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Becker ER, Price AD, Whitrock JN, Smith M, Baucom MR, Makley AT, Goodman MD. Re-evaluating the Use of High Sensitivity Troponin to Diagnose Blunt Cardiac Injury. J Surg Res 2024; 300:150-156. [PMID: 38815513 DOI: 10.1016/j.jss.2024.04.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 04/18/2024] [Accepted: 04/28/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Blunt cardiac injury (BCI) can be challenging diagnostically, and if misdiagnosed, can lead to life-threatening complications. Our institution previously evaluated BCI screening with troponin and electrocardiogram (EKG) during a transition from troponin I to high sensitivity troponin (hsTnI), a more sensitive troponin I assay. The previous study found an hsTnI of 76 ng/L had the highest capability of accurately diagnosing a clinically significant BCI. The aim of this study was to determine the efficacy of the newly implemented protocol. METHODS Patients diagnosed with a sternal fracture from March 2022 to April 2023 at our urban level-1 trauma center were retrospectively reviewed for EKG findings, hsTnI trend, echocardiogram changes, and clinical outcomes. The BCI cohort and non-BCI cohort ordinal measures were compared using Wilcoxon's two-tailed rank sum test and categorical measures were compared with Fisher's exact test. Youden indices were used to evaluate hsTnI sensitivity and specificity. RESULTS Sternal fractures were identified in 206 patients, of which 183 underwent BCI screening. Of those screened, 103 underwent echocardiogram, 28 were diagnosed with clinically significant BCIs, and 15 received intervention. The peak hsTnI threshold of 76 ng/L was found to have a Youden index of 0.31. Rather, the Youden index was highest at 0.50 at 40 ng/L (sensitivity 0.79 and specificity 0.71) for clinically significant BCI. CONCLUSIONS Screening patients with sternal fractures for BCI using hsTnI and EKG remains effective. To optimize the hsTnI threshold, this study determined the hsTnI threshold should be lowered to 40 ng/L. Further improvements to the institutional protocol may be derived from multicenter analysis.
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Affiliation(s)
- Ellen R Becker
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Adam D Price
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jenna N Whitrock
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Maia Smith
- Cape Fox Federal Integrators, Manassas, Virginia
| | - Matthew R Baucom
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amy T Makley
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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2
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Biffl WL, Fawley JA, Mohan RC. Diagnosis and management of blunt cardiac injury: What you need to know. J Trauma Acute Care Surg 2024; 96:685-693. [PMID: 37968802 DOI: 10.1097/ta.0000000000004216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
ABSTRACT Blunt cardiac injury (BCI) encompasses a wide spectrum, from occult and inconsequential contusion to rapidly fatal cardiac rupture. A small percentage of patients present with abnormal electrocardiogram or shock, but most are initially asymptomatic. The potential for sudden dysrhythmia or cardiac pump failure mandates consideration of the presence of BCI, including appropriate monitoring and management. In this review, we will present what you need to know to diagnose and manage BCI.
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Affiliation(s)
- Walter L Biffl
- From the Division of Trauma/Acute Care Surgery (W.L.B., J.A.F.) and Division of Cardiology (R.C.M.), Scripps Clinic/Scripps Clinic Medical Group, La Jolla, California
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3
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Deep A, Chan C, Adamson PD, Troughton R, Woodcock E. Isolated Traumatic Membranous Interventricular Septal Rupture: A Rare Complication Following a Motor Vehicle Accident. CASE (PHILADELPHIA, PA.) 2024; 8:303-307. [PMID: 38765627 PMCID: PMC11096650 DOI: 10.1016/j.case.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
•Isolated VSRs are rare after blunt force trauma. •Traumatic VSRs more commonly occur within the apex. •Early diagnosis with echocardiography is imperative for optimal management of VSRs. •Treatment for VSRs involves percutaneous or surgical closure depending on the size.
