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Surgical Repair of Right Atrial Wall Rupture after Blunt Chest Trauma

Authors:
Jose Eduardo Telich at Hospitales Angeles
Jose Eduardo Telich
Javier E Anaya-Ayala at Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán
Javier E Anaya-Ayala
Michael Reardon at Houston Methodist Hospital
Michael Reardon
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Right atrial wall rupture after blunt chest trauma is a catastrophic event associated with high mortality rates. We report the case of a 24-year-old woman who was ejected 40 feet during a motor vehicle accident. Upon presentation, she was awake and alert, with a systolic blood pressure of 100 mmHg. Chest computed tomography disclosed a large pericardial effusion; transthoracic echocardiography confirmed this finding and also found right ventricular diastolic collapse.A diagnosis of cardiac tamponade with probable cardiac injury was made; the patient was taken to the operating room, where median sternotomy revealed a 1-cm laceration of the right atrial appendage. This lesion was directly repaired with 4-0 polypropylene suture. Her postoperative course was uneventful, and she continued to recover from injuries to the musculoskeletal system.This case highlights the need for a high degree of suspicion of cardiac injuries after blunt chest trauma. An algorithm is proposed for rapid recognition, diagnosis, and treatment of these lesions.
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Texas Heart Institute Journal Right Atrial Rupture after Blunt Chest Trauma 579
© 2012 by the Texas Heart ®
Institute, Houston
Surgical Repair of Right
Atrial Wall Rupture
after Blunt Chest Trauma
Right atrial wall rupture after blunt chest trauma is a catastrophic event associated with
high mortality rates. We report the case of a 24-year-old woman who was ejected 40 feet
during a motor vehicle accident. Upon presentation, she was awake and alert, with a sys-
tolic blood pressure of 100 mmHg. Chest computed tomography disclosed a large peri-
cardial effusion; transthoracic echocardiography confirmed this finding and also found right
ventricular diastolic collapse.
A diagnosis of cardiac tamponade with probable cardiac injury was made; the patient
was taken to the operating room, where median sternotomy revealed a 1-cm laceration of
the right atrial appendage. This lesion was directly repaired with 4-0 polypropolene suture.
Her postoperative course was uneventful, and she continued to recover from injuries to
the musculoskeletal system.
This case highlights the need for a high degree of suspicion of cardiac injuries after
blunt chest trauma. An algorithm is proposed for rapid recognition, diagnosis, and treat-
ment of these lesions. (Tex Heart Inst J 2012;39(4):579-81)
Right atrial wall rupture after blunt chest trauma is a catastropic event associat-
ed with high mortality rates. Clinical series have indicated a rate of right atrial
rupture af ter blunt trauma that ranges from 8% to 65% in patients with blunt
cardiac injury.1 The first report of successful direct repair of right atrial rupture was
published in 1955,2 but to this day successful surgical repair and survival of these pa-
tients remains uncommon.3 We report the prompt diagnosis and treatment of a right
atrial wall rupture in a young woman after a motor vehicle accident.
Case Report
In February 2011, a previously healthy 24-year-old woman was transferred to our hos-
pital after being involved in a car accident in which she was ejected 40 feet from the
vehicle. Upon arrival, she was awake, alert, and oriented to person, place, and time.
On physical examination, she had a systolic blood pressure of 100 mmHg, ecchy-
mosis surrounding the left orbit and on the anterior chest wall, and deformity of her
left shoulder. Cardiovascular evaluation revealed only distant-sounding heart sounds,
without hypotension or distended jugular veins. Her abdomen was mildly distended
with no peritoneal signs.
Laboratory tests showed a hemoglobin level of 9.2 g/dL, white blood cell count of
25.2 109/L, arteria l blood gas pH of 7.2, PCO2 of 33 mmHg, PO2of 93 mmHg, bicar-
bonate of 12.2 mEq/L, base excess of –15 mEq/L, alanine aminotransferase of 304
U/L, aspartate aminotransferase of 604 U/L, creatine kinase of 1,108 U/L, creatine
kinase-MB fraction of 14.9 ng/mL, and cardiac troponin of 0.82 ng/mL. Swan-Ganz
catheter readings revealed central venous pressure (CVP) of 26 mmHg, pulmonary
artery diastolic pressure of 25 mmHg, and pulmonary capillary wedge pressure of 25
mmHg. Cardiac output was 1.8 L/min and the patient’s arterial blood gas showed a
pH of 7.2.
