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Quintana EN, DeBose-Scarlett A, McLaren TA, Gondek SP, Smith MC, Alder MR, Baker MT, Shah AS, Absi TS. Acute cardiogenic shock secondary to blunt traumatic aortic valve injury. Trauma Case Rep 2024; 51:100995. [PMID: 38572422 PMCID: PMC10987328 DOI: 10.1016/j.tcr.2024.100995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 04/05/2024] Open
Abstract
Background Blunt cardiac injuries rarely result in aortic valve cusp rupture, leading to acute aortic insufficiency and cardiogenic shock. This rare clinical entity carries a high mortality rate if left undiagnosed and not managed surgically, with few patients surviving beyond 24 h. It presents a diagnostic challenge in the polytrauma patient in shock, with multiple possible and complementary etiologies. Case presentation We present a 56-year-old male with persistent hypotension, a wide pulse pressure, and elevated serum troponin levels suggesting blunt cardiac injury after a motor vehicle accident. Transthoracic and transesophageal echocardiography revealed normal biventricular function but severe aortic insufficiency due to prolapse of the left coronary cusp.He was taken emergently to surgery, where aortic valve exploration revealed complete left coronary cusp avulsion from the aortic annulus with a mid-cusp tear, requiring aortic valve replacement with a bioprosthetic valve. Postoperative echocardiography showed normal biventricular function with a well-seated bioprosthetic aortic valve with no insufficiency. Conclusions Traumatic aortic valve injury can lead to torn or prolapsed cusps causing acute aortic insufficiency leading to cardiogenic shock, but early recognition with appropriate and targeted diagnostic imaging is vital to prevent rapid patient deterioration and demise.
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Affiliation(s)
- Eric N. Quintana
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Alexandra DeBose-Scarlett
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Thomas A. McLaren
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Stephen P. Gondek
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Michael C. Smith
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Madeleine R. Alder
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Michael T. Baker
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Ashish S. Shah
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Tarek S. Absi
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
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Cimaroli S, Maniar Y, Ciancarelli J, Stright A, Joseph D. Takotsubo cardiomyopathy following blunt trauma: Early recognition and diagnosis. Trauma Case Rep 2023; 46:100855. [PMID: 37292438 PMCID: PMC10245330 DOI: 10.1016/j.tcr.2023.100855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2023] [Indexed: 06/10/2023] Open
Abstract
Background Takotsubo Cardiomyopathy (TTC) is characterized by reversible left ventricular apical ballooning in the absence of angiographically significant coronary artery disease. While TTC is usually preceded by an emotionally stressful event, physical trauma has been documented as a precipitating incident as well. Case summary An 82-year-old female with no past medical history, presented to the emergency department following a motor vehicle collision. Trauma workup was significant for an ulnar fracture, elevated cardiac enzymes, and ST-segment changes. Bedside echocardiogram revealed apical ballooning. She underwent cardiac catheterization, which failed to demonstrate significant coronary artery disease. The patient developed cardiogenic shock and required temporary vasopressor support after failing a trial of intra-aortic balloon pump. Conclusion Takotsubo Cardiomyopathy is a rare complication of trauma, which presents with signs and symptoms similar to acute coronary syndrome (ACS) but without evidence of obstructive coronary artery disease. Following trauma, signs of ACS in elderly women should raise provider's suspicion for TTC and prompting bedside echocardiography, which can assist with early diagnosis.
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Tomesch AJ, Negaard M, Keller-Baruch O. Chest and Thorax Injuries in Athletes. Clin Sports Med 2023; 42:385-400. [PMID: 37208054 DOI: 10.1016/j.csm.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Injuries to the chest and thorax are rare, but when they occur, they can be life-threatening. It is important to have a high index of suspicion to be able to make these diagnoses when evaluating a patient with a chest injury. Often, sideline management is limited and immediate transport to a hospital is indicated.
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Affiliation(s)
- Alexander J Tomesch
- Department of Emergency Medicine, University of Missouri, Columbia, MO, USA.
| | - Matthew Negaard
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA; Forte Sports Medicine and Orthopedics, Indianapolis, IN, USA. https://twitter.com/MattNegaard
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Nair L, Winkle B, Senanayake E. Managing blunt cardiac injury. J Cardiothorac Surg 2023; 18:71. [PMID: 36765392 PMCID: PMC9912488 DOI: 10.1186/s13019-023-02146-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 01/09/2023] [Indexed: 02/12/2023] Open
Abstract
Blunt cardiac injury (BCI) encompasses a spectrum of pathologies ranging from clinically silent, transient arrhythmias to deadly cardiac wall rupture. Of diagnosed BCIs, cardiac contusion is most common. Suggestive symptoms may be unrelated to BCI, while some injuries may be clinically asymptomatic. Cardiac rupture is the most devastating complication of BCI. Most patients who sustain rupture of a heart chamber do not reach the emergency department alive. The incidence of BCI following blunt thoracic trauma remains variable and no gold standard exists to either diagnose cardiac injury or provide management. Diagnostic tests should be limited to identifying those patients who are at risk of developing cardiac complications as a result of cardiac in jury. Therapeutic interventions should be directed to treat the complications of cardiac injury. Prompt, appropriate and well-orchestrated surgical treatment is invaluable in the management of the unstable patients.
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Affiliation(s)
- Lawrence Nair
- Department of Cardiothoracic Surgery, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia.
