The Occurrence of Thrombotic Complications Due to Combat Trauma Against the Background of the COVID-19 Pandemic
An important point in the provision of highly specialized cardiac surgical care for combat trauma is determination of the optimal time, method and volume of surgical intervention, taking into account the persisting threat of infection with the SARS-COV-2 virus and associated thrombotic complications.
The aim. To investigate the mechanism of development and methods of prevention of thrombotic complications resulting from combat trauma against the background of the COVID-19 pandemic.
Materials and methods. We analyzed clinical case of patient R., a 37-year-old soldier with a postinfarction thrombosed aneurysm of the left ventricle. The patient underwent standard clinical and laboratory tests, electrocardiography, echocardiography, coronary angiography, computed tomography of the chest, duplex scanning of carotid arteries, arteries and veins of the upper and lower extremities. It was established that 4 months ago, during a combat mission, the service-man received a mine-explosive injury, shrapnel wounds of lower extremities, multifragmentary fracture of the right ϐibula and a gunshot wound to the right chest. The causes of post-traumatic myocardial infarction are mine-explosive injury, intramural course of the left anterior descending artery, youngage, poorly developed collaterals of coronary arteries, long-term transportation during the stages of medical evacuation and post-traumatic stress disorder. A month ago, the patient was diagnosed with COVID-19, thromboembolism of the right main branch of the pulmonary artery, for which thrombolytic therapy was performed. Follow-up computed tomography showed the signs of thromboembolism of the pulmonary arteries. Ultrasound examination revealed thromboses of upper and lower limbs. Thrombotic complications against the background of combat polytrauma are the result of hypercoagulation, acute inϐlammation with the release of proinϐlammatory cytokines and damage of the endothelium. SARS-COV-2 infection triggers a state of hypercoagulation and creates additional conditions for the occurrence of arterial and venous thrombosis. Considering the nature of the thrombotic lesions, was made a decision to postpone the cardiosurgical intervention for 3 months.
Conclusions. Thrombotic complications are an urgent problem after combat trauma. COVID-19 is an additional risk factor for hypercoagulation and a reason for delaying elective cardiac surgery. Conducting an electrocardiography to the wounded, regardless of age, is crucial for timely diagnosis andtreatment of acute coronary events. It is important to initiate anticoagulant therapy after eliminating all possible sources of bleeding due to the high risk of thrombotic complications against the background of chest trauma and limb fractures.
- Clark ZT, Thiel N, Perry J, Minckler MR. A Case of Blunt Trauma-induced ST-elevation Myocardial Infarction Sustained During a Prison Brawl. Cureus. 2020;12(1):e6733. https://doi.org/10.7759/cureus.6733
- Velasco CE, Patel M, Mogollon J, Grodin JM, Stoler RC. Myocardial Infarction Related to Trauma. Rev Cardiovasc Med. 2015;16(4):261-4. https://doi.org/10.3909/ricm0795
- Ismailov RM, Ness RB, Weiss HB, Lawrence BA, Miller TR. Trauma associated with acute myocardial infarction in a multi-state hospitalized population. Int J Cardiol. 2005;105(2):141-6. https://doi.org/10.1016/j.ijcard.2004.11.025
- Maenza RL, Seaberg D, D’Amico F. A meta-analysis of blunt cardiac trauma: Ending myocardial confusion. Am J Emerg Med. 1996;14(3):237-41. https://doi.org/10.1016/S0735-6757(96)90165-5