A chest radiograph showed fractures of the f irst 4 right ribs and the first and second
left ribs. The referring hospital’s computed tomographic scan of the chest disclosed
a large pericardial effusion and a slight pulmonary contusion (Fig. 1). Transthoracic
echocardiography conf irmed the pericardial effusion and found a CVP of 24 mmHg,
together with right ventricular diastolic collapse (Fig. 2). A diagnosis of cardiac tam-
ponade and probable cardiac injury was made, and the patient was taken to the oper-
ating room.
Case
Reports
Jose E. Telich-Tarriba, MD
Javier E. Anaya-Ayala, MD
Michael J. Reardon, M D
Key words: Accidents, traf-
fic; algorithms; biological
markers/blood; blunt chest
trauma; cardiac tamponade/
etiology; echocardiography,
transesophageal; echocar-
diog raphy, transthoraci c;
heart atria/injuries; heart
rupture/diagnosis; pericar-
diocentesis; troponin/blood;
wounds, nonpenetrating/
diagnosis/surgery
From: Department of Car-
diovascular Surgery (Drs.
Anaya-Ayala, Reardon, and
Tel ic h -Ta rr iba) , M ethod ist
DeBakey Heart & Vascular
Center, The Methodist
Hospital; and The Methodist
Hospital Research Institute
(Drs. Anaya- Ayala and Rear-
don); Houston, Texas 77030
Dr. Telich-Tarriba is now
at the School of Medicine,
Universidad Panamericana,
Mexico City, Mexico.
Address for reprints:
Michael J. Reardon, MD,
Department of Cardiovas-
cular Surgery, Methodist
DeBakey Heart & Vascular
Center, 6550 Fannin St.,
Suite 1401, Houston, TX
7703 0
E-mail:
MReardon@tmhs.org
Volume 39, Number 4, 2012580 Right Atrial Rupture after Blunt Chest Trauma
After median sternotomy, the pericardium was seen
to be distended with blood. Opening the pericardium
enabled the release of several hundred cubic centime-
ters of blood and clot and resulted in an immediate rise
in systolic blood pressure, to 160 mmHg. An actively
bleeding 1-cm laceration to the right atrial appendage
was directly repaired with a double row of 4-0 polypro-
pylene monofilament sutures (Fig. 3). No other cardiac
injuries or bleeding sites were found.
The patient’s postoperative course was uneventful.
When last seen, she continued to recover from injuries
to the musculoskeletal system.
Discussion
Cardiovascular injuries are second only to central ner-
vous system injuries as the most frequent cause of death
after blunt trauma. Motor vehicle accidents account
for over 70% of all cases of blunt cardiac injury.4 The
rest are attributable to falls, sports injuries, and even to
cardiopulmonary resuscitation.5 The spectrum of po-
tential injuries to the heart after blunt chest trauma is
wide, including myocardial contusion, free wall or sep-
tal rupture, valvular disruptions, and injury to the great
vessels. In addition, pericardial involvement and dys-
rhythmic complications can occur.6,7 Chamber rupture
carries a high mortality index, and most patients do
not reach the emergency room.8 The National Trau-
ma Data Bank reports that chamber rupture represents
0.041% of all trauma cases and has an overall mortali-
ty rate of 89.2% .4 The right atrial appendage is the most
common site of rupture, probably due to its thin wall.3
The mechanisms of injury include direct mechanical
compression by the sternum and indirect effects due to
transfer of hydraulic pressure from the abdomen or ex-
tremities when compressed.9 Clinical features can vary
widely due to concomitant injuries. Chest pain is the
most common symptom6; other physical f indings re-
sult from cardiac dysfunction and relate, therefore, to
the patient’s hemodynamic status (for example, systemic
hypotension and elevated CVP).10 Cardiac tamponade
from chamber rupture is relatively frequent and is sus-
pected when hypotension, jugular distention, and muf-
fled heart sounds (the Beck triad) are present. In an
acute setting, it is life-threatening, leading to a decline
in cardiac output secondary to the increased pericardial
pressure and ultimately resulting in cardiogenic shock.
