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 Table of Contents  
INTERESTING CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 220-222

Role of Point-of-care Ultrasonography in Cardiac Surgical Emergencies Like Left Ventricular Puncture


1 Department of Cardiac Anaesthesia, JNMC, Wardha, Maharashtra, India
2 Department of Cardiac Surgery, Smt. B. K. Shah Medical Institute and Research Center, Vadodara, Gujrat, India

Date of Submission28-Dec-2019
Date of Decision15-Jan-2020
Date of Acceptance19-Feb-2020
Date of Web Publication19-Aug-2020

Correspondence Address:
Dr. Mangesh Sudhakar Choudhari
Department of Cardiac Anaesthesia, JNMC, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_56_19

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  Abstract 

Point-of-care ultrasonography (POCUS) is the application of emergency ultrasonography at the place of patient care to make immediate patient care decisions. POCUS has an important role to play in emergency medical departments because POCUS can shorten time between the onset of symptoms and definitive treatment. Chest tube drain insertion is a simple procedure and routinely practiced. Left ventricular (LV) puncture due to chest drain is a lethal complication of chest tube placement. Early diagnosis and management is essential to save the patient. This case highlights the role of emergency echocardiography in managing LV puncture due to misplaced chest drain and its advantages over contrast-enhanced computerized tomographic scanning. In this case, POCUS helped in finding quick answers to clinical doubts and helped in the management of emergent conditions.

Keywords: Chest tube insertion, emergency echocardiography, left ventricular puncture, point of care ultrasonography


How to cite this article:
Choudhari MS, Pohekar PH. Role of Point-of-care Ultrasonography in Cardiac Surgical Emergencies Like Left Ventricular Puncture. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:220-2

How to cite this URL:
Choudhari MS, Pohekar PH. Role of Point-of-care Ultrasonography in Cardiac Surgical Emergencies Like Left Ventricular Puncture. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2020 Oct 27];4:220-2. Available from: https://www.jiaecho.org/text.asp?2020/4/2/220/292636


  Introduction Top


Medical ultrasound is in use since the Second World War. The role of medical ultrasound has changed over a period of time. It is being used as an important supportive investigation of choice to the clinical examination in medical emergencies.[1],[2] Frequently, cardiac surgical team encounters fatal injuries to the chest like gunshot injuries, stab injuries, blast injuries, etc. The aim of the point-of-care ultrasonography (POCUS) is to reduce the delay between the presentation of symptoms and definitive treatment.[2]

Intercostal drain insertion is a life-saving procedure in case of symptomatic secondary spontaneous pneumothorax.[3] There can be injury to vital structures such as the pulmonary blood vessels, aorta, spleen, liver, lung parenchyma, or heart.[4],[5],[6] Injury to the heart and its perforation due to intercostal drain is probably underreported. To our knowledge, 14 cases have been reported in the literature. In the past, computerized tomographic (CT) scanning or contrast-enhanced CT scan had been routinely advised to see the extent of penetrating thoracic injuries and it is used to be the investigation of choice.[4],[5],[6] CT angiography is much more time consuming than ultrasonography. Monitoring and resuscitation is also compromised during transportation to the radiology suite. POCUS helps in precise diagnosis and management of such cases without compromising resuscitation.[7],[8]


  Clinical Presentation Top


A 30-year-old male patient, known case of multidrug-resistant pulmonary tuberculosis, presented to the emergency medical department with severe breathlessness and perspiration. His room air saturation on pulse oxymeter was 60%. On auscultation of the lungs, it was found that air entry was absent on the left side. Chest wall movements were severely restricted on the left side. X-ray chest was suggestive of left-sided pneumothorax. Intercostal drain was inserted on the left side of the chest. Immediately, gush of pulsatile blood was noticed coming out of the chest tube. The patient was pulseless for sometime. The patient was resuscitated with intravenous fluids and was intubated. Drainage bottle was full of blood. A cardiac surgeon was called for help. The cardiac surgeon clamped the drain tube. The patient's blood pressure slowly recovered to a systolic blood pressure of 80 mmHg. The patient was immediately shifted to the operation theater without any further investigations.

Vascular injury was suspected either to the descending thoracic aorta, pulmonary blood vessels, or heart. Injury to the lung parenchyma was not suspected because there was no air leak from the intercostal drain. There was confusion regarding the further plan of action. Injury to the descending thoracic aorta or pulmonary blood vessels would have required a lateral thoracotomy approach, and one-lung ventilation while injury to the heart might have required median sternotomy approach and cardiopulmonary bypass. X-ray of the chest showed an intercostal drain placed in the mediastinum [Figure 1]. The left lung was small and collapsed.
Figure 1: X-ray chest in anterioposterior view shows intercostal drain on the left side of the chest. Drain tip is hitting the middle mediastinum

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Transthoracic echocardiography was available; an echo probe was placed in the parasternal long-axis view. An intercostal drain was seen in the left ventricle [Figure 2]. Hence, it was decided to perform the repair in a supine position with median sternotomy approach and support of cardiopulmonary bypass. His hemoglobin was 4 g/dl. The femoral artery and right internal jugular vein were cannulated. The patient was induced with ketamine. Cardiopulmonary bypass was instituted. A rent was noted in the left ventricle at the apex. The rent was repaired with the Teflon patch. The patient was weaned off cardiopulmonary bypass with ionotropic support of noradrenaline, at a rate of 0.2 mcg/kg/min. The patient was shifted to the intensive care unit. He remained stable for 2 days. On the 3rd day, he went into sepsis and shock. On the 4th day, he succumbed to death.
Figure 2: Transthoracic parasternal long axis view shows intercostal drain lying in the left ventricle

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  Discussion Top


Chest tube drain placement is a routine procedure done in the emergency medical departments to treat symptomatic patients with secondary spontaneous pneumothorax.[3] Lethal injury to the vital organs is known during the placement of chest tube drainage.[4],[5],[6] Every minute counts in such dire emergencies. Contrast-enhanced CT scanning is a conventional radiological investigation of choice that had been used previously for the diagnosis of penetrating injury to the chest. Transportation of patients to the CT scan suite can be time consuming. Monitoring and resuscitation of the patient is likely to get compromised during transportation to the radiology department.