| | - Brendan Winkle
- Department of Surgery, Royal Darwin Hospital, Darwin, NT, Australia
| | - Eshan Senanayake
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
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El-Qawaqzeh K, Anand T, Richards J, Hosseinpour H, Nelson A, Akl MN, Obaid O, Ditillo M, Friese R, Joseph B. Predictors of Mortality in Blunt Cardiac Injury: A Nationwide Analysis. J Surg Res 2023; 281:22-32. [PMID: 36108535 DOI: 10.1016/j.jss.2022.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/28/2022] [Accepted: 07/29/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Blunt thoracic injury (BTI) is one of the most common causes of trauma admission in the United States and is uncommonly associated with cardiac injuries. Blunt cardiac injury (BCI) after blunt thoracic trauma is infrequent but carries a substantial risk of morbidity and sudden mortality. Our study aims to identify predictors of concomitant cardiac contusion among BTI patients and the predictors of mortality among patients presenting with BCI on a national level. MATERIALS AND METHODS We performed a 1-y (2017) analysis of the American College of Surgeons Trauma Quality Improvement Program. We included all adults (aged ≥ 18 y) with the diagnosis of BTI. We excluded patients who were transferred, had a penetrating mechanism of injury, and who were dead on arrival. Our primary outcomes were the independent predictors of concomitant cardiac contusions among BTI patients and the predictors of mortality among BCI patients. Our secondary outcome measures were in-hospital complications, differences in injury patterns, and injury severity between the survivors and nonsurvivors of BCI. RESULTS A total of 125,696 patients with BTI were identified, of which 2368 patients had BCI. Mean age was 52 ± 20 y, 67% were male, and median injury severity score was 14 [9-21]. The most common type of cardiac injury was cardiac contusion (43%). Age ≥ 65 y, higher 4-h packed red blood cell requirements, motor vehicle collision mechanism of injury, and concomitant thoracic injuries (hemothorax, flail chest, lung contusion, sternal fracture, diaphragmatic injury, and thoracic aortic injuries) were independently associated with concomitant cardiac contusion among BTI patients (P value < 0.05). Age ≥ 65 y, thoracic aortic injury, diaphragmatic injury, hemothorax, and a history of congestive heart failure were independently associated with mortality in BCI patients (P value < 0.05). CONCLUSIONS Predictors of concomitant cardiac contusion among BTI patients and mortality among BCI patients were identified. Guidelines on the management of BCI should incorporate these predictors for timely identification of high-risk patients.
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Nathwani JN, Baucom MR, Salvator A, Makley AT, Tsuei BJ, Droege CA, Goodman MD, Nomellini V. Evaluating the Utility of High Sensitivity Troponin in Blunt Cardiac Injury. J Surg Res 2023; 281:104-111. [PMID: 36152398 DOI: 10.1016/j.jss.2022.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 07/28/2022] [Accepted: 08/19/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Screening for blunt cardiac injury (BCI) includes obtaining a serum troponin level and an electrocardiogram for patients diagnosed with a sternal fracture. Our institution has transitioned to the use of a high sensitivity troponin I (hsTnI). The aim of this study was to determine whether hsTnI is comparable to troponin I (TnI) in identifying clinically significant BCI. MATERIALS AND METHODS Trauma patients presenting to a level I trauma center over a 24-mo period with the diagnosis of sternal fracture were screened for BCI. Any initial TnI more than 0.04 ng/mL or hsTnI more than 18 ng/L was considered positive for potential BCI. Clinically significant BCI was defined as a new-bundle branch block, ST wave change, echocardiogram change, or need for cardiac catheterization. RESULTS Two hundred sixty five patients with a sternal fracture were identified, 161 underwent screening with TnI and 104 with hsTnI. For TnI, the sensitivity and specificity for detection of clinically significant BCI was 0.80 and 0.79, respectively. For hsTnI, the sensitivity and specificity for detection of clinically significant BCI was 0.71 and 0.69, respectively. A multivariate analysis demonstrated the odds ratio for significant BCI with a positive TnI was 14.4 (95% confidence interval, 3.9-55.8, P < 0.0001) versus an odds ratio of 5.48 (95% confidence interval 1.9-15.7, P = 0.002) in the hsTnI group. CONCLUSIONS The sensitivity of hsTnI is comparable to TnI for detection of significant BCI. Additional investigation is needed to determine the necessity and interval for repeat testing and the need for additional diagnostic testing.
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Affiliation(s)
- Jay N Nathwani
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
| | - Matthew R Baucom
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Ann Salvator
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amy T Makley
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Betty J Tsuei
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Tang CC, Huang JF, Kuo LW, Cheng CT, Liao CH, Hsieh CH, Fu CY. The highest troponin I level during admission is associated with mortality in blunt cardiac injury patients. Injury 2022; 53:2960-2966. [PMID: 35750532 DOI: 10.1016/j.injury.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/28/2022] [Accepted: 06/08/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cardiac troponin I (cTnI) levels are usually measured in primary evaluations of blunt cardiac injury (BCI) patients. We evaluated the associations of cTnI levels with the outcomes of BCI patients at different times. METHODS From 2015 to 2019, blunt chest trauma patients with elevated cTnI levels were compared with patients without elevated cTnI levels using propensity score matching (PSM) to minimize selection bias. The cTnI levels at different times in the survivors and nonsurvivors were compared. RESULTS A total of 2,287 blunt chest trauma patients were included, and 57 (2.5%) of the patients had BCIs. PSM showed that patients with and without elevated cTnI levels had similar mortality rates (13.0% vs. 11.1%, p-value = 0.317], hospital lengths of stay (LOSs) [17.3 (14.4) vs. 15.5 (22.2) days, p-value = 0.699] and intensive care unit (ICU) LOSs [7.7 (12.1) vs. 6.4 (15.4) days, p-value = 0.072]. Among the BCI patients, nonsurvivors had a significantly higher highest cTnI level during the observation period than survivors. Additionally, patients who needed surgical intervention had significantly higher highest cTnI levels than patients who did not. CONCLUSIONS An elevated cTnI level is insufficient for the evaluation of BCI and the determination of the need for further treatment. The highest cTnI level during the observation period may be related to mortality and the need for surgery in BCI patients.
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Affiliation(s)
- Chia-Chun Tang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Jen-Fu Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Ling-Wei Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan.
