Blunt trauma to the heart and great vessels

Predictors of poor outcomes after significant chest trauma in multiply injured patients: a retrospective analysis from the German Trauma Registry (Trauma Register DGU®)

Background

Blunt thoracic trauma is one of the critical injury mechanisms in multiply injured trauma victims. Although these patients present a plethora of potential structural damages to vital organs, it remains debated which injuries actually influence outcome and thereby should be addressed initially. Hence, the aim of this study was to identify the influence of critical structural damages on mortality.

Methods

All patients in the database of the TraumaRegister DGU® (TR-DGU) from 2002–2011 with AIS Chest ≥ 2, blunt trauma, age of 16 or older and an ISS ≥ 16 were analyzed.

Outcome parameters were in-hospital mortality as well as ventilation time in patients surviving the initial 14 days after trauma.

Results

22613 Patients were included (mean ISS 30.5 ± 12.6; 74.7% male; Mean Age 46.1 ± 197 years; mortality 17.5%; mean duration of ventilation 7.3 ± 11.5; mean ICU stay 11.7 ± 14.1 days).

Only a limited number of specific injuries had a significant impact on survival. Major thoracic vessel injuries (AIS ≥5), bilateral lung contusion, bilateral flail chest, structural heart injury (AIS ≥3) significantly influence mortality in study patients. Several extrathoracic factors (age, blood transfusion, systolic blood pressure and extrathoracic severe injuries) were also predictive of increased mortality.

Most injuries of the thoracic wall had no or only a moderate effect on the duration of ventilation. Injuries to the lung (laceration, contusion or pneumothoraces) had a moderate prolonging effect. Cardiac injuries and severe injuries to the thoracic vessels induced a substantially prolonged ventilation interval.

Conclusions

We demonstrate quantitatively the influence of specific structural damages of the chest on critical outcome parameters. While most injuries of the chest wall have no or only limited impact in the study collective, injuries to the lung overall show adverse outcome. Injuries to the heart or thoracic vessels have a devastating prognosis following blunt chest trauma.

Spontaneous obliteration of right ventricular pseudoaneurysm after blunt chest trauma: diagnosis and follow-up with multidetector CT

Right ventricular (RV) pseudoaneurysm caused by trauma is very rare. We report a case of RV pseudoaneurysm which resolved without surgical treatment in a patient who survived a falling accident. Echocardiography failed to identify the pseudoaneurysm. Electrocardiography-gated CT showed a 17-mm-sized saccular pseusoaneurysm arsing from the RV outflow tract with a narrow neck. Follow-up CT after two months showed spontaneous obliteration of the lesion.

Traumatic acute myocardial ischaemia involving two vessels

Myocardial infarctions caused by coronary artery injury after blunt chest trauma is a fatal, but rare occurrence. In the case reported on here, a fatally injured 69-year-old male driver sustained such trauma in a frontal car collision. The autopsy found a laceration of the left anterior descending artery as well as a subsequent subepicardial haematoma surrounding this artery and the circumflex artery. Using triphenyl tetrasolium chloride and hematoxillin-eosin stains, an acute myocardial ischaemia of the anterior left ventricle wall and the septum was diagnosed as the cause of death. Since coronary injuries affecting more than one vessel in blunt chest trauma are extremely rare, only a few papers have yet to refer to this type of coronary injury in addition to the case presented here.

The role of post-mortem CT (PMCT) imaging in the diagnosis of pericardial tamponade due to hemopericardium: A case report

Hemopericardium (HP) is frequently found at autopsy, but it represents a challenge for the forensic pathologist when having to assess its etiopathological relationship in causing death, particularly in those cases where ante-mortem clinical and instrumental data are not available. The diagnosis of pericardial tamponade (PT), in fact, is based on signs, symptoms and instrumental evidence and not only on the presence of HP. Post-mortem imaging techniques are actually considered a useful and non-invasive method able to enhance traditional procedures in demonstrating critical forensic findings; consequently, post-mortem imaging methods have been widely introduced in forensic investigations. We report a case of death clearly due to PT caused by ruptured dissected aneurysm of the aorta, submitted to post-mortem CT (PMCT) and PMCT angiography prior to autopsy. PMCT imaging permitted to solve the case without performing autopsy. In the paper we identify PMCT findings suggestive of PT with the aim of verifying the possibility to use post-mortem evidence to retrospectively demonstrate an in vivo dynamic clinical condition, such as PT.

