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Emergency Open Cardiac Massage Via Subxyphoid Approach in Ruptured Type a Aortic Dissection

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Emergency Open Cardiac Massage Via Subxyphoid Approach in Ruptured Type a Aortic Dissection SIGNA VITAE 2010; 5(2): 32 -34 CASE REPORT CHAO-WEN CHEN ( ) Department of Trauma Emergency Open Cardiac Kaohsiung Medical University Hospital 100 Tzyou 1st Road Kaohsiung 807, Taiwan Phone: +88673125895 ext 7553 Massage via Subxyphoid Fax: +88673208255 Approach in Ruptured Type E-mail: [email protected] HSING-LIN LIN • WEI-CHE LEE • SHING-GHI LIN • LIANG-CHI KUO • A Aortic Dissection YUAN-CHIA CHENG Department of Trauma Kaohsiung Medical University Hospital HSING-LIN LIN • WEI-CHE LEE • SHING-GHI LIN • LIANG-CHI KUO • Kaohsiung Medical University YUAN-CHIA CHENG • CHAO-WEN CHEN Kaohsiung, Taiwan HSING-LIN LIN • WEI-CHE LEE KUO • YUAN-CHIA CHENG Department of emergency Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung, Taiwan HSING-LIN LIN Division of General Surgery Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung, Taiwan HSING-LIN LIN MD Graduate Institute of Healthcare Administration Kaohsiung Medical University Kaohsiung, Taiwan ABSTRACT Patient sustained cardiac tamponade caused by rupture of type A aortic dissection may result in sudden death. Pericardio- centesis is a lifesaving procedure; nevertheless, blood may occlude the catheter and fail to relieve the pressure. However, open-chest cardiac massage in resuscitation has been studied in animal models by some medical centers and laboratories with inspiring results. We report a 58-year-old woman who was transferred from a local hospital with the diagnosis of cardiac tamponade caused by ruptured type A aortic dissection. Pulseless electrical activity followed by cardiac arrest occurred thereafter. Successful resuscitation in the emergency department was achieved using open cardiac massage through the sub-xyphoid region by opening a pericardial window. Therefore, in unstable patients with cardiac tamponade due to aortic dissection, this resuscitative procedure is feasible, safe and efficient. Keywords: direct cardiac compres- by physicians without specialty training successfully after suddenly collapsing. sion, resuscitation, sub-xyphoid in cardiothoracic surgery. However, (1) The benefit of open thoracotomy is approach, cardiac tamponade, aortic inserting a pericardiocentesis need- that it provides not only cardiac tampo- dissection le may cause unexpected heart injury nade relief but also enables direct car- and the clotted blood may occlude the diac compression. We report a patient Introduction draining catheter. Open thoracotomy is with a similar situation who was also Patients who have aortic dissection not routinely used in the resuscitation successfully resuscitated employing are at great risk of rupture, which may of patients sustaining cardiac tampo- an alternative method to thoracotomy. cause cardiac tamponade and result in nade owing to the complex nature of We resuscitated the patient through sudden death. Traditionally, cardiocen- the procedure. Nevertheless, in a report the open chest via the sub-xyphoid tesis was performed to relieve the pre- by Yanagawa Y et al. a patient with region using pressure relief following ssure in the pericardial sac, especially lateral thoracotomy was resuscitated direct cardiac massage. Comparing 32 www.signavitae.com to the traditional median sternotomy, this is an early way to approach the heart, and provides a better and easier method to relieve hemorrhagic cardiac tamponade. Case report A 58-year-old woman presented to a local emergency department (ED) with reported altered mental status after blacking out, falling down, and recei- Figure 1a. The chest radiograph Figure 2a. A midline skin incision ving a head injury. According to reports shows widening of the superior about 8-10 cm is made below the mediastinum. xyphoid process. from her family, she awoke soon after the blackout and complained about Figure 1b and 1c. Chest CT scans Figure 2b. The pre-peritoneum space head and chest pain. Her family denied shows rupture of the aortic dissec- is dissected without opening the any previous trauma, toxic ingestions, tion with false, true lumens and an peritoneum. fevers, chills, rashes, recent illnesses, intimal flap (black arrow). Heteroge- neous hyperattenuating fluid collec- Figure 2c. Blunt dissection by fingers or respiratory, cardiac, genitourinary, or ted in the pericardium as indicated is used to separate the tissue under gastrointestinal complaints. The patient by the white arrow. the sternum. had a medical history of hypertension. After arrival at the ED of a local hospi- Figure 2d. A pericardial window is tal, her vital signs were stable, with a rapid endotracheal intubation. Once made (hollow arrow) prior to cardi- ac compression between