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Al-Khouja F, Paladugu A, Ruiz A, Prentice K, Kirby K, Santos J, Rockne W, Nahmias J. Evaluating the Need for Prolonged Telemetry Monitoring in Patients With Isolated Sternal Fractures. J Surg Res 2022; 280:320-325. [PMID: 36030608 DOI: 10.1016/j.jss.2022.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/31/2022] [Accepted: 07/04/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Isolated sternal fractures (ISFs) often result from deceleration or chest wall trauma. Current guidelines recommend screening ISF patients for blunt cardiac injury (BCI) with electrocardiogram (ECG) and troponin. If either is abnormal, 24-h telemetry monitoring is recommended. This study sought to determine if ISF patients with abnormal ECG will manifest any cardiac-related complications within 6 h of hospital arrival. METHODS A retrospective study was performed at a single level I trauma center. Patients with diagnosed sternal fracture and an Abbreviated Injury Scale <2 for head/neck, face, abdomen, and extremities were included. Patients with multiple rib fractures or hemopneumothorax were excluded. Demographic data, ECG, troponin, and echocardiogram results were collected. The primary outcome was cardiac-related complications or procedures. Complications included hypotension, arrhythmia, and hemodynamic instability. Procedures included sternal stabilization, cardiac catheterization, or sternotomy/thoracotomy. Descriptive statistics were performed. RESULTS One hundred twenty-nine ISF patients were evaluated, 68 (52.7%) had an ECG abnormality. Eight patients had elevated troponin (6.2%). One patient (0.78%) suffered a cardiac-related complication (arrhythmia); however, this was 82 h into hospitalization. Two patients suffered noncardiac complications (urinary tract infection and acute kidney injury) (1.55%). Three patients had echocardiogram abnormality (2.33%), but no patients sustained a BCI or underwent a BCI-related procedure. CONCLUSIONS After ISF, <1% of patients suffered a cardiac-related complication and none had BCI. These findings suggest 24-h monitoring for patients with ISF and abnormal ECG may be unnecessarily long. A prospective multicenter study to evaluate the validity of these results is needed prior to change of practice.
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Affiliation(s)
- Fares Al-Khouja
- University of California, Irvine (UCI), Department of Surgery, Orange, California
| | - Anushka Paladugu
- University of California, Irvine (UCI), Department of Surgery, Orange, California
| | - Andres Ruiz
- University of California, Irvine (UCI), Department of Surgery, Orange, California
| | - Kylie Prentice
- University of California, Irvine (UCI), Department of Surgery, Orange, California
| | - Kate Kirby
- University of California, Irvine (UCI), Department of Surgery, Orange, California
| | - Jeffrey Santos
- University of California, Irvine (UCI), Department of Surgery, Orange, California
| | - Wendy Rockne
- University of California, Irvine (UCI), Department of Surgery, Orange, California
| | - Jeffry Nahmias
- University of California, Irvine (UCI), Department of Surgery, Orange, California.
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9
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Dou LW, Du Z, Zhu JH, Wang TB. Changes and significance of serum troponin in trauma patients: A retrospective study in a level I trauma center. World J Emerg Med 2022; 13:27-31. [PMID: 35003412 PMCID: PMC8677921 DOI: 10.5847/wjem.j.1920-8642.2022.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 10/12/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Elevated troponin I (TnI) is common among trauma patients. TnI is an indicator of myocardial injury, but clinical diagnosis of blunt cardiac injury cannot be based solely on an increase in TnI. Therefore, this study aims to explore the changes and clinical significance of serum TnI in trauma patients. METHODS The clinical data of consecutive trauma patients admitted to our trauma center between July 1, 2017 and July 31, 2020 were retrospectively analyzed. According to TnI levels within 24 hours of admission, patients were divided into the elevated and normal TnI groups. According to the TnI levels after 7 days of admission, a graph depicting a change in trend was drawn and then analyzed whether TnI was related to in-hospital mortality. RESULTS A total of 166 patients (69 and 97 cases with elevated and normal TnI, respectively) were included in this study. The average hospital stay, intensive care time, mechanical ventilation time, and in-hospital mortality were higher in the elevated TnI group than in the normal TnI group (P<0.05). The TnI level of trauma patients gradually increased after admission and peaked at 48 hours (7.804±1.537 ng/mL). Subsequently, it decreased, and then recovered to normal within 7 days. However, 13 patients did not recover. Logistic regression analysis revealed that abnormal TnI at 7 days was independently related to in-hospital mortality. CONCLUSIONS Trauma patients with elevated TnI levels may have a worse prognosis. Monitoring the changes in serum TnI is important, which can reflect the prognosis better than the TnI measured immediately after admission.
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Affiliation(s)
- Li-wen Dou
- Emergency Department, Peking University People’s Hospital, Beijing 100044, China
| | - Zhe Du
- Trauma Center, Peking University People’s Hospital, Beijing 100044, China
| | - Ji-hong Zhu
- Emergency Department, Peking University People’s Hospital, Beijing 100044, China
| | - Tian-bing Wang
- Trauma Center, Peking University People’s Hospital, Beijing 100044, China
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Shoar S, Hosseini FS, Naderan M, Khavandi S, Tabibzadeh E, Khavandi S, Shoar N. Cardiac injury following blunt chest trauma: diagnosis, management, and uncertainty. Int J Burns Trauma 2021; 11:80-89. [PMID: 34094699 PMCID: PMC8166660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 01/26/2021] [Indexed: 06/12/2023]
Abstract
Due to the evolving nature of injuries caused by high-speed motor vehicle accidents, the incidence rate of blunt chest trauma is continuously increasing. Blunt cardiac injury (BCI) is a potentially lethal entity as a result of trauma to the chest. Due to its indistinct clinical presentation and heterogeneous definition, BCI might be missed during the initial survey of trauma patients in the acute care setting. Additionally, unnecessary operation in hemodynamically stable patients in whom the extent of cardiac injury has not been thoroughly evaluated might result in adverse clinical outcome. Due to ongoing advances in the diagnostic modalities and minimally invasive procedures in the acute care and trauma setting, patients with blunt trauma to the chest, who are also suspected of having a BCI, can be monitored with more confidence and managed accordingly as the clinical scenario evolves. While low-yield diagnostics such as chest X ray, electrocardiogram, and a bedside ultrasonography are still routinely performed in patients with suspected BCI, high-yield modalities such as computed tomography, highly sensitive cardiac biomarkers, and transesophageal echocardiography are all a next step in the management approach. In either case, the clinical judgment of the medical team plays a pivotal role in transition to the next step with adequate resuscitation remaining an inevitable part.