Management of the congenital aneurysm of the left ventricle associated with mitral insufficiency in a child: a case report

The combination of congenital left ventricular aneurysm associated with mitral insufficiency is rare. We describe the case of a girl aged 11 years, bearing these two entities simultaneously. Aneurysmal resection of the left ventricle was performed with Dor technic to allow remodelation of the anatomy of the left ventricle. Mitral annuloplasty was performed through a transseptal approach. Three months after surgery, the child presents a good myocardial contractility without mitral regurgitation and normal ejection fraction.

Blunt polytrauma: evaluation with 64-section whole-body CT angiography

Blunt polytrauma remains a leading cause of death and disability worldwide. With the major advances in computed tomography (CT) technology over the past decade, whole-body CT is increasingly recognized as the emerging standard for providing rapid and accurate diagnoses within the narrow therapeutic window afforded to trauma victims with multiple severe injuries. With a single continuous acquisition, whole-body CT angiography is able to demonstrate all potentially injured organs, as well as vascular and bone structures, from the circle of Willis to the symphysis pubis. As its use becomes more widespread, the large volume of information inherent to whole-body CT poses new challenges to radiologists in providing efficient and timely interpretation. An awareness of trauma scoring systems and injury mechanisms is essential to maintain an appropriate level of suspicion in the search for multiple injuries, and the use of multiplanar reformation and three-dimensional postprocessing techniques is important to maximize efficiency in the search. Knowledge of the key injuries that require urgent surgical or percutaneous intervention, including major vascular injuries and active hemorrhage, diaphragmatic rupture, unstable spinal fractures, pancreatic injuries with ductal involvement, and injuries to the mesentery and hollow viscera, is also necessary.

Stentless bioprosthesis for treatment of traumatic aortic valve rupture

Aortic valve rupture after blunt trauma to the chest is an infrequent complication that should be considered at the outset in examination of an accident victim. The presence of aortic regurgitation with hemodynamic instability is an indication for surgery. We implanted a stentless bioprosthesis after aortic valve rupture due to chest trauma in a 31-year-old man with schizophrenia.

Shot to the heart: a case of traumatic ventricular septal aneurysm and review of the literature

Traumatic cardiac injuries are an uncommon diagnosis in the pediatric population. Of the traumatic cardiac injuries, more than 95% are contusions. Traumatic ventricular aneurysms are exceptionally rare, and most are detected during long-term follow-up. They are usually successfully managed medically but can require emergent surgical intervention. We report the case of a 6-year-old boy who was in a motor vehicle collision. He was found to have profound sinus bradycardia during initial resuscitation with hypotension. An electrocardiogram showed complete heart block. A cardiologist was consulted, and an echocardiogram was performed, which revealed a ventricular septal aneurysm. The case is followed by a review of the literature on traumatic cardiac injuries and ventricular septal aneurysms in the pediatric population.

[Coronary artery dissection complicated by myocardial infarction in a head trauma patient]

Acute myocardial infarction, following coronary artery dissection, is a rare, but potentially fatal, syndrome after blunt chest trauma. The treatment is more complicated when intracerebral lesions are present, because of the need of anticoagulation. We report the case of a 37-year-old male patient, suffering from a polytraumatism with intracranial petechial haemorrhages who have a left coronary artery dissection with acute myocardial infarction.

