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Regrowing New Muscle In Trauma Patients

The Pentagon and the University of Pittsburgh have developed a new technique for growing functional muscle in vivo. The process starts with insertion of an extracellular matrix containing growth factor proteins from pig bladders. Stem cells move to the area and begin the process of wound repair and tissue growth, which normally does not occur in mature muscle. 

The really interesting thing about this process is that, after intensive rehab begins, not only does the muscle grow back, but also tendons and nerves to innervate the muscle! The process has been used successfully in four patients so far.

Bottom line: This may become a new standard of care in the next few years. It will simplify soft tissue reconstruction in mangled extremities and motorcycle injuries, to name a few.

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What The Heck? The Answer

Obviously, there’s a big knife in this image, and it appears to coincide with our patient. Remember, you can’t tell the relative positions of objects in the z axis in a two dimensional radiograph. However, you know that it is not on top of or under this patient, because there is an obvious hemothorax.

First, this patient should have been a trauma activation, since there is a penetrating injury of the chest. The first decision point is based on vital signs: is the patient hemodynamically normal? If not, do the essentials quickly (quick exam, lines, blood draw for blood bank) and move to the OR. The quick exam is important, especially of the back, since you may not see it for the next few hours and additional injuries there could be trouble.

If the patient is stable, then it’s time to do the essentials and figure out what you are going to need to do in the next hour. A chest xray can be very helpful. However, given the size of the knife and the fact that it appears to be buried to the hilt allows you to calculate the trajectory in your mind. The only question is if it went in far enough to enter the abdomen.

The xray shows a moderate hemothorax and a tip that extends well into some part of the abdomen, no matter how you look at it. It has also come alarmingly close to the heart. If the knife had not penetrated as deeply and was obviously only in the chest, then removal of the knife with insertion of a chest tube would be appropriate. 

However, in the case of this xray, the patient still needs to go to the OR. The chest and abdomen need to be prepped and the abdomen opened first. Once the knife is located, the next steps can be planned. If there is concern for the heart, the pericardial surface of the diaphragm can be opened to look for blood. If found, extension of the laparotomy incision into a sternotomy is appropriate for cardiac repair. If not, the tip of the knife should be visualized and the weapon slowly removed under direct vision. Any bleeding structures can be dealt with first as it goes, followed by any injuries to a hollow viscus.

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ED Thoracotomy Part 3: Clamping The Aorta

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Finally, the chest is open and the tamponade has been relieved. But your patient has little volume. In order to conserve any circulating blood and pump it only to the heart and the head, it’s time to cross clamp the aorta. This task is best left to the surgeon, because it is not a simple matter.

First, you have to locate the aorta, ideally somewhere just above the diaphragm. Unfortunately, if the patient is hypovolemic it’s very difficult to distinguish the aorta from the esophagus, which lie right next to each other (see picture above). In order to make them feel different, insert a gastric tube through the mouth or nose.

Next, separate the aorta and esophagus. They are both covered by pleura. The structure nearest you without the tube in it will be the aorta. Sometimes it’s possible to use a finger to dissect through the pleura and around the aorta. However, the younger the patient, the tougher this tissue is. It may be necessary to incise the pleura with scissors while your assistant holds the lung anteriorly, our of the way.

Finally, once you can pass a finger completely around the aorta, use it to guide the placement of a gently curved DeBakey type clamp (see picture on the left). Squeeze it until it clicks once, and you are done! Now rapidly infuse warmed blood into the patient and run to the OR!

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ED Thoracotomy Part 2: The Heart

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Once the chest is open, the first item of business is to check the heart. In some patients, the inferior pulmonary ligament may prevent you from pushing the lung laterally and superiorly, out of the way. This ligament is a piece of pleura that attaches the lower lobe to the medial diaphragm and mediastinum. Locate it with your fingers and carefully cut it (blindly) with your scissors.

Now look at the heart. What is the rhythm? Put your hands around it. What is the patient’s volume status? If there is the possibility of a penetrating injury, open the pericardium. This structure is tough, and if tamponade is present it will be stretched tight. I find it very difficult to grab the pericardium with forceps and make the initial incision with scissors. Toothed forceps may work, but I just make a very small nick, carefully and directly, with a scalpel. The incision should be placed anterior to the phrenic nerve and vessels, which are usually plainly visible. See the picture on the left, above. The color of the pericardial fluid will immediately indicate whether a cardiac injury is present.

Next, extend the incision (parallel to the bed) to the top and bottom of the ventricle and eviscerate the heart. This will allow careful inspection of all but the atria. If an injury is present, a finger can be used to occlude it until preparations for a repair are made.

Holding the heart is both diagnostic and potentially therapeutic. The “fullness” of this organ is an excellent indicator of the volume status, and if a finger is being used to plug a hole, the temperature of the blood and infused fluids can be determined quickly. All volume resuscitation in this situation should be warmed fluids. And if need be, open cardiac massage is very effective for augmenting circulation.

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Image from my personal archive. Not treated at Regions Hospital.

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