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Affiliation(s)
- Saeed Shoar
- Department of Clinical Research, ScientificWriting CorpHouston, TX, USA
| | | | - Mohammad Naderan
- Faculty of Medicine, Tehran University of Medical SciencesTehran, Iran
| | - Siamak Khavandi
- Department of Ophthalmology, Tabriz University of Medical SciencesTabriz, Iran
| | - Elsa Tabibzadeh
- Department of Anaesthesiology and Critical Care, Tabriz University of Medical SciencesTabriz, Iran
| | - Soheila Khavandi
- Department of Cardiology, Tabriz University of Medical SciencesTabriz, Iran
| | - Nasrin Shoar
- Faculty of Medicine, Kashan University of Medical SciencesKashan, Iran
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Mashiko K, Matsumoto H, Yasumatsu H, Ueda T, Yamamoto M, Funaki Y, Toshimitsu Y. Emergent surgery for cardiac herniation coexisting with complex blunt cardiac injury: A case report. Trauma Case Rep 2021; 32:100464. [PMID: 33816745 PMCID: PMC8010855 DOI: 10.1016/j.tcr.2021.100464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 11/16/2022] Open
Abstract
A 38-year-old man was pressed on his trunk by a heavy object weighing about 100 kg. The patient was in shock status on arrival to the hospital. Circular collapse progressed rapidly during contrast computed tomography (CT) scanning. CT images revealed exacerbation of the right lateral deviation of the heart that was earlier seen on X-ray imaging. Considering cardiac herniation based on CT findings, we immediately performed resuscitative thoracotomy and clamshell thoracotomy at the emergency department. Intraoperative findings showed a pericardial defect, and the heart had deviated to the right thoracic cavity. Immediate repositioning revealed a marked improvement in circulation. Full-thickness cardiac injury was observed in the anterior wall of the left ventricle; no active bleeding was observed. We performed temporary thoracic wall closure after cardiorraphy for damage control. After admission to the intensive care unit, he presented with respiratory failure associated with pulmonary contusion. Therefore, veno-venous extracorporeal membrane oxygenation (V-V ECMO) was used from the 2nd to the 5th hospital day. After confirming no intra-thoracic events on the 6th hospital day, chest wall closure was performed. The patient subsequently developed heart failure and mitral regurgitation associated with papillary muscle rupture. On the 62nd hospital day, he underwent mitral annuloplasty at the cardiovascular surgery division; After rehabilitation till 152nd hospital day, he was discharged without any neurological abnormality. This was an extremely rare case with concomitant full-thickness myocardial injury, intracardiac injury, and cardiac herniation. Rapid resuscitative thoracotomy and damage control including V-V ECMO yielded good results. Retrospectively, cardiac herniation should have been suspected earlier basis this observation. Our report highlights that cardiac herniation should be considered in case of cardiac shadow aberrations in cases of blunt chest trauma, familiarity with condition and its characteristic imaging findings are critical for the doctor overseeing initial trauma treatment.
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Affiliation(s)
- Kazuki Mashiko
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Hisashi Matsumoto
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Hiroshi Yasumatsu
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Taichiro Ueda
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Mariko Yamamoto
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Yutaka Funaki
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Yasuko Toshimitsu
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
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Keskpaik T, Starkopf J, Kirsimägi Ü, Mihnovitš V, Lomp A, Raamat EM, Saar S, Talving P. The role of elevated high-sensitivity cardiac troponin on outcomes following severe blunt chest trauma. Injury 2020; 51:1177-1182. [PMID: 31955863 DOI: 10.1016/j.injury.2019.12.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 12/14/2019] [Accepted: 12/30/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Blunt cardiac injuries (BCI) result in poor outcomes following chest trauma. Admission ECG and troponin levels are frequently obtained in patients with suspected BCI, nevertheless, the prognostic value of cardiac troponins remains controversial. The purpose of the current study was to review the prognostic value of elevated high-sensitivity cardiac troponin T (hs-cTnT) in patients with severe blunt chest injuries. We hypothesized that elevated hs-cTnT result in poor outcomes in this subgroup of severe trauma patients. METHODS After IRB approval, all consecutive patients with Injury Severity Score (ISS) > 15 and chest Abbreviated Injury Scale (AIS) score ≥3 admitted to the major trauma centers between 1/2015 and 6/2017 were retrospectively reviewed. Primary outcomes were in-hospital and one-year mortality. Secondary outcomes included ventilator days and Glasgow Outcome Scale (GOS) score at hospital discharge. RESULTS Overall, 147 patients were included. Mean age was 49.0 (19.1) years and 75% were male. Serum troponin levels on admission were accrued in 82 (56%) patients with elevated and normal hs-cTnT levels found in 54 (66%) and in 28 (34%) patients, respectively. Elevated hs-cTnT group had significantly higher ISS and lactate level, and lower systolic blood pressure on admission. In-hospital mortality was significantly higher in patients with elevated hs-cTnT levels compared to patients with normal hs-cTnT levels (26% vs. 4%, p = 0.02). Hs-cTnT level > 14 ng/L was significantly associated with extended ventilator days and lower GOS score at hospital discharge. CONCLUSION Blunt chest trauma victims with elevated hs-cTnT levels experience significantly poorer adjusted outcomes compared to patients with normal levels. Compliance with EAST practice management guidelines following severe blunt chest trauma was not fully complied in our study cohort that warrants prospective performance improvement measures.
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Affiliation(s)
- Triinu Keskpaik
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Estonia; Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Estonia.
| | - Joel Starkopf
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Estonia; Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Estonia.
| | - Ülle Kirsimägi
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Estonia.
| | - Vladislav Mihnovitš
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Estonia.
| | - Andrus Lomp
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Estonia.
| | | | - Sten Saar
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Estonia; Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Estonia
| | - Peep Talving
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Estonia; Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Estonia.
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13
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Grigorian A, Milliken J, Livingston JK, Spencer D, Gabriel V, Schubl SD, Kong A, Barrios C, Joe V, Nahmias J. National risk factors for blunt cardiac injury: Hemopneumothorax is the strongest predictor. Am J Surg 2018; 217:639-642. [PMID: 30060913 DOI: 10.1016/j.amjsurg.2018.07.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 07/20/2018] [Accepted: 07/24/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Blunt cardiac injury (BCI) can occur after chest trauma and may be associated with sternal fracture (SF). We hypothesized that injuries demonstrating a higher transmission of force to the thorax, such as thoracic aortic injury (TAI), would have a higher association with BCI. METHODS We queried the National Trauma Data Bank (NTDB) from 2007-2015 to identify adult blunt trauma patients. RESULTS BCI occurred in 15,976 patients (0.3%). SF had a higher association with BCI (OR = 5.52, CI = 5.32-5.73, p < 0.001) compared to TAI (OR = 4.82, CI = 4.50-5.17, p < 0.001). However, the strongest independent predictor was hemopneumothorax (OR = 9.53, CI = 7.80-11.65, p < 0.001) followed by SF and esophageal injury (OR = 5.47, CI = 4.05-7.40, p < 0.001). CONCLUSION SF after blunt trauma is more strongly associated with BCI compared to TAI. However, hemopneumothorax is the strongest predictor of BCI. We propose all patients presenting after blunt chest trauma with high-risk features including hemopneumothorax, sternal fracture, esophagus injury, and TAI be screened for BCI. SUMMARY Using the National Trauma Data Bank, sternal fracture is more strongly associated with blunt cardiac injury than blunt thoracic aortic injury. However, hemopneumothorax was the strongest predictor.
