Blunt Chest Trauma Causing a Thrombosis of a Vein Graft to the “Widow Maker” Coronary Artery

Flatline to Lifeline With Dr. Long

In a small Oregon coastal fishing port, a 60 y.o. male fell from a ladder on a pier trying to get into his boat. He fell 6 feet breaking his sternum, causing a cardiac arrest. The fall was witnessed by 3 men who hoisted him to the top of the pier, where EMTs awaited him. The man wasn’t breathing, had no pulses, and was unconscious.

Local EMTs did cardiac life support, including endotracheal intubation and defibrillating him multiple times for recurring ventricular fibrillation. They began CPR and transported the patient to the local hospital which was not a trauma center.

In the ER, the emergency physician (EP) tried using Advanced Cardiac Life Support (ACLS) drugs, providing the patient with a pulse and low blood pressure, but the patient kept fibrillating. The ECG tracing was compatible with an acute anterior lateral myocardial infarction.

The EP noticed the patient had a median sternotomy incision on his chest. A review of the hospital medical records revealed this patient had a single bypass vein graft to the left anterior descending coronary artery (LAD), aka the widowmaker). The EP assumed the fall may have damaged the vein graft causing it to clot, causing the patient’s current symptoms.

The patient was too unstable to transfer by either land or air ambulance. He called our trauma center, and asked if we could help him stabilize this patient. A cardiothoracic (CT) surgeon taking trauma call realized that this patient would need some mechanical cardiac support if the patient had a chance for survival.

The CT/trauma surgeon mobilized the MSTT and our perfusionist to help load the portable IntraAortic Balloon Pump (IABP), a mechanical device that helps to augment blood flow into the coronary arteries, into the BK 117 Critical Care helicopter to fly to this hospital. During this time, the patient required at least 4 more electrical defibrillations.

Upon arrival at the referring hospital, the MSTT team with the IABP went straight to the hospital’s emergency department where the team inserted the IABP long balloon catheter into the common femoral artery and advanced the balloon end of the cannula as far as the origin of descending thoracic aorta, and initiated balloon pumping.

The patient's vital signs (blood pressure and heart rhythm) improved and he developed a palpable peripheral pulse. We transferred the patient and the IABP to Emanuel where we took the patient directly to the Cardiac Catheterization Laboratory where an interventional cardiologist awaited us with his team. Coronary and vein graft angiograms revealed a clot midway down the length of the vein graft. He gave Streptokinase, an anticoagulant, via the vein graft to lyse the clot and restore circulation to the LAD. This was successful.

In our combined Trauma & Cardiac Surgical ICU he recovered over the next 5 days, after which we removed the IABP cannula. Meanwhile he regained consciousness and responded to simple commands, and was moving all 4 limbs to command.

We sent him home on oral anticoagulants. 3 months later, on follow up in our trauma clinic, his echocardiogram ejection fraction had returned to normal. According to his family, his mentation and activity had returned to normal.

Medical Clarifications:

This was the first time we used a mechanical cardiac support (IABP) to transport a patient successfully from any hospital.

The IABP doesn’t cure the causes of shock that cause heart failure; it buys the heart time to recover from the shock episode.

To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.
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Producer: Esther McDonald
Director & Technical Support: Lindsey Kealey, Host of The PAWsitive Choices Podcast

© Flatline to Lifeline 2024

Chapters

1. Blunt Chest Trauma Causing a Thrombosis of a Vein Graft to the “Widow Maker” Coronary Artery (00:00:00)

2. Improving Trauma Care and Saving Lives (00:00:01)

3. Distractions and Treatment of Cardiac Arrest (00:11:15)

4. IABP and Portable Life-Saving Techniques (00:26:04)

5. Treating Blocked Arteries and Heart Recovery (00:41:24)