Right atrial rupture due to blunt trauma: CT evaluation

Isolated right atrial rupture from blunt trauma: a case report with systematic review of a lethal injury

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.

Nonaortic mediastinal injuries from blunt chest trauma

In addition to traumatic aortic injuries (TAI), blunt chest trauma may damage other structures in the mediastinum, including the tracheobronchial tree, the heart and pericardium, and rarely the esophagus. Tracheobronchial injuries may be difficult to separate radiographically from accompanying parenchymal lung injuries. Experience with diagnosis by computed tomography (CT) is still limited. Cardiac injuries often require emergent surgery before extensive imaging can be done. Some patients, usually those with chamber ruptures of the right heart, survive long enough to receive a chest CT, at which time hemopericardium can be detected. Upper esophageal injuries may occur in conjunction with lower cervical or upper thoracic spine injures. Distal esophageal injuries are rarely caused by blunt trauma.