- Parmley LF, Manion WC, Mattingly TW. Nonpenetrating Traumatic Injury of the Heart. Circulation. 1958;18(3):371-96. https://doi.org/10.1161/01.cir.18.3.371
- Ginzburg E, Dygert J, Parra-Davila E, Lynn M, Almeida J, Mayor M. Coronary artery stenting for occlusive dissection after blunt chest trauma. J Trauma. 1998;45(1):157-61. https://doi.org/10.1097/00005373-199807000-00034
- Galiuto L, Favoccia C, Tortorolo L, Danza ML, De Vito E, Fedele E, et al. Post-traumatic myocardial infarction with hemorrhage and microvascular damage in a child with myocardial bridge: is coronary anatomy actor or bystander? Signa Vitae. 2013;8(2):61-63. https://doi.org/10.22514/SV82.102013.11
- Gogayeva O. [Treatment for patients with symptomatic tunneled coronary arteries]. Ukrainian Journal of Cardiovascular Surgery. 2019;(2 (35)):13-7. Ukrainian. https://doi.org/10.30702/ujcvs/19.3505/009013-017
- Jacquet-Smailovic M, Brennsthul MJ, Denis I, Kirche A, Tarquinio C, Tarquinio C. Relationship between Post-traumatic Stress Disorder and subsequent myocardial infarction: a systematic review and meta-analysis. J Affect Disord. 2022;297:525-35. https://doi.org/10.1016/j.jad.2021.10.056
- Bahloul M, Dlela M, Bouchaala K, Kallel H, Ben Hamida C, Chelly H, et al Post-traumatic pulmonary embolism: incidence, physiopathology, risk factors of early occurrence, and impact outcome. A narrative review. Am J Cardiovasc Dis. 2020;10(4):432-43.
- Maeda S, Takahashi S, Sato M. Serum Thrombomodulin as a Newly Identified Biomarker for Postoperative Lung Injury: A Prospective Observational Study. Tohoku J Exp Med. 2012;228(2):135-41. https://doi.org/10.1620/tjem.228.135
- Knudson MM, Gomez D, Haas B, Cohen MJ, Nathens AB. Three Thousand Seven Hundred Thirty-Eight Posttraumatic Pulmonary Emboli: A New Look At an Old Disease. Ann Surg. 2011;254(4):625-32. https://doi.org/10.1097/SLA.0b013e3182300209
- Bahloul M, Regaieg K, Chtara K, Turki O, Baccouch N, ChaariA, et al. [Posttraumatic thromboembolic complications: incidence, risk factors, pathophysiology and prevention]. Ann Cardiol Angeiol (Paris). 2017;66(2):92-101. French. https://doi.org/10.1016/j.ancard.2016.12.003
- Brakenridge SC, Toomay SM, Sheng JL, Gentilello LM, Shafi S. Predictors of early versus late timing of pulmonary embolus after traumatic injury. Am J Surg. 2011;201(2):209-15. https://doi.org/10.1016/j.amjsurg.2009.12.005
- Avila J, Long B, Holladay D, Gottlieb M. Thrombotic complications of COVID-19. Am J Emerg Med. 2021;39:213-8. https://doi.org/10.1016/j.ajem.2020.09.065
- Branchford BR, Carpenter SL. The Role of Inflammation in Venous Thromboembolism. Front Pediatr. 2018;6:142. https://doi.org/10.3389/fped.2018.00142
- Di Minno A, Ambrosino P, Calcaterra I, Di Minno MND. COVID-19 and Venous Thromboembolism: A Meta-Analysis of Literature Studies. Semin Thromb Hemost. 2020;46(7):763-71. https://doi.org/10.1055/s-0040-1715456
- Gogayeva OK, Rudenko ML, Ioffe NO. [Surgical Treatment of Postinfarction Thrombosed Left Ventricular Aneurysm after Bilateral Polysegmental COVID-19-Associated Pneumonia. Case Report]. Ukrainian Journal of Cardiovascular Surgery. 2022;30(1):71-6. Ukrainian. https://doi.org/10.30702/jcvs/22.30(01)/GR019-7176
- Hornor MA, Duane TM, Ehlers AP, Jensen EH, Brown PS Jr, Pohl D, et al. American College of Surgeons’ Guidelines for the Perioperative Management of Antithrombotic Medication. J Am Coll Surg. 2018;227(5):521-36.e1. https://doi.org/10.1016/j.jamcollsurg.2018.08.183
- Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al.; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41(4):543-603. https://doi.org/10.1093/eurheartj/ehz405