Blunt traumatic pericardial rupture
1
Blunt Traumatic Pericardial Rupture and Cardiac Herniation with a Penetrating Twist Sherren P B 1 , Galloway R 1 , Healy M 2 1 SpR Intensive care, 2 Consultant Anaesthesia and Intensive care, The Royal London Hospital, London, UK. INTRODUCTION Blunt Traumatic Pericardial Rupture (BTPR) and cardiac herniation following chest trauma is an unusual and often fatal condition. Although there has been a multitude of case reports of this condition in past literature, the recurring theme is that of a missed injury 1,2 . Its occurrence in severe blunt trauma is in the order of 0.4% 3,4 . It is an injury that frequently results in pre/early hospital death and diagnosis at autopsy, probably owing to a combination of diagnostic difficulties, lack of familiarity, associated polytrauma and injuries 3,5 . Of the patients who survive to hospital attendance, the mortality rate within trauma centres is in the order of 57-64% 6 . CASE REPORTS DISCUSSION METHODOLOGY We present two interesting cases of BTPR and cardiac herniation and a literature review. The initial chest radiograph (Figure 2a) and coronal chest CT (Figure 2b) can be seen below. 2a. 2b. After 16 hours on the ICU the blood output from the left basal thoracostomy tube suddenly rose to 600ml/hour, with associated lactic acidosis and transfusion requirement. He was taken to theatre for a left-sided thoracotomy where the following injuries were found and repaired: left-sided longitudinal rupture of the pericardium and cardiac herniation; left ventricular laceration secondary to overlying rib fractures; multiple lung lacerations; and multiple flail ribs. A 3-week ITU admission ensued, which was complicated by pulmonary ARDS and recurrent atrial flutter. He was discharged home after 6 weeks fully independent. Pathophysiology - Pericardial tears may involve either the superior, left or right pleuropericardium or the diaphragmatic pericardium. The defect can allow cardiac luxation and, in the case of diaphragmatic pericardial tear, herniation of abdominal contents. Clarke et al. reviewed 142 cases and found the superior/left/right pleuropericardium were injured in 4%/50%/17% respectively with 27% occurring in the diaphragmatic pericardium 3,6 . The rate of cardiac herniation was 28% 3 ; however, in a more recent literature search, a rate of 64% of BTPR developed cardiac herniation 6 . Defects of the pleuropericardium usually occur vertically along the phrenic nerve 7 . If the tear is approaching 8- 12cm, the heart can sublux through the defect 8 . The resulting torsion of the great vessels can lead to a form of obstructive cardiogenic shock 7 . Clinical Presentation – Road traffic collisions and sudden decelerations are the most common mechanisms for BTPR. The following pattern of associated injuries should also arouse suspicion of BTPR 3 : •Cardiac - contusions and dysrrthmias (28%) Penetrating cardiac injury secondary to rib fractures seen in case 2, is not something previously reported. • Chest - rib fractures, haemopneumothoraces and pulmonary contusions are almost universally seen. • Neurological - thoracic spine fractures, SCI and traumatic brain injuries (32%) • Abdominal injuries (27%) • Pelvic and long bone fracture indicative of a high velocity/energy impact (49%) Symptoms - The patient may report palpitations, shortness of breath, chest and angina-type pains 2 . Case 1. A 21-year-old male was admitted to the Royal London hospital (RLH) via a district general hospital following a motorbike accident. He was initially hypoxic, cardiovascularly stable, unable to move his legs and had a GCS of 15/15. Over the next 36 hours his haemodynamic indices deteriorated despite bilateral tube thoracostomies, fluids and inotropes; spinal shock was implicated and transferred as such. Peri-transfer, the patient’s condition deteriorated and on arrival he was in cardiorespiratory extremis. In the handover, little mention was made of his newly developed dextracardia, high Alveolar-arterial gradient and extreme inotropic support. The patient was re-trauma called and the following chest radiograph (Figure 1a) and coronal chest computed tomography (Figure 1b) images were obtained. 