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Affiliation(s)
- Aashna Deep
- Department of Cardiology, Christchurch Hospital, Christchurch, Canterbury, New Zealand
| | - Christina Chan
- Department of Cardiology, Christchurch Hospital, Christchurch, Canterbury, New Zealand
| | - Philip D. Adamson
- Department of Cardiology, Christchurch Hospital, Christchurch, Canterbury, New Zealand
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, Canterbury, New Zealand
| | - Richard Troughton
- Department of Cardiology, Christchurch Hospital, Christchurch, Canterbury, New Zealand
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, Canterbury, New Zealand
| | - Ellen Woodcock
- Department of Cardiology, Christchurch Hospital, Christchurch, Canterbury, New Zealand
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, Canterbury, New Zealand
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Maayah M, Grubman S, Allen S, Ye Z, Park DY, Vemmou E, Gokhan I, Sun WW, Possick S, Kwan JM, Gandhi PU, Hu JR. Clinical Interpretation of Serum Troponin in the Era of High-Sensitivity Testing. Diagnostics (Basel) 2024; 14:503. [PMID: 38472975 DOI: 10.3390/diagnostics14050503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 03/14/2024] Open
Abstract
Cardiac troponin (Tn) plays a central role in the evaluation of patients with angina presenting with acute coronary syndrome. The advent of high-sensitivity assays has improved the analytic sensitivity and precision of serum Tn measurement, but this advancement has come at the cost of poorer specificity. The role of clinical judgment is of heightened importance because, more so than ever, the interpretation of serum Tn elevation hinges on the careful integration of findings from electrocardiographic, echocardiographic, physical exam, interview, and other imaging and laboratory data to formulate a weighted differential diagnosis. A thorough understanding of the epidemiology, mechanisms, and prognostic implications of Tn elevations in each cardiac and non-cardiac etiology allows the clinician to better distinguish between presentations of myocardial ischemia and myocardial injury-an important discernment to make, as the treatment of acute coronary syndrome is vastly different from the workup and management of myocardial injury and should be directed at the underlying cause.
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Affiliation(s)
- Marah Maayah
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Scott Grubman
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephanie Allen
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Zachary Ye
- Department of Internal Medicine, Temple University Medical Center, Philadelphia, PA 19140, USA
| | - Dae Yong Park
- Department of Internal Medicine, Cook County Hospital, Chicago, IL 60612, USA
| | - Evangelia Vemmou
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Ilhan Gokhan
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Wendy W Sun
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephen Possick
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Jennifer M Kwan
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Parul U Gandhi
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
- Department of Cardiology, Veterans Affairs Connecticut Health Care System, West Haven, CT 06516, USA
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
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Tetsumoto K, Takayama M, Koyama T, Kayawake H, Saito M, Nakamura K, Takahashi Y, Hamakawa H. Penetrating cardiac injury caused by multiple rib fractures following high-energy trauma: Usefulness of the exploratory video-assisted thoracoscopic surgery. Acute Med Surg 2024; 11:e938. [PMID: 38596161 PMCID: PMC11002335 DOI: 10.1002/ams2.938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/03/2024] [Accepted: 02/25/2024] [Indexed: 04/11/2024] Open
Abstract
Background Penetrating cardiac injuries are usually fatal and associated with poor survival rates. Case Presentation A 69-year-old man was injured in a motor vehicle accident and suffered from left hemothorax and multiple rib fractures near the heart. A comprehensive assessment raised suspicions of lacerated pericardium and myocardial injury. Consequently, a thoracoscopy was performed 9 h after injury. A penetrating cardiac injury was detected and surgically treated via video-assisted thoracoscopic surgery. The patient recovered uneventfully and was discharged on postoperative day 16. Conclusion Exploratory video-assisted thoracoscopic surgery may play a key role in the primary diagnosis of patients with high-energy chest traumas with cardiac injury and simultaneously allow for the appropriate surgical interventions.