Role of imaging in penetrating and blunt traumatic injury to the heart

Cardiac injury due to blunt or penetrating chest trauma is common and is associated with significant morbidity and mortality. Understanding the mechanisms, types, and complications of cardiac injuries and the roles of various imaging modalities in characterizing them is important for appropriate diagnosis and treatment. These injuries have not been well documented at imaging, but there are now fast and accurate methods for evaluating the heart and associated mediastinal structures. The authors review the broad spectrum of injuries that can result from blunt or penetrating trauma to the chest, as well as the imaging modalities commonly used in the acute trauma setting for evaluation of the heart and mediastinal structures. A pictorial review of both common and, to date, rarely documented cardiac injuries imaged with a variety of modalities is also presented. While many imaging modalities are available, the authors demonstrate the value of multidetector computed tomography (CT) for the initial evaluation of patients with blunt or penetrating chest trauma. With the advent of multidetector CT, imaging of cardiac injury has increased and accurate identification of these rare but potentially lethal injuries has become paramount for improving survival. Selection of the most appropriate modality for evaluation and recognition of the imaging findings in cardiac injuries in the acute trauma setting is important to expedite treatment and improve survival.

A Rare Case of Acute Myocardial Infarction due to Coronary Artery Dissection and Heparin-Induced Thrombocytopenia

Although both coronary artery dissection and heparin-induced thrombocytopenia may provoke myocardial infarction, it is extremely rare for both conditions to develop simultaneously in a single patient. We report a case of a 69-year-old woman who sustained a head-on motor vehicle accident with associated chest trauma. During a subsequent hospitalization, she was exposed to subcutaneous heparin and developed significant thrombocytopenia. Shortly thereafter, she re-presented with an acute myocardial infarction. Coronary angiography revealed a spiral dissection with superimposed thrombosis within the right coronary artery, while laboratory testing confirmed the diagnosis of heparin induced thrombocytopenia. She was treated with catheter-based thrombectomy and adjunctive direct thrombin inhibitor therapy, followed by three months of systemic anticoagulation with warfarin. To our knowledge, this represents the first published case of a native vessel myocardial infarction due to the combination of coronary artery dissection and heparin-induced thrombocytopenia.

Ventricular septal necrosis after blunt chest trauma

Ventricular Septal Defect (VSD) after blunt chest trauma is a very rare traumatic affection. We report here a case of blunt chest injury-related VSD and pseudoaneurysm. A 30-year old male truck driver was referred from a trauma center to our hospital seven days after a blunt chest trauma and rib fracture. The patient had severe pulmonary edema and echocardiography showed large VSD. Several mechanisms are involved in the pathogenesis of this affection including an acute compression of the heart muscle between the sternum and the spine, leading to excessive changes in the intrathoracic and most likely the intracardiac pressure after blunt chest injury. Traumatical patients with the same symptoms may be at risk of sudden death. Therefore, a high grade of suspicion is mandatory even without solid evidence of myocardial damage on the initial evaluation. In continue some hidden angles of this case was discussed. Given the prognostic implications of traumatic VSD with associated pseudoaneurysm, its detection has critical value for preventing its clinical sequelae.

Dobutamine stress echocardiography assessment of myocardial contusion due to blunt impact in dogs

We sought to investigate the role of two-dimensional stress echocardiography in the early assessment of myocardial contusion. For this purpose, 12 dogs, weighing 11.36 ± 1.50 kg, were selected and the myocardial contusion was experimentally induced. Two-dimensional dobutamine stress echocardiography (DSE) was used to detect abnormal myocardial motions segments at time phases of baseline and 0.5, 2, 4, and 8 h post-wounding. Finally, the above results were compared with pathological findings. The data show that after the dogs were induced to have severe myocardial contusion, 122 segments were found with abnormal myocardial wall motions at 0.5 h post-wounding, 133 segments at 2 h post-wounding, and 142 segments, each, at 4 h and 8 h post-wounding. The wall motion score (WMS) and wall motion score index (WMSI) increased (P < 0.001) as compared with the pre-impaction values. Considering the left ventricular axis view as the standard section, in the 60 segments examined by echocardiography, 54 segments were found to have wall motion abnormalities. Comparing with the results of pathological TTC staining, the sensitivity and specificity were found to be 100 and 66.6%, respectively. It was, therefore, concluded that two-dimensional DSE was a valuable technique in the early diagnosis of myocardial contusion due to its better sensitivity and specificity.