1a. 1b. Given the large pneumopericardium and displaced heart on computed tomography (CT), a clamshell thorocotomy was performed and a large right-sided tear of the pericardium with cardiac herniation was found. The heart was relocated and the pericardium was repaired. There was an immediate reduction in inotropic support. Post operative issues included a ventilator acquired pneumonia, paraplegia secondary to a spinal cord injury (SCI) and AF. That aside, he made a good recovery during his 14-day ICU stay. CONCLUSION BTPR and cardiac herniation is a complex and often fatal injury that usually presents under the umbrella of polytrauma. Clinicians must maintain a high index of suspicion for BTPR but, even then, the diagnosis is fraught with difficulty. In blunt chest trauma, patients should be considered high risk for BTPR when presenting with: • Cardiovascular instability with no obvious cause •Prominent or displaced cardiac silhouette and asymmetrical large volume pneumopericardium In the majority of cases, it is still an injury diagnosed at autopsy or thoracotomy. With increasing awareness of the injury and improved use and availability of imaging modalities, the survival rates will improve and cardiac ‘H’erniation could even be considered the 5 th H of reversible causes of blunt traumatic PEA arrest. REFERENCES •Tachycardia and dysrrthymias may be seen, such as the atrial tachyarrythmias. • Displaced and heaving apex beat 2,7 • A splashing murmur “bruit de Moulin” as a result of the heart moving in a haemopneumopericardium 9 . Investigations - There are a multitude of investigations available to assist in the diagnosis: i.Electrocardiogram - dysrrthymias, axis deviation 2,7,10 and bundle branch block 8,9 may all be present. Ischaemic changes may be noted as a result of extra luminal coronary artery occlusion 7,10 . Rippey et al 10 reported an elevated Troponin I of 9.20 μg/L. ii.Chest radiograph – is a valuable tool and abnormalities include a prominent cardiac silhouette (“boot shaped”); distinct visible pericardial contour; pneumopericardium; pneumomediastinum; bowel loops within pericardial sac and cardiac herniation into either hemithorax 2,7,9 . Associated pulmonary and skeletal pathology will usually be seen 10 . •Echocardiography - Has been used but the sensitivity for diagnosing even large pericardial defects is thought to be low 6 . The importance of transthoracic echo lies in its ability to rule out differential diagnoses (cardiac contusion/ tamponade) quickly in the shocked patient. •CT - is a more sensitive tool for identifying BTPR and cardiac herniation than plain radiographs. Changes indicative of pericardial rupture include 6 : - Focal pericardial dimpling and discontinuity - Pneumopericardium - Interposition of lung between mediastinal structures. Characteristic changes for a cardiac heniation 6 : - “Empty pericardial sac” sign - “Collar” sign, constriction of the cardiac contour by the pericardial band/defect •Magnetic Resonance Imaging (MRI) – Cardiac MR has been used in diagnostic uncertainties 6 . Management - Once BTPR and cardiac herniation is recognised, the treatment is simple and effective and involves rapid surgical relocation of the heart and closure of pericardial defect 3,9 . 1. Bettman R B et al. Herniation of the heart. Ann. Surg 1948: 128; 1012-1014. 2. Wright MP et al. Herniation of the heart. Thorax 1970:25;656-666. 3. Clark DE et al. Traumatic rupture of the pericardium. Surgery 1983: 93; 495-503. 4. Fulda G et al. Blunt traumatic rupture of the heart and the pericardium: A ten-year experience(1979--1989). J Trauma 1991: 31; 167-173 5. Farhataziz N et al. Pericardial rupture after blunt chest trauma. J Thorac Imaging 2005: 20; 50-52 6. Sohn JH et al. Pericardial rupture and cardiac herniation after blunt trauma: a case diagnosed using cardiac MRI. The British Journal of Radiology 2005: 78; 447–449 7. Thomas et al. Diagnosis by video assisted thoracoscopy of traumatic pericardial rupture with delayed luxation of the heart: case report. J Trauma 1995: 38; 967–70. 8. Carillo EH et al. Cardiac Herniation Producing Tamponade: The Critical Role of Early Diagnosis. The journal of Trauma injury, infection and critical care. 1997; 43(1): 19-23
Transcript of Blunt traumatic pericardial rupture
Blunt Traumatic Pericardial Rupture and Cardiac Herniation with a Penetrating Twist
Sherren P B1, Galloway R1, Healy M2
1SpR Intensive care, 2Consultant Anaesthesia and Intensive care, The Royal London Hospital, London, UK.