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Affiliation(s)
- Areg Grigorian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.
| | - Jeffrey Milliken
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Joshua K Livingston
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Dean Spencer
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Viktor Gabriel
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Sebastian D Schubl
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Allen Kong
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Cristobal Barrios
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Victor Joe
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Jeffry Nahmias
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
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14
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Carmichael SP, Bounds MC, Shafii AE, Chang PK. Emergency department repair of blunt right atrial rupture utilizing cardiopulmonary bypass. Trauma Case Rep 2017; 12:1-3. [PMID: 29644273 PMCID: PMC5887067 DOI: 10.1016/j.tcr.2017.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2017] [Indexed: 11/26/2022] Open
Abstract
Blunt cardiac injury (BCI) with free wall rupture carries a high risk of pre-hospital death. Cardiopulmonary bypass (CPB) has been utilized as a bridge to repair of cardiac lesions in select patients. We present an interesting case of emergency department repair of right atrial rupture with cardiopulmonary bypass.
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Affiliation(s)
- Samuel P. Carmichael
- General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, KY, United States
- Corresponding author at: University of Kentucky, 800 Rose Street, C-234, Lexington, KY 40536-0298, United States.University of Kentucky800 Rose StreetC-234LexingtonKY40536-0298United States
| | - Michael C. Bounds
- General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Alexis E. Shafii
- Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Phillip K. Chang
- Division of General Surgery – Section of Trauma and Critical Care, University of Kentucky College of Medicine, Lexington, KY, United States
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15
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Abstract
Patients with traumatic cardiac injuries can present with wide variability in their severity of illness. The most severe will present in cardiac arrest, whereas the most benign may be altogether asymptomatic; most will fall somewhere in between. Management of cardiac injuries largely depends on mechanism of injury and patient physiology. Understanding the spectrum of injuries and their associated manifestations can help providers react more quickly and initiate potentially life-saving therapies more efficiently when time is critical. This article discusses the workup and management of both blunt and penetrating cardiac injuries.
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Affiliation(s)
- Seth A Bellister
- Division of Trauma and Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Bradley M Dennis
- Division of Trauma and Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA.
| | - Oscar D Guillamondegui
- Division of Trauma and Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
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16
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Abstract
The management of critically ill pediatric patients with trauma poses many challenges because of the infrequency and diversity of severe injuries and a paucity of high-level evidence to guide care for these uncommon events. This article discusses recent recommendations for early resuscitation and blood component therapy for hypovolemic pediatric patients with trauma. It also highlights the specific types of injuries that lead to severe injury in children and presents challenges related to their management.
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Affiliation(s)
- Omar Z Ahmed
- Department of General and Thoracic Surgery, Division of Trauma and Burn Surgery, Children's National Medical Center, 111 Michigan Avenue Northwest, Washington, DC 20010, USA
| | - Randall S Burd
- Department of General and Thoracic Surgery, Division of Trauma and Burn Surgery, Children's National Medical Center, 111 Michigan Avenue Northwest, Washington, DC 20010, USA.
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17
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Leite L, Gonçalves L, Nuno Vieira D. Cardiac injuries caused by trauma: Review and case reports. J Forensic Leg Med 2017; 52:30-34. [PMID: 28850860 DOI: 10.1016/j.jflm.2017.08.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 04/28/2017] [Accepted: 08/23/2017] [Indexed: 11/16/2022]
Abstract
Assessment of suspected cardiac injuries in a trauma setting is a challenging and time-critical matter, with clinical and imaging findings having complementary roles in the formation of an accurate diagnosis. In this article, we review the supporting literature for the pathophysiology, classification and evaluation of cardiac injuries caused by trauma. We also describe 4 cardiac trauma patients seen at a tertiary referral hospital.
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Affiliation(s)
- Luís Leite
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal; Department of Cardiology, Coimbra Hospital and University Center, Coimbra, Portugal.
| | - Lino Gonçalves
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal; Department of Cardiology, Coimbra Hospital and University Center, Coimbra, Portugal
| | - Duarte Nuno Vieira
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal; National Institute of Legal Medicine and Forensic Sciences, Coimbra, Portugal
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18
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Ishida K, Kinoshita Y, Iwasa N, Nakae M, Sakaki M, Ieki Y, Takahashi K, Shimahara Y, Sogabe T, Shimono K, Noborio M, Sadamitsu D. Emergency room thoracotomy for acute traumatic cardiac tamponade caused by a blunt cardiac injury: A case report. Int J Surg Case Rep 2017; 35:21-24. [PMID: 28427001 PMCID: PMC5397131 DOI: 10.1016/j.ijscr.2017.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Traumatic blunt cardiac injuries have a high mortality rate, and prompt diagnosis and treatment can be lifesaving in cardiac tamponade. PRESENTATION OF CASE A 62-year-old man was transferred to the emergency department after a motor vehicle accident. He was hemodynamically unstable. A focused assessment with sonography in trauma (FAST) showed pericardial fluid with right ventricular collapse consistent with cardiac tamponade in the subxiphoid view. He collapsed despite a subxiphoid pericardiotomy. Owing to the ongoing hemodynamic instability, we performed a left anterolateral thoracotomy. Direct incision of the pericardium showed blood and clots within the pericardial space, indicating hemopericardium. The heart stroke and hemodynamic status recovered on removing the clot. DISCUSSION Although the physical findings of cardiac tamponade are not always apparent in life-threatening acute cardiac tamponade after blunt trauma, FAST is a reliable tool for diagnosing and following cardiac tamponade. A median sternotomy is a standard approach for evaluating cardiac injury in hemodynamically stable patients with or without cardiopulmonary bypass. However, a left anterior thoracotomy was the fastest, simplest life-saving procedure considering the need for open-chest cardiac massage given our patient's life-threatening condition. CONCLUSION A prompt diagnosis using FAST and treatment can be lifesaving in traumatic acute cardiac tamponade. A pericardiotomy via a thoracotomy is mandatory for lifesaving cardiac decompression in acute traumatic cardiac tamponade in cases of ineffective drainage due to clot formation within the pericardial space.