Fig. 1 Computed tomography. A) Coronal and B) axial views
disclose pericardial effusion (arrow).
Fig. 2 A transthoracic echocardiogram (2-dimensional apical
view) confirms the presence of moderate pericar dial effusion,
with a central venous pressure of 24 mmHg and right ventricular
collapse.
A
B
Fig. 3 Intraoperative photograph. The lesion was directly
repaired with a double row of 4- 0 polypropylene monofilament
sutures. No other cardiac or great vessel injuries were found.
Texas Heart Institute Journal Right Atrial Rupture after Blunt Chest Trauma 581
In chest trauma patients who present with no evident
clinical signs, the diagnosis of blunt cardiac injury is
often difficult to make and requires the use of several
diagnostic tests.10 Up to 80 % of patients wi th blunt car-
diac injury develop nonspecific changes on electrocar-
diography,1 but normal electrocardiograms have a high
negative predictive value for cardiac complications.11
Cardiac enzyme values are commonly measured dur-
ing diagnostic evaluation. Creatinine kinase and its
myocardial-band fraction are often elevated in trauma
patients and are neither sensitive nor specific for blunt
cardiac injury. Cardiac troponins I and T are highly
specific to myocardial injury and can be helpful in the
screening of blunt cardiac injury; moreover, a normal
concentration of troponins is reported to be an indica-
tor of the absence of blunt cardiac injury.1,10,12 Certain-
ly echocardiography provides direct visualization of the
cardiac anatomy and has been shown to be one of the
most useful tools for the detection of blunt cardiac inju-
ry, cardiac tamponade, and noncardiac injuries as well.
Transthoracic echocardiography should be performed
promptly in patients who exhibit unexplained hypoten-
sion or evidence of cardiac failure.9
No diagnostic test is accurate enough, by itself, to
confirm or rule out blunt cardiac injury; therefore, we
are proposing the use of a diagnostic algorithm that is
based on the patient’s hemodynamic status (Fig. 4). Pa-
tients with chamber rupture and tamponade require
emergency cardiac surgical consultation. Pericardiocen-
tesis via the subxiphoid approach under ultrasonic guid-
ance can be useful in the acute setting, because removal
of the pericardial fluid produces a dramatic improve-
ment in overall hemodynamics.3 Surgical repair of the
defect is the def initive treatment: the standard approach
uses a median sternotomy to expose the heart and great
vessels, and the rupture usually can be repaired by sim-
ple suture under direct compression or after application
of a vascular clamp without cardiopulmonary bypass.3
In conclusion, our case highlights the need for a high
degree of suspicion of cardiac injuries after blunt chest
trauma and the importance of prompt diagnosis and
treatment of these lesions.
References
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3. Hirai S, Hamanaka Y, Mitsui N, Isaka M, Kobayashi T. Suc-
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5. Reardon MJ, Gross DM, Vallone AM, Weiland AP, Walker
WE. Atrial rupture in a child from cardiac massage by his par-
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ma. J Emerg Med 2008;35(2):127-33.
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septal rupture, flail tricuspid valve, and complete heart block
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Hiebert CA. Survival following nonpenetrating traumatic
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532-5.
9. Karalis DG, Victor MF, Davis GA, McAllister MP, Cova-
lesky VA, Ross JJ Jr, et al. The role of echocardiography in
blunt chest trauma: a transthoracic and transesophageal echo-
cardiographic study. J Trauma 1994;36(1):53-8.
10. Sybrandy KC, Cramer MJ, Burgersdijk C. Diagnosing cardiac
contusion: old wisdom and new insights. Heart 2003;89(5):
485-9.