[Traumatic tricuspid valve insufficiency with right-to-left shunt: bridging using extracorporeal venovenous membrane oxygenation]

The case of a young male motor vehicle driver is reported who suffered multiple trauma in a car accident with pulmonary and cardiac contusions. In the course of severe pneumonia and traumatic tricuspid valve insufficiency a right-to-left shunt with refractory hypoxemia developed across a pre-existing atrial septal defect (ASD). The patient could be successfully treated by the combination of extracorporeal membrane oxygenation for bridging, interventional ASD occlusion and in the long-term by operative reconstruction of the tricuspid valve.

Blunt cardiac injury in trauma patients with thoracic aortic injury

Trauma patients with thoracic aortic injury (TAI) suffer blunt cardiac injury (BCI) at variable frequencies. This investigation aimed to determine the frequency of BCI in trauma patients with TAI and compare with those without TAI. All trauma patients with TAI who had admission electrocardiography (ECG) and serum creatine kinase-MB (CK-MB) from January 1999 to May 2009 were included as a study group at a level I trauma center. BCI was diagnosed if there was a positive ECG with either an elevated CK-MB or abnormal echocardiography. There were 26 patients (19 men, mean age 45.1 years, mean ISS 34.4) in the study group; 20 had evidence of BCI. Of 52 patients in the control group (38 men, mean age 46.9 years, mean ISS 38.7), eighteen had evidence of BCI. There was a significantly higher rate of BCI in trauma patients with TAI versus those without TAI (77% versus 35%, P < 0.001).

Ventricular septal defect as a result of direct trauma from mechanical mitral valve prosthesis

We present a case of a patient with preexisting mechanical mitral valve who developed a traumatic ventricular septal defect following a motor vehicle accident. Serial transthoracic echocardiography revealed the progressive nature of the defect. Surgical repair was delayed due to significant noncardiac comorbidities. The ventricular septal defect was found in an unusual location in the membranous portion of the interventricular septum. We discuss the possible etiologic mechanisms of injury as well as the importance of timely surgical repair.

Acute myocardial infarction caused by coronary artery dissection after a blunt chest trauma

Acute myocardial infarction is a life-threatening condition. Coronary dissection after blunt chest trauma is a rare event. Chest pain is a common symptom after chest trauma, which may relate to chest contusion without cardiac injury or myocardial infarction. Differentiation between minor cardiac contusion and significant cardiac injury is difficult and it is a challenge for physicians to diagnose traumatic cardiac injury early. We report a case of a 40-year-old man suffering from coronary artery dissection after a blunt chest trauma and intracranial hemorrhage after percutaneous coronary intervention.

Partial aortic annulus avulsion and formation of aortic-left ventricle tunnel through interventricular septum after blunt cardiac trauma

Traumatic aortic-left ventricle tunnel through interventricular septum was particularly a rare event that has never previously been described. A 58-year-old male, with a history of blunt thoracic trauma caused by falling from height, was admitted to our institute for effort dyspnea. Chest computed tomography scan showed subaortic interventricular septal lumen communicating with coronary sinus and left ventricular outflow tract (LVOT). Transthoracic echocardiography revealed a shuttle flow from coronary sinus to LVOT bypassing aortic annulus during diastole. Operation examination found partial aortic annulus avulsion outside right coronary cusp involving superior interventricular septum dissection forming a tunnel breakthrough into left ventricular outflow tract. Both aortic orifice and LVOT orifice of the tunnel were closed with running Prolene suture and right coronary cusp annulus was fastened to aortic root with intermittent mattress suture. The postoperative course was uneventful. Echocardiography confirmed complete closure of the tunnel with residual trivial to mild aortic regurgitation during 1-month follow-up.