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Affiliation(s)
- Kenichiro Ishida
- Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, Osaka, Japan.
| | - Yoshihiro Kinoshita
- Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Nobutaka Iwasa
- Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Masaro Nakae
- Department of Cardiovascular Surgery, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Masayuki Sakaki
- Department of Cardiovascular Surgery, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Yohei Ieki
- Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Kyosuke Takahashi
- Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Yumiko Shimahara
- Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Taku Sogabe
- Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Keiichiro Shimono
- Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Mitsuhiro Noborio
- Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Daikai Sadamitsu
- Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, Osaka, Japan
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19
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Yamaji F, Okada H, Nakajima Y, Suzuki K, Yoshida T, Mizuno Y, Okamoto H, Kitagawa Y, Tanaka T, Nakano S, Nachi S, Doi T, Kumada K, Yoshida S, Ishida N, Shimabukuro K, Ushikoshi H, Toyoda I, Doi K, Ogura S. Blunt cardiac injury due to trauma associated with snowboarding: a case report. J Med Case Rep 2017; 11:80. [PMID: 28340603 PMCID: PMC5366129 DOI: 10.1186/s13256-017-1242-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 02/13/2017] [Indexed: 11/10/2022] Open
Abstract
Background Cardiac trauma is associated with a much higher mortality rate than injuries to other organ systems, even though cardiac trauma is identified in less than 10% of all trauma admissions. Here we report blunt trauma of the left atrium due to snowboarding trauma. Case presentation A 45-year-old Asian man collided with a tree while he was snowboarding and drinking. He lost consciousness temporarily. An air ambulance was requested and he was transported to an advanced critical care center. On arrival, a pericardial effusion was detected by a focused assessment with sonography for trauma. His presenting electrocardiogram revealed normal sinus rhythm and complete right bundle branch block. Laboratory findings included a white blood cell count of 13.5 × 103/μl, serum creatine kinase level of 459 IU/l, and creatine kinase–myocardial band level of 185 IU/l. Enhanced computed tomography showed a large pericardial effusion and bleeding from his left adrenal gland. There were no pelvic fractures. A diagnosis of cardiac tamponade due to blunt cardiac injury and left adrenal injury due to blunt trauma was made. Subsequently, emergency thoracic surgery and transcatheter arterial embolization of his left adrenal artery were performed simultaneously. A laceration of the left atrial appendage in the lateral wall of his left ventricle was detected intraoperatively and repaired. His postoperative course progressed favorably, although a pericardial effusion was still detected on chest computed tomography on hospital day 35. His electrocardiogram showed normal sinus rhythm and the complete right bundle branch block pattern changed to a narrow QRS wave pattern. He was discharged on hospital day 40. Conclusions The present case report illustrates two points: (1) severe injuries resulted from snowboarding, and (2) complete right bundle branch block was caused by blunt cardiac injury. The present report showed blunt trauma of the left atrium with complete right bundle branch block as an electrocardiogram change due to snowboarding trauma. To detect cardiac trauma in snowboarding accidents, an examination of an electrocardiogram is required in all patients who might have a bruised chest.
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Affiliation(s)
- Fuminori Yamaji
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Hideshi Okada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Yasuhiro Nakajima
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Kodai Suzuki
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Takahiro Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Yosuke Mizuno
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Haruka Okamoto
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Yuichiro Kitagawa
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Taku Tanaka
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Shiho Nakano
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Sho Nachi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tomoaki Doi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Keisuke Kumada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Shozo Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Narihiro Ishida
- General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Katsuya Shimabukuro
- General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Hiroaki Ushikoshi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Izumi Toyoda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Kiyoshi Doi
- General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
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20
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Abstract
The elderly population is rapidly increasing in number. Therefore, geriatric trauma is becoming more prevalent. All practitioners caring for geriatric trauma patients should be familiar with the structural and functional changes naturally occurring in the aging heart, as well as common preexisting cardiac diseases in the geriatric population. Identification of the shock state related to cardiac dysfunction and targeted assessment of perfusion and resuscitation are important when managing elderly patients. Finally, management of cardiac dysfunction in the trauma patient includes an appreciation of the inherent effects of trauma on cardiac function.
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21
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Hammer MM, Raptis DA, Cummings KW, Mellnick VM, Bhalla S, Schuerer DJ, Raptis CA. Imaging in blunt cardiac injury: Computed tomographic findings in cardiac contusion and associated injuries. Injury 2016; 47:1025-30. [PMID: 26646729 DOI: 10.1016/j.injury.2015.11.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 10/08/2015] [Accepted: 11/05/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Blunt cardiac injury (BCI) may manifest as cardiac contusion or, more rarely, as pericardial or myocardial rupture. Computed tomography (CT) is performed in the vast majority of blunt trauma patients, but the imaging features of cardiac contusion are not well described. PURPOSE To evaluate CT findings and associated injuries in patients with clinically diagnosed BCI. MATERIALS AND METHODS We identified 42 patients with blunt cardiac injury from our institution's electronic medical record. Clinical parameters, echocardiography results, and laboratory tests were recorded. Two blinded reviewers analyzed chest CTs performed in these patients for myocardial hypoenhancement and associated injuries. RESULTS CT findings of severe thoracic trauma are commonly present in patients with severe BCI; 82% of patients with ECG, cardiac enzyme, and echocardiographic evidence of BCI had abnormalities of the heart or pericardium on CT; 73% had anterior rib fractures, and 64% had pulmonary contusions. Sternal fractures were only seen in 36% of such patients. However, myocardial hypoenhancement on CT is poorly sensitive for those patients with cardiac contusion: 0% of right ventricular contusions and 22% of left ventricular contusions seen on echocardiography were identified on CT. CONCLUSION CT signs of severe thoracic trauma are frequently present in patients with severe BCI and should be regarded as indirect evidence of potential BCI. Direct CT findings of myocardial contusion, i.e. myocardial hypoenhancement, are poorly sensitive and should not be used as a screening tool. However, some left ventricular contusions can be seen on CT, and these patients could undergo echocardiography or cardiac MRI to evaluate for wall motion abnormalities.
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Affiliation(s)
- Mark M Hammer
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, United States.
| | - Demetrios A Raptis
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, United States.
| | | | - Vincent M Mellnick
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, United States.