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No further
evaluation f or BCI
Consider
other causes
Cardiac
monitoring and
treatment of
underlying cause
Cardiac
monitoring for
24–48 hours
Obtain 12-lead
ECG
Hemodynamically
stable patient
Normal echo Abnormal echoNormal ECG Abnormal ECG
Hemodynamically
unstable patient
Obtain
transthoracic or
transesophageal
echocardiogram
Blunt chest
trauma
Suspicion of BCI
Fig. 4 Proposed algorithm for the evaluation of patients under
clinical suspicion of blunt car diac injur y.
BCI = blunt cardiac injury; ECG = electrocardiogram;
echo = echocardiogram
... Blunt cardiac injury (BCI) is a rare clinical entity with an incidence ranging from 0.16% to 2%, primarily due to the high mortality rate associated with the condition before patients can reach the emergency department (ED) [1]. The incidence of cardiac trauma reported varies significantly, from 8% in autopsy studies to 76% in clinical series [2,3]. ...
... For patients presenting with signs of instability, adherence to Advanced Trauma Life Support (ATLS) protocols, clinical suspicion, echocardiography, and surgical exploration under general anesthesia via sternotomy or thoracotomy is crucial [2]. The pathophysiological mechanisms leading to blunt cardiac rupture remain poorly understood [1]. It is hypothesized that the injury results from a rapid increase in intracardiac pressure due to direct trauma increased venous pressure from abdominal and lower extremity compression, or the heart being compressed between the sternum and spine during deceleration, most commonly in motor vehicle collisions (MVC) [1,3,5]. ...
... The pathophysiological mechanisms leading to blunt cardiac rupture remain poorly understood [1]. It is hypothesized that the injury results from a rapid increase in intracardiac pressure due to direct trauma increased venous pressure from abdominal and lower extremity compression, or the heart being compressed between the sternum and spine during deceleration, most commonly in motor vehicle collisions (MVC) [1,3,5]. In light of these challenges, we report a case of an 18-year-old male who sustained blunt cardiac trauma resulting in right atrial cardiac rupture. ...
An Emergency Adaptation of Anterolateral and Clamshell Thoracotomy for Blunt Traumatic Right Atrial Rupture: A Case Report
Article
Full-text available
  • Nov 2023
The high mortality rate of blunt cardiac injuries is primarily due to the condition's severity and the challenges associated with pre-hospital survival. The absence of definitive diagnostic modalities necessitates prompt and adaptable surgical intervention. We present an 18-year-old male who sustained a right atrial blunt traumatic cardiac rupture following a motor vehicle collision. Despite initial stabilization with blood products and vasopressors and the necessitated emergent surgical exploration, the case required various surgical techniques, including anterolateral followed by an extension to a clamshell thoracotomy and laparotomy to manage the complex cardiac rupture and associated injuries. Furthermore, it underscores the critical nature of surgical incision in such patients and its impact on the overall prognosis. The successful outcome, highlighted by intraoperative decision-making and proper postoperative care, demonstrates that with timely and adaptable surgical approaches, even the most severe cases of traumatic blunt cardiac ruptures can be managed effectively.
View
... Prior to 1882 when the first ever successful myocardial suturing was done, traumatic cardiac injuries were seen as death sentences [1] with injuries ranging from contusions to chamber wall ruptures as well as great vessel and valvular injuries [2]. These cardiac injuries may lead to death via exsanguination or development of cardiac tamponade [1]. ...
... According to Araujo et al. in 2016 in Manaus, 86.2% out of 138 cases reported with cardiac trauma died at the scene. It is mainly as a result of cardiac chamber rupture following traumatic cardiac injury with the right-sided chambers been the most commonly implicated in literature [2] [5] as found in this case where there was a pinhole laceration of the right ventricle .This was in contrast to the observation by Araujo et al., who reported that the left ventricle was the most commonly affected side of cardiac trauma while considering single lesions. Ac-cording to the National Trauma Data Bank of the United States of America, cardiac chamber ruptures in traumatic cardiac injuries was associated with a high mortality rate of almost 90% [2]. ...