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Affiliation(s)
- Keisuke Tetsumoto
- Department of Thoracic SurgeryKobe City Medical Center General HospitalKobeJapan
- Department of Thoracic SurgeryHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Masakazu Takayama
- Department of Thoracic SurgeryKobe City Medical Center General HospitalKobeJapan
| | - Tadaaki Koyama
- Department of Cardiovascular SurgeryKobe City Medical Center General HospitalKobeJapan
| | - Hidenao Kayawake
- Department of Thoracic SurgeryKobe City Medical Center General HospitalKobeJapan
| | - Masao Saito
- Department of Thoracic SurgeryKobe City Medical Center General HospitalKobeJapan
| | - Ken Nakamura
- Department of Cardiovascular SurgeryKobe City Medical Center General HospitalKobeJapan
| | - Yutaka Takahashi
- Department of Thoracic SurgeryKobe City Medical Center General HospitalKobeJapan
| | - Hiroshi Hamakawa
- Department of Thoracic SurgeryKobe City Medical Center General HospitalKobeJapan
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Bae CM, Cho JY, Jung H, Son SA. Serum pro-B-type natriuretic peptide levels and cardiac index as adjunctive tools of blunt cardiac injury. BMC Cardiovasc Disord 2023; 23:81. [PMID: 36765285 PMCID: PMC9912581 DOI: 10.1186/s12872-022-02990-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 12/02/2022] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Blunt cardiac injury (BCI) has a variety of symptoms that may be a potentially life-threatening injury that can lead to death. Depending on the diagnosis of BCI, treatment direction and length of stay may vary. In addition, the utility of other diagnostic tests for cardiac disease as diagnostic tools for BCI remain unclear. The purpose of this study was to investigate the competence of N-terminal pro-B-type natriuretic peptide (NT pro-BNP) and cardiac index (C.I) as adjunctive diagnostic tools for BCI. METHODS From January 2018 to March 2020, severe trauma patients with sternum fracture who were admitted to the traumatic intensive care unit (TICU) were included this study. Patients with sternum fracture, 18 years of age or older, and with an injury severity score > 16 who required intensive care were included. Invasive measurement for the analysis of the pulse contour for C.I monitoring and intravenous blood sampling for NT pro-BNP measurement were performed. Sampling and 12-lead electrocardiogram were performed at different time points as follows: immediately after TICU admission and at 24 h and 48 h after trauma. RESULTS Among 103; 33 patients with factors that could affect NT pro-BNP were excluded; therefore, 63 patients were included in this study. According to the American Association for the Surgery of Trauma Cardiac Injury Scale, 33 patients were diagnosed with non-BCI, and 30 patients constituted with BCI. The median ages of the patients were 58 (52-69), and 60 (45-69) years in the non-BCI and BCI groups, respectively (p = 0.77). The median NT pro-BNP values were higher in the BCI group on admission, hospital day (HD) 2, and HD 3, however, no statistical difference was observed (125 (49-245) vs. 130 (47-428) pg/mL, p = 0.08, 124 (68-224) vs. 187 (55-519) pg/mL, p = 0.09, and 121(59-225) vs. 133 (56-600) pg/mL, p = 0.17, respectively). On the contrary, significantly lower values were observed in the median C.I measurement on admission and HD 3 in the BCI group (3.2 (2.8-3.5) vs. 2.6 (2.3-3.5) L/min/m2, p < 0.01 and 3.2 (3.1-3.9) vs. 2.9 (2.4-3.2) L/min/m2, p < 0.01, respectively); however, no significant difference was observed on HD 2 (3.4 (3.0-3.7) vs. 2.6 (2.4-3.4) L/min/m2, p = 0.17), Furthermore, The median lactate levels in the BCI group upon admission, HD 2, and HD 3 were significantly higher than those in the non-BCI group (1.8 (1.1-2.6) vs. 3.1 (2.1-4.4) mmol/L, p < 0.01; 1.3 (0.8-2.3) vs. 3.0 (2.2-4.7) mmol/L, p < 0.01; and 1.5 (0.9-1.5) vs. 2.2 (1.3-3.7) mmol/L, p < 0.01, respectively). CONCLUSION Consecutive values of NT pro-BNP and C.I show no correlation with ECG-based BCI diagnosis. However, lactate level measurement may help in the early recognition of BCI as an adjunctive tool. It should be noted that this is a hypothesis-generating study for BCI diagnosis. Further studies should be conducted in larger populations with a prospective approach.
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Affiliation(s)
- Chae-Min Bae
- grid.411235.00000 0004 0647 192XDepartment of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, Republic of Korea
| | - Joon Yong Cho
- grid.411235.00000 0004 0647 192XDepartment of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, Republic of Korea
| | - Hanna Jung
- grid.411235.00000 0004 0647 192XDepartment of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, Republic of Korea
| | - Shin-Ah Son
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, Republic of Korea.