INTRODUCTIONBlunt Traumatic Pericardial Rupture (BTPR) and cardiac herniation following chest trauma is an unusual and often fatal condition. Although there has been a multitude of case reports of this condition in past literature, the recurring theme is that of a missed injury1,2. Its occurrence in severe blunt trauma is in the order of 0.4%3,4. It is an injury that frequently results in pre/early hospital death and diagnosis at autopsy, probably owing to a combination of diagnostic difficulties, lack of familiarity, associated polytrauma and injuries3,5. Of the patients who survive to hospital attendance, the mortality rate within trauma centres is in the order of 57-64%6. CASE REPORTS
DISCUSSION
METHODOLOGYWe present two interesting cases of BTPR and cardiac herniation and a literature review.
The initial chest radiograph (Figure 2a) and coronal chest CT (Figure 2b) can be seen below.2a.
2b.
After 16 hours on the ICU the blood output from the left basal thoracostomy tube suddenly rose to 600ml/hour, with associated lactic acidosis and transfusion requirement. He was taken to theatre for a left-sided thoracotomy where the following injuries were found and repaired: left-sided longitudinal rupture of the pericardium and cardiac herniation; left ventricular laceration secondary to overlying rib fractures; multiple lung lacerations; and multiple flail ribs.A 3-week ITU admission ensued, which was complicated by pulmonary ARDS and recurrent atrial flutter. He was discharged home after 6 weeks fully independent.Pathophysiology - Pericardial tears may involve either the superior, left or right pleuropericardium or the diaphragmatic pericardium. The defect can allow cardiac luxation and, in the case of diaphragmatic pericardial tear, herniation of abdominal contents. Clarke et al. reviewed 142 cases and found the superior/left/right pleuropericardium were injured in 4%/50%/17% respectively with 27% occurring in the diaphragmatic pericardium3,6. The rate of cardiac herniation was 28%3; however, in a more recent literature search, a rate of 64% of BTPR developed cardiac herniation6. Defects of the pleuropericardium usually occur vertically along the phrenic nerve7. If the tear is approaching 8-12cm, the heart can sublux through the defect8. The resulting torsion of the great vessels can lead to a form of obstructive cardiogenic shock7. Clinical Presentation – Road traffic collisions and sudden decelerations are the most common mechanisms for BTPR. The following pattern of associated injuries should also arouse suspicion of BTPR3:•Cardiac - contusions and dysrrthmias (28%) Penetrating cardiac injury secondary to rib fractures seen in case 2, is not something previously reported.• Chest - rib fractures, haemopneumothoraces and pulmonary contusions are almost universally seen. • Neurological - thoracic spine fractures, SCI and traumatic brain injuries (32%)• Abdominal injuries (27%)• Pelvic and long bone fracture indicative of a high velocity/energy impact (49%)Symptoms - The patient may report palpitations, shortness of breath, chest and angina-type pains2. Clinical signs - may be subtle but include:• Signs similar to that of tamponade; hypotension, pulsus paradoxus and raised JVP2. This haemodynamic compromise may manifest itself despite fluid administration and inotropic support. • Fluctuating haemodynamic parameters, sometimes to the extent of sudden cardiac arrest (often as a result of change in patient’s position) which should evoke a very high index of suspicion of BTPR.
Case 1. A 21-year-old male was admitted to the Royal London hospital (RLH) via a district general hospital following a motorbike accident. He was initially hypoxic, cardiovascularly stable, unable to move his legs and had a GCS of 15/15. Over the next 36 hours his haemodynamic indices deteriorated despite bilateral tube thoracostomies, fluids and inotropes; spinal shock was implicated and transferred as such. Peri-transfer, the patient’s condition deteriorated and on arrival he was in cardiorespiratory extremis. In the handover, little mention was made of his newly developed dextracardia, high Alveolar-arterial gradient and extreme inotropic support. The patient was re-trauma called and the following chest radiograph (Figure 1a) and coronal chest computed tomography (Figure 1b) images were obtained. 1a.
1b.
Given the large pneumopericardium and displaced heart on computed tomography (CT), a clamshell thorocotomy was performed and a large right-sided tear of the pericardium with cardiac herniation was found. The heart was relocated and the pericardium was repaired. There was an immediate reduction in inotropic support. Post operative issues included a ventilator acquired pneumonia, paraplegia secondary to a spinal cord injury (SCI) and AF. That aside, he made a good recovery during his 14-day ICU stay.Case 2. A 45-year-old male who was the driver in a road traffic collision and was brought into the RLH by air ambulance. Pre-hospital, he was intubated with drug assistance and had bilateral thoracostomies. He was noted on arrival to have a multitude of rib fractures, flail chest and surgical emphysema. Bilateral tube thoracostomies were placed with immediate improvement in ventilation/oxygenation. Of note cardiac pulsations were felt with the finger sweep of the left pleural space.