one hand temperature of 36.6°C, blood pressure the endotracheal tube was successfu- on the sternum and the other hand of 114/65 mm Hg, pulse of 100 beats lly placed and the position confirmed, on the infra-posterior aspect of the per minute, and a respiratory rate of 26 needle pericardiocentesis was perfor- heart. breaths per minute. Brain-computed med with fresh blood drawn. However, tomography (CT) was obtained and her heart remained in asystole without there was no intracranial lesion. She any response after the drainage pro- Discussion felt chest pain and dyspnea during the cedure and cardiopulmonary resusci- Open cardiac massage has been found ED observation. A chest radiograph tation (CPR). With the aim of rapid eva- to be superior than closed chest com- was performed with the finding of medi- cuation of pericardial blood, the sub- pressions as indicated by the doubled- astinal widening (figure 1a). A chest xyphoid pericardial window was then up cardiac index and coronary perfusi- CT was then performed and Type A opened (figure 2). An eight cm medial on pressure. (2) In the past, open-chest aortic dissection was uncovered with a incision just caudal to the xyphoid pro- cardiopulmonary resuscitation was massive pericardial effusion (figures 1b cess was made. With preservation of limited in the emergency room at level I and 1c). Due to lack of backup of car- the xyphoid process, finger dissection trauma centers and performed especi- diothoracic surgery facilities, she was was made along the retrosternal space. ally in traumatic cardiac arrest patients. soon transferred to our hospital with After approaching the pericardium, a (3-6) Although there is still controversy the diagnosis of ruptured type A aortic three cm opening in the pericardium over open-chest CPR being used in dissection with hemopericardium. was created for blood drainage. By clinical practice to revive the non-trau- Upon her arrival at the ED, rapid asse- placing a hand over the infra-posterior matic cardiac arrest victim, (7) there are ssment was initiated, she was found aspect of the heart as well as the other still sporadic reports about successful to have a patent airway, and breathing hand on the sternum, a combination of resuscitation with direct open chest sounds were equal bilaterally. Heart closed and open cardiac massage was cardiac compression in cardiac tam- sounds diminished, and pulses were performed in this manner (figure 2d). ponade. (1) weak bilaterally. Her vital signs were The resuscitative procedure lasted for Most physicians do not have suffici- notable for a blood pressure of 66/45 approximately 15 minutes with several ent confidence to perform resuscitative mmHg, and a heart rate of 96 bpm. intravenous injections of epinephrine thoracotomy due to lack of experience. Despite rapid resuscitation, the patient till signs of life including palpable pulse Advanced Trauma Life Support® also became unconscious within 10 minu- and reactive pupils were identified. With claims qualified surgeons are essential tes of arrival. Moreover, her blood pre- the assistance of an in-house cardiot- while making the decision for resus- ssure suddenly dropped and cardiac horacic surgeon, she was rapidly sent citative thoracotomy. Conventionally, monitoring revealed pulseless electrical to the operating room and the aorta antero-lateral thoracotomy is used to activity. Advanced Cardiac Life Support was repaired along with the extended achieve good exposure and bleeding (ACLS) guidelines were followed with wound created at the ED. control of intra-thoracic injuries. Howe- www.signavitae.com 33 ver, without the aid of a rib retractor, xyphoid approach would not create hod has not been discussed before. one cannot perform cardiac massage another wound compared with conven- Further studies are necessary. easily through the narrow intercostal tional anterolateral thoracotomy. This Although direct cardiac compression space. Alternatively, the sub-xyphoid manner is indeed of benefit for decrea- is still continuously studied in animal approach provides preferable acce- sing morbidity and promoting recovery. models, (7-10) we suggest that it not ss. The midline sub-xyphoid incision is In our patient, we also performed a only provides better prognosis in trau- easily marked and made. With particu- combination of open and closed cardi- matic cardiac arrest patients but also in lar attention to avoiding diaphragmatic ac massage as shown in figure 2. Open those with cardiac tamponade caused injury, we can insert a whole hand into cardiac massage has been proven to by medical problems. Since hemorrha- the retrosternal space without enco- be more effective than the closed met- gic cardiac tamponade caused by a tra- untering overt anatomical obstacles. hod in each cardiac stroke. (2) In open- umatic or nontraumatic ruptured aorta In addition,
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