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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] [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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Rastogi S, Sharma NR, Rastogi B, Pokhrel M, Sharma J. A Rent in the Left Ventricle: A Sea-Saw Between Life and Death. Cureus 2022; 14:e30665. [PMID: 36439584 PMCID: PMC9685679 DOI: 10.7759/cureus.30665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 06/16/2023] Open
Abstract
Penetrating injuries to the precordium are life-threatening and require early detection and immediate intervention. We present a case of penetrating cardiac injury who presented with a definitive airway and hemodynamically unstable. During the primary survey, the patient had a cardiac arrest with pulseless ventricular tachycardia. The patient was resuscitated as per advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) guidelines with manual digital compression at the penetrating site leading to a return of spontaneous circulation (ROSC). After ROSC, he was shifted for emergency explorative median sternotomy. During the sternotomy, we found a clotted rent in the anterior wall of the left ventricle, which was repaired. Aggressive resuscitation and appropriate management strategy in the emergency department (ED) resulted in a successful outcome, and he was discharged after 10 days of hospital stay. Our case highlights the importance of early diagnosing and managing penetrating cardiac trauma.
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Affiliation(s)
- Suman Rastogi
- Emergency Medicine, Sikkim Manipal Institute of Medical Sciences, Gangtok, IND
| | - Nava R Sharma
- Medicine, Manipal College of Medical Sciences, Pokhara, NPL
| | - Bandana Rastogi
- Medicine, National Medical College and Teaching Hospital, Birgunj, NPL
| | - Madalasa Pokhrel
- Internal Medicine, Montefiore Medical Center, New Rochelle, New Rochelle, USA
| | - Jagdish Sharma
- Medicine, Manipal College of Medical Sciences, Pokhara, NPL
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White A, Cullen P, Hinchion J. Traumatic avulsion of the tricuspid valve: an unusual cardiac complication of an equine accident. BMJ Case Rep 2022; 15:e248580. [PMID: 35606029 PMCID: PMC9125735 DOI: 10.1136/bcr-2021-248580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2022] [Indexed: 11/04/2022] Open
Abstract
A stablehand in his 20s presented with increasing dyspnoea on exertion and chest pain months after being kicked directly in the chest by a horse. Further investigations revealed severe isolated, primary tricuspid regurgitation due to partial avulsion of the anterior leaflet. Open surgical repair was successfully performed from which he recovered uneventfully with resolution of his symptoms and minimal residual tricuspid regurgitation. Although uncommon, blunt force trauma to the chest is becoming increasingly recognised as a rare cause of tricuspid regurgitation. Symptoms may be insidious, and a high index of suspicion is required to avoid missing the diagnosis.
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Affiliation(s)
- Alexandra White
- Cardiothoracic Surgery, Galway University Hospitals, Galway, Ireland
| | - Paul Cullen
- Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
| | - John Hinchion
- Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
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Gentile G, Tambuzzi S, Giovanetti G, Zoja R. Sudden death due to cardiac contusion: Forensic implications in a rare pediatric case. J Forensic Sci 2021; 66:1996-2001. [PMID: 33960426 PMCID: PMC8453835 DOI: 10.1111/1556-4029.14741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 10/28/2022]
Abstract
Blunt chest trauma (BCT) often results in blunt cardiac injuries of little clinical concern, but cases of severe heart damage with high mortality rates have also been described. In particular, BCT should never be underestimated, especially when it is located in the anterior thoracic region. Among traffic accidents, motorcyclists are the most vulnerable and at the greatest risk. We report the case of a 14-year-old boy who experienced BCT following a motorcycle accident. He was evaluated at the hospital and was found to be in good medical condition, without bruises or rib fractures. Electrocardiography revealed a left bundle branch block. The patient was kept overnight for observation and was discharged the following morning in a good health condition. However, five days later, the patient suddenly died. Autopsy revealed a cardiac contusion associated with a full-thickness myocardial rupture and massive hemopericardium. Histologically, hemorrhagic infiltration foci, fibrin deposits, neutrophilic granulocytes, and well-defined areas of necrosis were detected in the context of recent fibrosis. Coronary thrombosis was not observed. The cause of death was identified as cardiac contusion that caused myocardial necrosis and, ultimately, cardiac rupture. Because the boy suffered a recent BCT and was assessed at the hospital, issues of medical malpractice were raised. This case demonstrates the potential lethality of blunt chest trauma in pediatric patients and demonstrates the importance of not underestimating such events, even in the absence of clinically identified chest injuries.