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, United States.
| | - Douglas J Schuerer
- Department of Surgery, Washington University in St. Louis, St. Louis, MO, United States.
| | - Constantine A Raptis
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, United States.
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22
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Abstract
Background Road traffic accident accounts for 70 % to 80 % of the blunt cardiac injury. The true incidence varies in the literature due to non-uniform criteria for diagnosis. Case Presentation Here, we describe the case of a young male presenting after blunt chest injury and hemodynamic instability. Initially, the patient had frequent episodes of arrhythmias and hypotension due to cardiac injury per se. However, he was stabilized by day 2. Subsequently, patient developed cellulitis followed by septic shock and succumbed to cellulitis on day 5 of injury. Conclusion Sepsis is difficult to be diagnosed and treated in the presence of cardiac injury. Myocardial depression has been found in sepsis, which contributes as an added comorbidity in an already compromised heart function. Sepsis also interferes with the diagnosis and follow-up of progress of blunt cardiac injury.
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Affiliation(s)
- Neha Garg
- Department of Anaesthesia and Intensive Care, All India Institute of Medical Sciences, Ansari Nagar East, Gautam Nagar, New Delhi, 110029 India
| | - Kapil Dev Soni
- Division of Critical & Intensive care, All India Institute of Medical Sciences, Ansari Nagar East, Gautam Nagar, New Delhi, 110029 India
| | - Richa Aggarwal
- Division of Critical & Intensive care, All India Institute of Medical Sciences, Ansari Nagar East, Gautam Nagar, New Delhi, 110029 India
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23
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Joseph B, Jokar TO, Khalil M, Haider AA, Kulvatunyou N, Zangbar B, Tang A, Zeeshan M, O'Keeffe T, Abbas D, Latifi R, Rhee P. Identifying the broken heart: predictors of mortality and morbidity in suspected blunt cardiac injury. Am J Surg 2016; 211:982-8. [PMID: 26879418 DOI: 10.1016/j.amjsurg.2015.10.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 10/21/2015] [Accepted: 10/28/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Blunt cardiac injury (BCI) is an infrequent but potentially fatal finding in thoracic trauma. Its clinical presentation is highly variable and patient characteristics and injury pattern have never been described in trauma patients. The aim of this study was to identify predictors of mortality in BCI patients. METHODS We performed an 8-year retrospective analysis of all trauma patients diagnosed with BCI at our Level 1 trauma center. Patients older than 18 years, blunt chest trauma, and a suspected diagnosis of BCI were included. BCI was diagnosed based on the presence of electrocardiography (EKG), echocardiography, biochemical cardiac markers, and/or radionuclide imaging studies. Elevated troponin I was defined as more than 2 recordings of greater than or equal to .2. Abnormal EKG findings were defined as the presence of bundle branch block, ST segment, and t-wave abnormalities. Univariate and multivariate regression analyses were performed. RESULTS A total of 117 patients with BCI were identified. The mean age was 51 ± 22 years, 65% were male, mean systolic blood pressure was 93 ± 65, and overall mortality rate was 44%. Patients who died were more likely to have a lactate greater than 2.5 (68% vs 31%, P = .02), hypotension (systolic blood pressure < 90) (86% vs 14%, P = .001), and elevated troponin I (86% vs 11%, P = .01). There was no difference in the rib fracture (58% vs 56%, P = .8), sternal fracture (11% vs 21%, P = .2), and abnormal EKG (89% vs 90%, P = .6) findings. Hypotension and lactate greater than 2.5 were the strongest predictors of mortality in BCI. CONCLUSIONS BCI remains an important diagnostic and management challenge. However, once diagnosed resuscitative therapy focused on correction of hypotension and lactate may prove beneficial. Although the role of troponin in diagnosing BCI remains controversial, elevated troponin may have prognostic significance.
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Affiliation(s)
- Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA.
| | - Tahereh O Jokar
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Mazhar Khalil
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Ansab A Haider
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Narong Kulvatunyou
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Bardiya Zangbar
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Andrew Tang
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Muhammad Zeeshan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Terence O'Keeffe
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Daniyal Abbas
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Rifat Latifi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Peter Rhee
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ, USA
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24
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Vogiatzis I, Dapcevic I. Dissection of the right coronary artery following blunt cardiac injury. Hippokratia 2015; 19:278-280. [PMID: 27418793 PMCID: PMC4938481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Coronary artery dissection is a rare complication of blunt thoracic trauma which can become rapidly lethal necessitating prompt diagnosis and treatment. Most reported cases of coronary artery injury, including dissection, involve the left anterior descending coronary artery, given its anatomical location in relation to the impact. DESCRIPTION OF CASE A 72-year-old male, who was involved in a vehicular accident, sustained blunt thoracic trauma which resulted in isolated right coronary artery dissection and acute myocardial infarction. The culprit lesion was found in coronary angiography in the proximal right coronary artery and was successfully repaired with percutaneous coronary intervention and one drug-eluting stent placement. CONCLUSION Traumatic dissection of coronary arteries must be suspected in blunt thoracic trauma. It can be treated with interventional management and results in a fairly good prognosis. Hippokratia 2015; 19 (3): 278-280.
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Affiliation(s)
- I Vogiatzis
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
| | - I Dapcevic
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
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Kittaka H, Yagi Y, Zushi R, Hazui H, Akimoto H. Combination of blunt cardiac and pericardial injury presenting a massive hemothorax without hemopericardium. Acute Med Surg 2015; 2:257-259. [PMID: 29123734 DOI: 10.1002/ams2.112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 12/24/2014] [Indexed: 11/11/2022] Open
Abstract
Case A 64-year-old man was injured after falling from a height of 5 m and was transported to our institution. On presentation, his hemodynamic state was unstable, and both focused assessment with sonography for trauma and enhanced computed tomography imaging revealed massive left pleural effusion, but no pericardial effusion. He went into cardiopulmonary arrest just before surgery, so an urgent left anterolateral thoracotomy followed by open chest cardiac massage and aortic clamping were carried out. By performing an additional right anterior thoracotomy, a left pleuropericardial laceration and a perforation measuring 1 cm in diameter at the left ventricle were found. The patient's dynamic state stabilized following the restoration of hemostasis by suturing the rupture site. Outcome The patient's postoperative course was favorable, and he was discharged after 20 days of hospitalization. Conclusion Blunt cardiac and pericardial injury rarely causes massive hemothorax with no hemopericardium, resulting in hemorrhagic shock.