... It is mainly as a result of cardiac chamber rupture following traumatic cardiac injury with the right-sided chambers been the most commonly implicated in literature [2] [5] as found in this case where there was a pinhole laceration of the right ventricle .This was in contrast to the observation by Araujo et al., who reported that the left ventricle was the most commonly affected side of cardiac trauma while considering single lesions. Ac-cording to the National Trauma Data Bank of the United States of America, cardiac chamber ruptures in traumatic cardiac injuries was associated with a high mortality rate of almost 90% [2]. A rare case of cardiac tamponade was reported by Ryu and Lee resulting from an aortic injury [5]. ...
View
... Other etiologies include, but are not limited to, falls, sports, weight lifting, combat, domestic violence, and more [10]. Of interest, Lu et al. reported a case of a new-born baby that suffered from IRAR due to the high-pressured descent through the vaginal wall during labour, demonstrating the variety of IRAR etiologies [15]. ...
... The RA has unique electrophysiological components and more than 80% of blunt cardiac injuries (BCIs) result in dysrhythmias [15]. It is unclear how BCIs causes dysrhythmias, but dysfunction of the vagal sympathetic innervating RA myocytes has been theorized, as well as disruption of the neuromuscular junctions between myocytes [56][57][58]. ...
... This is because injury to the ventricles is more likely to produce a ventricular tachyarrhythmia or fibrillation. Conversely, RA injury is more likely to develop a bradyarrhythmia due to SA node dysfunction, similar to our patient that presented with profound bradycardia [15,55]. ...
Isolated right atrial rupture from blunt trauma: A case report with systematic review of a lethal injury
Article
Full-text available
  • Feb 2019
  • J CARDIOTHORAC SURG
Background Isolated right atrial rupture (IRAR) from blunt chest trauma is rare. There are no physical exam findings and non-invasive testing specific to the condition, which result in diagnostic delays and poor outcomes. We present a case of IRAR along with a systematic review of similar cases in the literature. Case report A 23-year-old male presented following a motor vehicle accident (MVA). He was bradycardic and hypotensive during transportation; and required intubation. There were contusions along the right chest wall with clear breath sounds, and no jugular venous distension, muffled heart sounds. Hemodynamic status progressively worsened, ultimately leading to his death. However, no external sources of bleeding or evidence of cardiac tamponade was found. Methods A search of PubMed, Ovid, and the Cochrane Library using: (Blunt OR Blunt trauma) AND (Laceration OR Rupture OR Tear) AND (Right Atrium OR Right Atrial). Articles were included if they were original articles describing cases of IRAR. Results Forty-five reports comprising seventy-five (n = 75) cases of IRAR. Conclusion IRAR most commonly occurs following MVAs as the result of blunt chest trauma. Rupture occurs at four distinct sites and is most commonly at the right atrial appendage. IRAR is a diagnostic challenge and requires a high index of suspicion, as patients’ hemodynamics can rapidly deteriorate. The presentations vary depending on multiple factors including rupture size, pericardial integrity, and concomitant injuries. Cardiac tamponade may have a protective effect by prompting the search for a bleeding source. A pericardial window can be diagnostic and therapeutic in IRAR. Outcomes are favourable with timely recognition and prompt surgical intervention.
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... The impact or compression can cause contusion or injury to the heart muscle, leading to rupture and subsequent cardiac tamponade [7,10]. The location of the rupture is determined by the phase of the cardiac cycle in which the injury took place: ventricular rupture is more likely to occur during the end-diastolic phase when the ventricle is at its most extended and the compression forces of the ventricle are greatest [11,12]. ...
View
... 4 Pledged or nonpledged polypropylene suture repair had been used in several reports. 6,7 Because of the extent of the large laceration and contusion into the atrioventricular groove with the right coronary artery in the present case, resection of this damaged region was not possible. We decided to reserve and reinforce it with a double Dacron patch. ...
Coronary Sinus Rupture Due to Blunt Cardiac Trauma
Article
Full-text available
  • Jan 2022
We present a very rare case of devastating blunt cardiac trauma with large right atrial rupture, contusion of the right atrioventricular groove, and coronary sinus tear. Surgical repair was successfully performed by urgently establishing cardiopulmonary bypass via the femoral vein and artery simultaneously with a median sternotomy. (Level of Difficulty: Intermediate.)