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Affiliation(s)
- Guendalina Gentile
- Dipartimento di Scienze Biomediche per la Salute, Sezione di Medicina Legale e delle Assicurazioni, Università degli Studi di Milano, Milano, Italy
| | - Stefano Tambuzzi
- Dipartimento di Scienze Biomediche per la Salute, Sezione di Medicina Legale e delle Assicurazioni, Università degli Studi di Milano, Milano, Italy
| | - Giulio Giovanetti
- Dipartimento di Scienze Biomediche per la Salute, Sezione di Medicina Legale e delle Assicurazioni, Università degli Studi di Milano, Milano, Italy
| | - Riccardo Zoja
- Dipartimento di Scienze Biomediche per la Salute, Sezione di Medicina Legale e delle Assicurazioni, Università degli Studi di Milano, Milano, Italy
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Janicic D, Simatovic M, Roljic Z, Krupljanin L, Karabeg R. Urgent Surgical Treatment of Blunt Chest Trauma Followed by Cardiac and Pericardial Injuries. Med Arch 2021; 74:115-118. [PMID: 32577052 PMCID: PMC7296422 DOI: 10.5455/medarh.2020.74.115-118] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Introduction Widespread opinion that penetrating chest injuries are more urgent, in terms of treatment and care, contributed to underestimation of the urgency of blunt chest trauma, which in most cases is treated conservatively. It remains an open question frequency when the injuries of the heart and pericardium are not timely diagnosed and surgically treated. Aim To demonstrate the importance of well-timed surgical treatment of blunt chest trauma, when coupled with cardiac and pericardial injuries. Methods At the Thoracic Surgery Clinic of the University Clinical Centre Banja Luka, Bosnia and Herzego vina, during period of 10 years (01.01. 2008 - 31.01.2018.), the total of 66 patients were treated for urgent thoracotomy due to clinically and radiologically unclear findings after blunt chest trauma. In general, diagnostic examinations, apart from laboratory analysis, included radiological imaging and Multi Slice Computed Tomography (MSCT) of the chest, followed by an ultrasound of the heart in cases when sternum was injured or when pericardial tamponade was suspected. Results presented in the study where obtained from the retrospective analysis of patients data. This work presents a retrospective observational cross-sectional study, which results in the assessment of the correctness of a particular diagnostic test. Statistical methods used descriptive statistics, counting measures (frequencies and percentages), central tendency measures (arithmetic mean), variability measures (standard deviation). Results Sixty six patients were treated with urgent thoracotomy after a blunt trauma of the chest due to the unclear clinical and radiological finding. In the case of 11 patients (10 men and 1 woman), presenting 16.6% of the total sample, pericardial and cardiac injuries were detected and treated intraoperatively. Further, in the case of the one patient, pericardiotomy and suturing of the right heart chamber where performed, with the creation of a pericardial window. Transthoracic echocardiogram was not used as the primary screening module, but rather as a diagnostic test for patients who had unexplained hypotension and arrhythmia. Radiographs of the chest showed cardiomegaly with or without epicardial fat pad sign suggesting a pericardial effusion. Conclusion Blunt cardiac and pericardial injuries represent a serious therapeutic problem, which, if not treated properly, result in a high mortality rate. Echocardiography is the primary diagnostic method for initial detection of pericardial effusion. Pericardial fluid first accumulates posterior to the heart, when the patient is examined in the supine position. As the effusion increases, it extends laterally and with large effusions the echo-free space expands to surround the entire heart. The size of the effusion may be graded as small ( echo free spaces in diastole <10 mm, corresponding to approxymately 300 ml), moderate (10-20 mm, corresponding to 500 ml), and large ( >20 mm, corresponding to >700 ml). When the ability of the pericardium to stretch is exceeded by rapid or massive accumulation of fluid, any additional fluid causes the pressure with the pericardial sac. Early recognition, pericardiotomy with pericardial window creation and/or ventricular rupture suture remain the "gold standard" in the treatment of blunt cardiac and pericardial injuries.