Cardiogenic shock following blunt chest trauma

Cardiac contusion, usually caused by blunt chest trauma, has been recognized with increased frequency over the past decades. Traffic accidents are the most frequent cause of cardiac contusions resulting from a direct blow to the chest. Other causes of blunt cardiac injury are numerous and include violent fall impacts, interpersonal aggression, explosions, and various types of high-risk sports. Myocardial contusion is difficult to diagnose; clinical presentation varies greatly, ranging from lack of symptoms to cardiogenic shock and arrhythmia. Although death is rare, cardiac contusion can be fatal. We present a case of cardiac contusion due to blunt chest trauma secondary to a fall impact, which manifested as cardiogenic shock.

Cardiac rupture following blunt trauma

Cardiac rupture is the most extreme manifestation of blunt cardiac injury. In the first half of the 20th century this lesion was uniformly fatal. Since the first successful post-traumatic cardiorrhaphy by Desforges in 1955, multiple case reports and retrospective reviews have documented successful operative repair and survival of patients with this injury. Despite these successes, blunt cardiac rupture remains associated with a high mortality rate. The rarity of this condition and the heterogeneity of the literature make determination of exact epidemiologic data difficult. The classic clinical presentation is not universal and a subset of patients may present asymptomatically. Rapid transportation to medical care, accurate timely diagnosis and emergent operative intervention are essential for successful outcome. The use of ultrasonography in the trauma bay is a key component of early identification of these injuries. Specific outcome factors associated with survival are difficult to determine and even in those who survive to medical attention mortality rates remain as high as 60—90%.

Pictorial review: computed tomography features of cardiovascular emergencies and associated imminent decompensation

Multi-detector computed tomography (MDCT) scanner is available in most hospitals and is increasingly being used as the first line imaging in trauma and suspected cardiovascular emergencies, such as acute coronary syndrome, pulmonary artery thrombo-embolism, abdominal aortic aneurysm and acute haemorrhage (Ryan et al. Clin Radiol 60:599-607, 2005). A significant number of these patients are haemodynamically unstable and can rapidly progress into shock and death. Recognition of computed tomography (CT) signs of imminent cardiovascular decompensation will alert the clinical radiologist to the presence of shock. In this review, the imaging findings of cardiovascular emergencies in both acute traumatic and non-traumatic settings with associated signs of imminent decompensation will be described and illustrated.

Delayed presentation of a post-traumatic left ventricular pseudoaneurysm in a child

Left ventricular pseudoaneurysms can occur after myocardial infarction or trauma, but are extremely rare in pediatric patients. We present a case of post-traumatic left ventricular pseudoaneurysm, in whom the causative event was some time before the acute clinical deterioration. The 9-year-old boy had repeated presentations for chest pain and lethargy for some months prior to admission. The report describes an effective primary suture repair.

Multidetector computed tomography in post-traumatic ventricular pseudoaneurysm

We report a 20-year-old male with rare asymptomatic aneurysm of the left ventricle that was concluded to be a pseudoaneurysm given its calcified walls and the history of severe blunt chest trauma 8 years ago. Multidetector computed tomography (CT) angiography of the coronary vessels helped exclude vascular insult and suggest traumatic intramyocardial dissection as underlying etiopathogenesis, besides providing a good view of aneurysm and cardiac morphology in relation to coronary vessels.