View
... As the cardiac tamponade diagnosed, sternotomy immediately performed with no temporary decompression, namely pericardiocentesis or subxiphoid pericardial window. 16 In our report, the pericardiocentesis carried out, followed by sternotomy as the hemodynamic stable. In both reports, the operation employed was sternotomy, proceeded in the operating theatre the same as the case discussed in this study. ...
View
... Methods to temporize bleeding to allow time for definitive repair include the use of a foley balloon through the defect to occlude the opening or temporary closure with direct pressure, staplers or vascular clamps [1]. Definitive repair with double armed monofilament pledgeted suture repair either an interrupted or running technique has been described [9,14]. If large septal defects, uncontrollable bleeding or coronary artery injury is identified intraoperatively, consultation with a cardiothoracic surgeon is recommended. ...
Case reports of atrial and pericardial rupture from blunt cardiac trauma
Article
Full-text available
  • Jun 2018
  • J CARDIOTHORAC SURG
Background: Blunt cardiac trauma is diagnosed in less than 10% of trauma patients and covers the range of severity from clinically insignificant myocardial contusions to lethal multi-chamber cardiac rupture. The most common mechanisms of injury include: motor vehicle collisions (MVC), pedestrians struck by motor vehicles and falls from significant heights. A severe complication from blunt cardiac trauma is cardiac chamber rupture with pericardial tear. It is an exceedingly rare diagnosis. A retrospective review identified only 0.002% of all trauma patients presented with this condition. Most patients with atrial rupture do not survive transport to the hospital and upon arrival diagnosis remains difficult. Case presentation: We present two cases of atrial and pericardial rupture. The first case is a 33-year-old female involved in a MVC, who presented unresponsive, hypotensive and tachycardic. A left sided hemothorax was diagnosed and a chest tube placed with 1200 mL of bloody output. The patient was taken to the OR emergently. Intraoperatively, a laceration in the right pericardium and a 3 cm defect in the anterior, right atrium were identified. Despite measures to control hemorrhage and resuscitate the patient, the patient did not survive. The second case is a 58-year-old male involved in a high-speed MVC. Similar to the first case, the patient presented unresponsive, hypotensive and tachycardic with a left sided hemothorax. A chest tube was placed with 900 mL of bloody output. Based on the output and ongoing resuscitation requirements, the patient was taken to the OR. Intraoperatively, a 15 cm anterior pericardial laceration was identified. Through the defect, there was brisk bleeding from a 1 cm laceration on the left atrial appendage. The injury was debrided and repaired using a running 3-0 polypropylene suture over a Satinsky clamp. The patient eventually recovered and was discharged home. Conclusions: We present two cases of uncontained atrial and pericardial rupture from blunt cardiac trauma. Contained ruptures with an intact pericardium present as a cardiac tamponade while uncontained ruptures present with hemomediastinum or hemothorax. A high degree of suspicion is required to rapidly diagnose and perform the cardiorrhaphy to offer the best chance at survival.
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Left Atrial Appendage Rupture due to Blunt Chest Trauma during a Motor Vehicle Accident交通外傷による鈍的心損傷: —a Rare Case Report——左心耳破裂の1例—
Article
  • May 2021
Blunt traumatic rupture of the heart carries a high mortality rate. Anatomical injuries have included the atrium, appendage and ventricle but injury to the left appendage has been reported very rarely. We present the case of a 71-year-old female who was a driver in a motor collision with major front-end damage where air bags were deployed. After being intubated and receiving pericardiocentesis for cardiac tamponade at an advanced critical care and emergency medical center, the patient was taken to our hospital and emergently to the operating room for exploration. There was brisk bleeding coming from a 2 cm laceration on the left atrial appendage. The injury was repaired using 4-0 polypropylene felt pledget-supported horizontal mattress sutures on the beating heart with the assistance of cardiopulmonary bypass. The present report describes this patient and our findings from a literature review.