CONCLUSIONBTPR and cardiac herniation is a complex and often fatal injury that usually presents under the umbrella of polytrauma. Clinicians must maintain a high index of suspicion for BTPR but, even then, the diagnosis is fraught with difficulty. In blunt chest trauma, patients should be considered high risk for BTPR when presenting with:
• Cardiovascular instability with no obvious cause•Prominent or displaced cardiac silhouette and asymmetrical large volume pneumopericardium
In the majority of cases, it is still an injury diagnosed at autopsy or thoracotomy. With increasing awareness of the injury and improved use and availability of imaging modalities, the survival rates will improve and cardiac ‘H ’erniation could even be considered the 5th H of reversible causes of blunt traumatic PEA arrest.
REFERENCES
•Tachycardia and dysrrthymias may be seen, such as the atrial tachyarrythmias. • Displaced and heaving apex beat2,7
• A splashing murmur “bruit de Moulin” as a result of the heart moving in a haemopneumopericardium9.
Investigations - There are a multitude of investigations available to assist in the diagnosis:i.Electrocardiogram - dysrrthymias, axis deviation2,7,10 and bundle branch block8,9
may all be present. Ischaemic changes may be noted as a result of extra luminal coronary artery occlusion7,10. Rippey et al10 reported an elevated Troponin I of 9.20 μg/L. ii.Chest radiograph – is a valuable tool and abnormalities include a prominent cardiac silhouette (“boot shaped”); distinct visible pericardial contour; pneumopericardium; pneumomediastinum; bowel loops within pericardial sac and cardiac herniation into either hemithorax 2,7,9. Associated pulmonary and skeletal pathology will usually be seen10.•Echocardiography - Has been used but the sensitivity for diagnosing even large pericardial defects is thought to be low6. The importance of transthoracic echo lies in its ability to rule out differential diagnoses (cardiac contusion/ tamponade) quickly in the shocked patient.•CT - is a more sensitive tool for identifying BTPR and cardiac herniation than plain radiographs. Changes indicative of pericardial rupture include6:
- Focal pericardial dimpling and discontinuity - Pneumopericardium - Interposition of lung between mediastinal structures.
Characteristic changes for a cardiac heniation6:
- “Empty pericardial sac” sign- “Collar” sign, constriction of the cardiac contour by the pericardial band/defect
•Magnetic Resonance Imaging (MRI) – Cardiac MR has been used in diagnostic uncertainties6.
Management - Once BTPR and cardiac herniation is recognised, the treatment is simple and effective and involves rapid surgical relocation of the heart and closure of pericardial defect 3,9.
1. Bettman R B et al. Herniation of the heart. Ann. Surg 1948: 128; 1012-1014.
2. Wright MP et al. Herniation of the heart. Thorax 1970:25;656-666.
3. Clark DE et al. Traumatic rupture of the pericardium. Surgery 1983: 93; 495-503.
4. Fulda G et al. Blunt traumatic rupture of the heart and the pericardium: A ten-year experience(1979--1989). J Trauma 1991: 31; 167-173
5. Farhataziz N et al. Pericardial rupture after blunt chest trauma. J Thorac Imaging 2005: 20; 50-52
6. Sohn JH et al. Pericardial rupture and cardiac herniation after blunt trauma: a case diagnosed using cardiac MRI. The British Journal of Radiology 2005: 78; 447–449
7. Thomas et al. Diagnosis by video assisted thoracoscopy of traumatic pericardial rupture with delayed luxation of the heart: case report. J Trauma 1995: 38; 967–70.
8. Carillo EH et al. Cardiac Herniation Producing Tamponade: The Critical Role of Early Diagnosis. The journal of Trauma injury, infection and critical care. 1997; 43(1): 19-23
9. Janson JT et al.Pericardial rupture and cardiac herniation after blunt chest trauma Ann Thorac Surg 2003: 75; 581-582
10. Rippey JCR et al. Blunt traumatic rupture of the pericardium with cardiac herniation. CJEM 2004: 6(2); 126-129