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Affiliation(s)
- Hirotada Kittaka
- Department of Emergency Osaka Mishima Emergency Critical Care Center Takatsuki City Japan
| | - Yoshiki Yagi
- Department of Emergency Osaka Mishima Emergency Critical Care Center Takatsuki City Japan
| | - Ryosuke Zushi
- Department of Emergency Osaka Mishima Emergency Critical Care Center Takatsuki City Japan
| | - Hiroshi Hazui
- Department of Emergency Osaka Mishima Emergency Critical Care Center Takatsuki City Japan
| | - Hiroshi Akimoto
- Department of Emergency Osaka Mishima Emergency Critical Care Center Takatsuki City Japan
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Skinner DL, Laing GL, Rodseth RN, Ryan L, Hardcastle TC, Muckart DJJ. Blunt cardiac injury in critically ill trauma patients: a single centre experience. Injury 2015; 46:66-70. [PMID: 25264354 DOI: 10.1016/j.injury.2014.08.051] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 08/13/2014] [Accepted: 08/31/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE This study describes the incidence and outcomes of blunt cardiac injury (BCI) in a single trauma intensive care unit (TICU), together with the spectrum of thoracic injuries and cardiac abnormalities seen in BCI. METHODS We performed a retrospective observational study of 169 patients with blunt thoracic trauma admitted from January 2010 to April 2013. BCI was diagnosed using an elevated serum troponin in the presence of either clinical, ECG or transthoracic echocardiography (TTE) abnormalities in keeping with BCI. The mechanism of injury, associated thoracic injuries and TTE findings in these patients are reported. RESULTS The incidence of BCI among patients with blunt thoracic trauma was 50% (n=84). BCI patients had higher injury severity scores (ISS) (median 37 [IQR 29-47]; p=0.001) and higher admission serum lactate levels (median 3.55 [IQR 2.4-6.2], p=0.008). In patients with BCI, the median serum TnI level was 2823ng/L (IQR 1353-6833), with the highest measurement of 64950ng/L. TTEs were performed on 38 (45%) patients with BCI, of whom 30 (79%) had abnormalities. Patients with BCI had a higher mortality (32% vs. 16%; p=0.028) and trended towards a longer length of stay (17.0 days [standard deviation (SD) 13.5] vs. 13.6 days [SD 12.0]; p=0.084). CONCLUSIONS BCI was associated with an increased mortality and a trend towards a longer length of stay in this study. It is a clinically relevant diagnosis which requires a high index of suspicion. Screening of high risk patients with significant blunt thoracic trauma for BCI with serum troponins should be routine practise. Patients diagnosed with BCI should undergo more advanced imaging such as TTE or TOE to exclude significant cardiac structural injury.
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Affiliation(s)
- D L Skinner
- Department of Critical Care, King Edward VIII Hospital, P/Bag X02 Congella 4013, Durban, KwaZulu-Natal 4083, South Africa; Perioperative Research Group, Department of Anaesthetics & Critical Care, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - G L Laing
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - R N Rodseth
- Perioperative Research Group, Department of Anaesthetics & Critical Care, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - L Ryan
- Perioperative Research Group, Department of Anaesthetics & Critical Care, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - T C Hardcastle
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Level I Trauma Unit and Trauma Intensive Care, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - D J J Muckart
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Level I Trauma Unit and Trauma Intensive Care, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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Yeh DD, Hwabejire JO, DeMoya MA, Alam HB, King DR, Velmahos GC. Sternal fracture--an analysis of the National Trauma Data Bank. J Surg Res 2014; 186:39-43. [PMID: 24135374 DOI: 10.1016/j.jss.2013.08.025] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 08/23/2013] [Accepted: 08/27/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND The clinical significance of sternal fractures (SFs) after blunt trauma is heavily debated. We aimed to test the hypothesis that isolated SF is not associated with significant morbidity or mortality. MATERIALS AND METHODS The National Trauma Data Bank (NTDB) sets for 2007-2010 were retrospectively examined. Adult subjects with SF were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. Data collected included demographics, mechanisms of injury, clinical variables, and in-hospital mortality. The primary outcome measure was in-hospital mortality. Secondary outcome measures included hospital length of stay, intensive care unit days, and ventilator days. RESULTS A total of 32,746 subjects with SF were included. Motor vehicle crash (MVC) was the most common mechanism (84%) in this group and SF was present in 3.7% of all patients admitted after MVC. The mean age was 51 y, 66% were males, and most were white (74%). Overall in-hospital mortality was 8.8% and mortality with isolated SF was 3.5%. Increasing thoracic fracture burden (rib fracture, clavicular fracture, and scapular fracture) was associated with increasing hospital length of stay, intensive care unit days, ventilator days, and mortality. On multivariate regression analysis, other significant predictors of mortality were cardiac arrest, acute respiratory distress syndrome, pulmonary embolism, blunt cardiac injury, pulmonary contusion, increasing age, and lack of insurance. CONCLUSIONS SFs occur in 3.7% of victims after MVC. With isolated SF, the mortality rate is low (3.5%); the tendency for poorer outcomes is most heavily influenced by associated injuries (pulmonary contusions, other thoracic fractures), complications (cardiac arrest, pulmonary embolism, acute respiratory distress syndrome), comorbidities (currently on or requiring dialysis, residual neurologic deficit from stroke), and lack of insurance.
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Abstract
We present a 32-year-old male with ventricular septal defect (VSD) following blunt chest trauma. Traumatic VSD is a rare but potentially life-threatening injury, the severity, course and presentation of which are variable. While the diagnosis of myocardial injury may be challenging, cardiac troponins are useful as a screening and diagnostic test. The proposed pathophysiological mechanisms in the development of traumatic VSD are early mechanical rupture and delayed inflammatory rupture. We conducted a literature review to investigate the pathogenesis, distribution of patterns of presentation, and the associated prognoses in patients with VSD following blunt chest trauma. We found that traumatic VSDs diagnosed within 48 hours were more likely to be severe, require emergency surgery and were associated with a higher mortality. Children with traumatic VSDs had an increased mortality risk. Smaller lesions may be managed conservatively but should be followed up to detect late complications. In both groups elective repair was associated with a good outcome.
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Affiliation(s)
- Lisa Ryan
- Department of Anaesthetics, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
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