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Blunt cardiac rupture: A 5-year NTDB analysis
Article
  • Sep 2009
Because of its rarity and high rate of mortality, traumatic blunt cardiac rupture (BCR) has been poorly studied. The objective of this study was to use the National Trauma Data Bank to review the epidemiology and outcomes associated with traumatic BCR. After approved by the institutional review board, the National Trauma Data Bank (version 5.0) was queried for all BCR occurring between 2000 and 2005. Demographics, clinical injury data, interventions, and outcomes were abstracted for each patient. Statistical analysis was performed using an unpaired Student's t test or Mann-Whitney U test to compare means and chi analysis to compare proportions. Stepwise logistic regression analysis was performed to identify independent predictors of inhospital mortality. Of 811,531 blunt trauma patients, 366 (0.045%) had a BCR of which 334 were available for analysis, with the mean age of 45 years, 65% were men, and their mean Injury Severity Score was 58 +/- 19. The most common mechanism of injury was motor vehicle collision (73%), followed by pedestrian struck by auto (16%), and falls from height (8%). Twenty-one patients (6%) died on arrival and 140 (42%) died in the emergency room. The overall mortality for patients arriving alive to hospital was 89%. Of the patients surviving to operation, 42% survived >24 hours of which 87% were discharged. Survivors were significantly younger (39 vs. 46 years, p = 0.04), had a lower Injury Severity Score (47 vs. 56, p = 0.02), higher Glasgow Coma Scale (10 vs. 6, p < 0.001), and were more likely to present with an systolic blood pressure >or=90 mm Hg (p = 0.01). Nevertheless, none of these factors was found to be an independent risk factor for mortality. BCR is an exceedingly rare injury, occurring in 1 of 2400 blunt trauma patients. In patients arriving alive to hospital, traumatic BCR is associated with a high mortality rate, however, is not uniformly fatal.
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Survival Following Nonpenetrating Traumatic Rupture of Cardiac Chambers
Article
  • Dec 1987
  • ANN THORAC SURG
We report the cases of 3 patients who survived cardiac chamber rupture resulting from blunt external trauma. All were drivers in motor vehicle collisions. All were seen with signs of pericardial tamponade and were treated by pericardiocentesis followed by emergency thoracotomy performed in the operating room. Ruptures of the right atrium and right and left ventricles were repaired by manual suture techniques without cardiopulmonary bypass. The cases of 37 previously reported patients who survived this injury are reviewed. We believe that patients with cardiac rupture who reach the hospital alive can often be saved by prompt diagnosis and immediate surgical treatment.
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Atrial Rupture in a Child from Cardiac Massage by His Parent
Article
  • Jun 1987
  • ANN THORAC SURG
A 4-year-old boy presented with a single seizure following a viral syndrome. He had a pericardial effusion on admission, and this increased suddenly on the third day of hospitalization, producing cardiac tamponade. After blood was aspirated from the child's pericardial cavity, the father revealed that he performed cardiac massage on his son following the seizure. A laceration of the right atrium was repaired at operation, and the boy made a good recovery. Cardiopulmonary resuscitation by lay persons is not without hazard, and patients with such a history should be watched carefully for the possibility of damage to intrathoracic structures.
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The role of echocardiography in blunt chest trauma: A transthoracic and transesophageal echocardiographic study
Article
  • Feb 1994
  • J TRAUMA
Previous studies assessing the value of transthoracic echocardiography (TTE) in blunt chest trauma are limited because patients with severe chest wall injury often have suboptimal echocardiographic findings. Transesophageal echocardiography (TEE) can provide high quality images when the transthoracic image quality is poor. To provide complete echocardiographic assessment of cardiac structure and function we prospectively performed TTE in 105 patients with severe blunt chest trauma and TEE in 20 of the 105 patients (19%) whose TTE examination results were suboptimal. Myocardial contusion was diagnosed in 31 patients (30%), 22 by TTE and nine by TEE. Cardiac complications developed in 8 of 31 patients (26%) with myocardial contusion compared with 2 of 74 patients (3%) with normal echocardiographic findings (p = 0.001). Cardiac complications required treatment in only four patients. Echocardiography was of value in detecting severe right ventricular dysfunction as the cause of hypotension in two patients with suspected cardiac tamponade. Four patients with myocardial contusion died compared with two patients with normal echocardiographic findings (p = NS). No death was related to the cardiac status. In addition, TEE detected aortic injury in five patients, four with focal intimal tears and one with an aortic transection. We conclude that myocardial contusion is common following blunt chest trauma, rarely requires treatment, and is associated with a favorable prognosis. Only patients who develop cardiac complications benefit from echocardiography. Transesophageal echocardiography is of value when the TTE examination results are suboptimal and when aortic injury is suspected.
