know what you and Ameer think about this too, but um, for enclosing — the closure is interesting. The closure takes way longer than the actual exposure and the cardiac repair and everything you do on the inside. I find that this takes a long time, but it's pretty fun to do a meticulous job of the closure. But the drain issue is really important. And so, certainly with an anterolateral thoracotomy, you want to have the pleural space drained with a couple of chest tubes. You've been in that chest, and there's for sure going to be bleeding from the chest wall and from the pericardial edges and from the stab wound itself. And if there's an associated lung injury, there could be an air leak as well. So you want to make sure that that pleural space is well-drained with an anterolateral thoracotomy. I think that if there's gaps in the pericardium, it might be possible to just leave it at that with the drains in the pleural space. But if you have a nice trajectory to get the chest tube into the pericardium, that would be reassuring if you could also drain the pericardial space, but I think with a median sternotomy, the pericardium is nicely drained by 2 chest tubes coming from below in the epigastrium. So in the paper we say to make sure you go, sort of, through to the rectus muscles on both sides to avoid a hernia at the chest tube entry site. So, I usually try to, you know, tunnel 2 chest tubes from these incisions and these independent stab wound incisions in the epigastrium. One chest tube is an angle chest tube that sits sort of behind the heart and sort of takes a anterior–posterior trajectory, and one is a more, is a straight chest tube that goes more vertically up and sits anterior to the heart in the pericardial space, and then you can try to close the pericardium over that. Just one more, just going back for a moment to the anterolateral — sorry — to the anterolateral thoracotomy chest tube, you'd have to place those chest tubes a little bit lower than usual because they're, sort of, passing below that incision, which is usually in the line where we normally place chest tubes. So those have to be, sort of, guided in carefully manually just above the diaphragm a couple of centimeters or a couple of interspaces below your anterolateral thoracotomy incision.
Ameer Farooq 56:32
So what I'd like to do in closing is ask the both of you to talk about the top 3 pearls or tips, or pitfalls even. The top 3 things that you want our listeners to walk away from, after listening to this or watching this on our YouTube channel. Top 3 things that you want people to walk away with, with cardiac injuries. And maybe we'll start with Dr. Ball.
Chad Ball 56:57
Thanks, Ameer. That's a fun question. I guess in temporal sequence, I would say becoming very, very good at obtaining reasonable cardiac windows, and the extended FAST examination, is critical. The way I think that you do that, and the way that we all learn how to do all of this is just practice, practice, practice; iterations and volume, right? Same concept. You can't get your way around that. So looking at, as a trainee, every single heart you can in an emergency department for every single injured trauma patient, for example, is helpful because you really ingrain what's normal, and as soon as you see abnormal, boy, is it obvious to you. So the extended FAST examination would be number 1. I would also throw in there that although one of the dominant emergency medicine point-of-care ultrasound courses starts you in the right upper quadrant, never, ever do that. With Dr. Rozycki — Grace Rozycki — invented the FAST examination, the reason, again, as I said earlier, that you start at the heart is because that's what is going to change what you do in real-time immediately in terms of a physiologically critical patient, whether it was a precordial stab. So start at the heart, get good at it, and then trust it because it's a very good test outside of the scenarios that Dr. Hameed and I mentioned. Second thing I would just reiterate again, maybe for the second or third time, here, is get your sutures open early, and in general that's going to be a 3-0 Prolene on an SH — sorry, on an MH needle — MH — however, have other choices around, in particular a 4-0 Prolene on an SH and potentially a 5- or a 6-0 on an RB-1. The third thing I would say is, that we haven't really talked about, is the importance of evaluating the heart for internal injury after a lot of these stab injuries or stab traumas. So if you piece together the literature in the various series over the last 50 years or so, you could certainly defend the idea that about 15% of these patients will have internal cardiac injuries, meaning valvular injuries or septal injuries — things that you're not going to be able to see in the operating room repairing the, essentially the outside of the heart. And so all of these patients, as mandatory, should undergo postoperative, ideally transesophageal, [echocardiogram] and, if not, transthoracic [echocardiogram] to rule out those internal injuries, which as we all know now are often fixed percutaneously in really neat ways by our interventional cardiac surgeons and cardiologists. So those would be my big 3, I think, given our discussion. Thanks.
Ameer Farooq 59:53
Fantastic. Doctor Hameed.
Morad Hameed 59:55
I've had a couple of minutes to think about it. So I'm going to put mine under resuscitation exposure and control. So, for resuscitation, I think it's very important to take a team-based approach to this. Careful coordination with the emergency anesthesia and surgery teams, and in particular, you don't, you want to make sure the patient is well-resuscitated or on their way, with good access to being resuscitated, because you don't want to initiate positive pressure ventilation in a patient with tamponade unless you're prepared to resuscitate. And the idea is that if you could just create a little bit of intravascular volume and a little bit of central venous pressure, that's sometimes enough just to offset that tamponade, so that when you introduce positive pressure ventilation, the patient doesn't arrest. So that, just, simultaneous resuscitation intubation and decompression; it has to go on together, and you have to have good backup with resuscitation as you enter into this battle. In terms of exposure, I really like what Chad said about the clamshell extension. The incision should be made — the skin incision anyway, should be made, in my opinion, starting to the right of the sternum, actually, and then coming across to the left anterolateral thoracotomy, and then arcing up upward a little bit as you move laterally. I find that sometimes that incision is a little bit misplaced; you know, it can be sometimes too high through the breast or too low and the axis is limited. But 1 reliable landmark for this, I think, is the inframammary fold — everyone has it — and if you sort of centre on that inframammary fold, you don't have to landmark too much. You just take the knife, begin it to the right sternal border and just take it across that inframammary fold and down close to the bed, arcing up a little bit. It's super simple to do and you're already down into the chest wall in a few seconds, and then you can just punch into the intercostal space at that level. And usually that's the right spot. And then [with respect to] control, I would just say that everybody who's been committed to an anterolateral thoracotomy has to have the pericardium opened. Don't back down if you think the pericardium looks empty. I've definitely been fooled by that. And once you're in, you are committed to exploring that pericardial space and there's often a lot of blood in there that's kind of hidden. So do open the pericardium, and don't try to evaluate the heart from outside even though it's sometimes tempting to do so. Digital control is a very useful tool, as we highlighted. We didn't highlight things like aortic cross-clamping and pulmonary hilar cross-clamping, but I think those are very strong adjuncts to the — aortic cross-clamp is not just for controlling bleeding below the diaphragm; it is helpful to restore cardiac perfusion. So if the heart doesn't start by simple decompression of the pericardium, cross-clamping the aorta, starting compressions, might help you in coronary perfusion. Similarly, dividing the inferior pulmonary ligament and cross-clamping the pulmonary hilum in patients with associated lung injuries can prevent bleeding from the lung and also air embolism. So those are some important steps of control that we didn't highlight too much in our discussion but that are in the paper.
Ameer Farooq 59:52
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Posted March 7, 2023