In the majority of reported cases, CT angiography had been done to diagnose injury to the heart.[4],[5],[6] In this case, we could not do CT angiography because the patient was hemodynamically unstable. X-ray of the chest did not give a clear picture of site of injury. It neither showed mediastinal widening which is suggestive of pericardial collection nor any pleural collection which can point to an injury of the pulmonary vessels. It was not possible to make out whether there was an injury to the heart, aorta, or pulmonary vessels. Injury to the pulmonary vessels or descending thoracic aorta would have necessitated lateral thoracotomy approach as access to the distal pulmonary arteries and descending thoracic aorta by the midline approach is difficult, while the injury to the heart would have required midline sternotomy with the support of cardiopulmonary bypass. In few stable patients, the injury to the heart was repaired by the lateral thoracotomy approach also, although mediastinal contamination is a concern in empyema thoracic.[6] Transesophageal echocardiography (TEE) is a preferred investigation of choice in a hemodynamically unstable patient who is already intubated, but TEE probe was not available. However, transthoracic echocardiography probe was available. In this case, emergency two-dimensional echocardiography helped in quickly answering clinical doubts and resolving a dilemma about the approach. Various protocols such as extended focused assessment with sonography for trauma, focused assessed transthoracic echo, or focused echocardiographic evaluation in life support have been developed for easy and quick assessment in emergency situations.[7],[8],[9] POCUS has become a tool that can change the practice protocols and should be done first before asking for other invasive imaging technologies.[2] If all the clinical questions are not answered by POCUS, other modalities of imaging can be tried.

POCUS can be used in various clinical situations such as undifferentiated shock, cardiac arrest, trauma, chest pain, dyspnea, and blunt abdominal injuries.[2] It can be performed quickly at the places such as hospital wards, ambulances, emergency departments, and combat.[1] It helps in applying triage in mass casualties.[2] Nowadays, a greater proportion of patients is receiving their initial care and diagnostic testing at the emergency departments itself. Most cardiac injuries due to misplaced chest drain reported so far were related to anatomic distortions, mediastinal shifts, and cardiomegaly and more often when introducer trocar was used to insert a chest drain.[4] In this case, the left lung was destroyed due to tuberculosis, and hence, the left ventricle was closer to the chest wall. Pneumothorax ex vacuo was another possibility, but most of the time, it is restricted to one lobe.[10] This condition occurs due to an acute obstruction of the bronchus with mucus plug leading to sudden lung collapse and creation of pneumothorax due to leak of air in empty space. Treatment should be directed to relieve acute bronchial obstruction.[10] Negative aspiration of air in case of suspected pneumothorax should warrant the use of chest ultrasound to confirm a diagnosis, before insertion of a chest drain.


  Conclusion Top


POCUS can answer clinical doubts there itself. The treating physician can perform it without compromising resuscitation and monitoring.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Arntfield RT, Millington SJ. Point of care cardiac ultrasound applications in the emergency department and intensive care unit: A review. Curr Cardiol Rev 2012;8:98-108.  Back to cited text no. 1
    
2.
Rooney KD, Schilling UM. Point-of-care testing in the overcrowded emergency department – can it make a difference? Crit Care 2014;18:692.  Back to cited text no. 2
    
3.
MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65 Suppl 2:ii18-31.  Back to cited text no. 3
    
4.
Kim D, Lim SH, Seo PW. Iatrogenic perforation of the left ventricle during insertion of a chest drain. Korean J Thorac Cardiovasc Surg 2013;46:223-5.  Back to cited text no. 4
    
5.
Goltz JP, Gorski A, Böhler J, Kickuth R, Hahn D, Ritter CO. Iatrogenic perforation of the left heart during placement of a chest drain. Diagn Interv Radiol 2011;17:229-31.  Back to cited text no. 5
    
6.
Haron H, Rashid NA, Dimon MZ, Azmi MH, Sumin JO, Zabir AF, et al. Chest tube injury to left ventricle: Complication or negligence? Ann Thorac Surg 2010;90:308-9.  Back to cited text no. 6
    
7.
Jensen MB, Sloth E, Larsen KM, Schmidt MB. Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol 2004;21:700-7.  Back to cited text no. 7
    
8.
Breitkreutz R, Walcher F, Seeger FH. Focused echocardiographic evaluation in resuscitation management: Concept of an advanced life support-conformed algorithm. Crit Care Med 2007;35:S150-61.  Back to cited text no. 8
    
9.
Richards JR, McGahan JP. Focused assessment with sonography in trauma (FAST) in 2017: What radiologists can learn. Radiology 2017;283:30-48.  Back to cited text no. 9
    
10.
Woodring JH, Baker MD, Stark P. Pneumothorax ex vacuo. Chest 1996;110:1102-5.  Back to cited text no. 10
    


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