Evaluation and management of acute vascular trauma

With the technical advances and the increasing availability of sophisticated imaging equipment, techniques, and protocols, and with continually evolving transcatheter endovascular therapies, minimally invasive imaging and treatment options are being routinely used for the clinical management of trauma patients. Thus, the primary treatment algorithm for managing acute vascular trauma now increasingly involves the interventional radiologist or other endovascular specialist. Endovascular techniques represent an attractive option for both stabilizing and definitively treating patients who have sustained significant trauma, with resultant vascular injury. Endovascular treatment frequently offers the benefit of a focused definitive therapy, even in the presence of massive hemorrhage that allows for preservation of major vessels or injured solid organs and serves as an alternative to an open surgical intervention. This article presents an overview of various endovascular techniques that can be used for trauma patients presenting with vascular injuries.

Challenges in the diagnosis of blunt cardiac injuries

INTRODUCTION

Blunt thoracic injuries (BTIs) are directly responsible for 20-25% of all deaths, worldwide. Involvement of heart in BTIs is largely underestimated and ignored, but reasonable estimate would be around 15%. This study was planned to emphasize on clinical-presentation and diagnosis of blunt cardiac injuries (BCIs).

RESULTS

Clinical presentation of BCIs, varied from mild chest discomfort to haemodynamic shock secondary to rapid exsanguinations. Non-specific presentation with associated injuries diverts physician's attention and delayed appearance of clinical features makes diagnosis further difficult. Cardiac markers and ECG are not specific, but high sensitivity of 100% could be reached using combination of elevated cardiactroponin levels and alterations in ECG. Transoesophageal or transthoracic echocardiography, angiography, intravascular ultrasound and nuclear scan have proven to detect cardiac injuries in BTIs, but lack specificity.

CONCLUSION

Patients with suspicious-ECG finding need cardiac-monitoring for at least 24 hours. Haemodynamically stable young (<55 years) subjects, without underlying cardiac diseases and with normal-ECG and cardiac marker, could be discharged safely.

Blast injuries

Health-care providers are increasingly faced with the possibility of needing to care for people injured in explosions, but can often, however, feel undertrained for the unique aspects of the patient's presentation and management. Although most blast-related injuries (eg, fragmentation injuries from improvised explosive devices and standard military explosives) can be managed in a similar manner to typical penetrating or blunt traumatic injuries, injuries caused by the blast pressure wave itself cannot. The blast pressure wave exerts forces mainly at air-tissue interfaces within the body, and the pulmonary, gastrointestinal, and auditory systems are at greatest risk. Arterial air emboli arising from severe pulmonary injury can cause ischaemic complications-especially in the brain, heart, and intestinal tract. Attributable, in part, to the scene chaos that undoubtedly exists, poor triage and missed diagnosis of blast injuries are substantial concerns because injuries can be subtle or their presentation can be delayed. Management of these injuries can be a challenge, compounded by potentially conflicting treatment goals. This Seminar aims to provide a thorough overview of these unique primary blast injuries and their management.

Right atrial rupture from blunt thoracic trauma in a 4-year-old child

Blunt cardiac injury in the pediatric population has been less frequently reported than in the adult population. Cardiac chamber rupture is a rare but highly lethal injury in both populations. The lethality of this condition is further enhanced by the multiplicity of injuries that are frequently present. The diagnosis of cardiac chamber rupture is often delayed while other injuries are being addressed. A high index of suspicion and early use of the appropriate imaging studies are essential for the timely diagnosis of this condition. In this report, we present a 4-year-old child who survived 10 hours of pericardial tamponade secondary to blunt right atrial rupture.

Multidetector CT of blunt thoracic trauma

Thoracic injuries are significant causes of morbidity and mortality in trauma patients. These injuries account for approximately 25% of trauma-related deaths in the United States, second only to head injuries. Radiologic imaging plays an important role in the diagnosis and management of blunt chest trauma. In addition to conventional radiography, multidetector computed tomography (CT) is increasingly being used, since it can quickly and accurately help diagnose a wide variety of injuries in trauma patients. Furthermore, multiplanar and volumetric reformatted CT images provide improved visualization of injuries, increased understanding of trauma-related diseases, and enhanced communication between the radiologist and the referring clinician.