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Successful emergency repair of blunt right atrial rupture after a traffic accident.
Article
  • Sep 2002
A 53-year-old man crashed his motorcycle into a vehicle and was transported to our hospital by ambulance after about 30 min. Echocardiography revealed cardiac tamponade. Pericardiocentesis was immediately performed using a 5 Fr catheter via the subxiphoid approach and the results suggested cardiac injury. Surgery was commenced via median sternotomy about 2.5 hours after the accident. Patients with cardiac rupture who reach hospital alive can be saved by rapid transport, early detection, and early surgery. In particular, rapid echocardiography and pericardiocentesis via the subxiphoid approach under ultrasonic guidance are easy and helpful methods of making a diagnosis and achieving hemodynamic improvement prior to surgical intervention.
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Diagnosing cardiac contusion: Old wisdom and new insights
Article
  • Jun 2003
  • HEART
Cardiac contusion is usually caused by blunt chest trauma and therefore is frequently suspected in patients involved in car or motorcycle accidents. The diagnosis of a myocardial contusion is difficult because of non-specific symptoms and the lack of an ideal test to detect myocardial damage. Cardiac contusion can cause life threatening arrhythmias and cardiac failure. Many diagnostic methods, such as ECG, biochemical cardiac markers, transthoracic and transoesophageal echocardiography, and radionuclide imaging studies, have been investigated to determine their use in predicting such complications. Recently, cardiac troponin I and T were found to be highly sensitive for myocardial injury. Troponin I and T have also proved to be useful in the stratification of patients at risk for complications. Nevertheless, diagnosis of a cardiac contusion and identification of patients at risk remain a challenge. In this review the current diagnostic tests will be discussed. Also, based on these diagnostic tests, a screening strategy containing data from the latest studies is presented, with the intention of detecting patients at risk.
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Blunt cardiac injury
Article
  • Feb 2004
  • CRIT CARE CLIN
Blunt cardiac injury (BCI) encompasses a wide spectrum of clinical manifestations, ranging from an asymptomatic myocardial bruise to cardiac rupture and death [1]. Blunt injury to the heart is involved in up to 20% of all motor vehicle collision deaths [2]. The incidence of BCI in all blunt thoracic trauma patients is approximately 20%; however, in patients with severe thoracic injury or multiple injuries, the incidence of BCI may be as high as 76% [3-7]. No gold standard exists for the diagnosis of BCI. A mechanism of injury consistent with BCI, combined with altered cardiac function, provides a practical means of diagnosing BCI. Attention has focused on identifying those patients who will develop complications as a result of BCI. The difficulty in defining this phenomenon has led to a classification that defines BCI according to the sequela of the injury: (1) BCI with cardiac free wall rupture, (2) BCI with septal rupture, (3) BCI with coronary artery injury, (4) BCI with cardiac failure, (5) BCI with complex arrhythmias, and (6) BCI with minor ECG or cardiac enzyme abnormalities [1].
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Blunt cardiac injury
Article
  • May 2004
Blunt cardiac injury (BCI) is a common complication of chest trauma. With improvements in pre-hospital care and rapid regional transport, more patients with severe BCI may arrive at the hospital with signs of life. Prompt recognition and expeditious surgical and critical care treatment may increase the number of survivors. This paper reviews current clinical considerations in dealing with patients suffering BCI.
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Best evidence topic report. Use of troponin for the diagnosis of myocardial contusion after blunt chest trauma
Article
  • Apr 2005
  • EMERG MED J
A short cut review was carried out to establish the utility of troponin levels in diagnosing myocardial contusion following blunt chest trauma. Using the reported search, 75 papers were found, of which six presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.
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