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Affiliation(s)
- Dusan Janicic
- Clinic for Thoracic Surgery, University Clinical Center Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Milan Simatovic
- Clinic for General and Abdominal Surgery, University Clinical Center Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Zoran Roljic
- Clinic for Vascular Surgery, University Clinical Center Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Ljiljana Krupljanin
- Clinic for Thoracic Surgery, University Clinical Center Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Reuf Karabeg
- Private Clinic "Karabeg" Sarajevo, Bosnia and Herzegovina.,Faculty of Medicine,University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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12
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Early myocardial damage (EMD) and valvular insufficiency result in impaired cardiac function after multiple trauma in pigs. Sci Rep 2021; 11:1151. [PMID: 33441945 PMCID: PMC7806767 DOI: 10.1038/s41598-020-80409-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 10/20/2020] [Indexed: 12/14/2022] Open
Abstract
One third of multiple trauma patients present abnormal echocardiographic (ECHO) findings. Therefore, ECHO diagnostic after trauma is indicated in case of hemodynamic instability, shock, after chest trauma and after cardiac arrest. 20 male pigs underwent multiple trauma. Blood samples were collected 4 and 6 h after trauma and concentrations of heart-type fatty acid binding protein (HFABP) as a biomarker for EMD were measured. Myocardial damage was evaluated by scoring Hematoxylin–Eosin stained sections. At baseline, 3 and 6 h after trauma, transesophageal ECHO (TOE) was performed, invasive arterial and left ventricular blood pressure were measured to evaluate the cardiac function after multiple trauma. Systemic HFABP concentrations were elevated, furthermore heart injury score in multiple trauma animals was increased determining EMD. A significant decrease of blood pressure in combination with a consecutive rise of heart frequency was observed. Ongoing depression of mean arterial pressure and diastolic blood pressure were accompanied by changes in ECHO-parameters indicating diastolic and systolic dysfunction. Furthermore, a valvular dysfunction was detected. In this study complex myocardial and valvular impairment after multiple trauma in pigs has been observed. Therefore, detection of EMD and progressive valvular dysfunction might be crucial and therapeutically relevant.
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Abstract
BACKGROUND Blunt cardiac injury (BCI) increases with traffic accidents and is an important cause of death in trauma patients. In particular, for patients who need surgical treatment, the mortality rate is extremely high unless the patient is promptly operated on. This study aimed to explore early recognition and expeditious surgical intervention to increase survival. METHODS All patients with BCIs during the past 15 years were reviewed, and those who underwent operative treatment were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome. RESULTS A total of 348 patients with BCIs accounted for 18.3% of 1903 patients with blunt thoracic injury (BTI). Of 348 patients, 43 underwent operative treatment. The main cause of injury was traffic accidents, with an incidence of 48.8%. Of them, steering wheel injuries occurred in 15 patients. In 26 patients, a preoperative diagnosis was obtained by echocardiography, CT scanning, etc. In the remaining 17, who had to undergo urgent thoracotomy without any preoperative imaging, a definitive diagnosis of BCI was proven during the operation. The volume of preoperative infusion or crystalloid was <1000 ml in 31 cases. Preoperative pericardiocentesis was not used in anyone. In 12 patients, the operation commenced within 1 h. Overall mortality was 32.6%. The death was caused by BCI in 9. CONCLUSIONS Facing a patient with BTI, a high index of suspicion for BCI must be maintained. To manage those requiring operations, early recognition and expeditious thoracotomy are essential. Preoperatively, limited fluid resuscitation is emphasized. We do not advocate preoperative pericardiocentesis.
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Lackner I, Weber B, Miclau T, Holzwarth N, Baur M, Gebhard F, Teuben M, Halvachizadeh S, Cinelli P, Pfeifer R, Lipiski M, Cesarovic N, Haffner-Luntzer M, Pape HC, Kalbitz M. Reaming of femoral fractures with different reaming irrigator aspirator systems shows distinct effects on cardiac function after experimental polytrauma. J Orthop Res 2020; 38:2608-2618. [PMID: 32827323 DOI: 10.1002/jor.24830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/11/2020] [Accepted: 08/18/2020] [Indexed: 02/04/2023]
Abstract
Cardiac injuries are recorded after multiple trauma and are associated with a poor patient outcome. Reaming prior to locked intramedullary nailing is a frequently used technique to stabilize femoral diaphysis fractures. However, in polytraumatized patients, complications such as fat emboli and acute respiratory distress syndrome have been associated with reaming. The reaming irrigator aspirator (RIA) system provides concomitant irrigation and suction of the intramedullary contents, and should, therefore, reduce reaming-associated complications. The aim of the study was to investigate cardiac function after multiple trauma with regard to two different RIA devices (RIAI vs RIAII). 15 male pigs were included in the study. Pigs received either sham treatment or multiple trauma (chest trauma, femur fracture, liver laceration, and hemorrhagic shock), followed by intramedullary nailing after reaming with either the RIAI or RIAII system (RIAII: reduced diameter of the reamer, improved control of irrigation and suction). Cardiac function was assessed by transesophageal echocardiography and systemic inflammation as well as local cardiac damage examined. Pigs of both treatment groups showed impaired cardiac function, valvular insufficiency, and cardiac damage. Systemic inflammation and local cardiac alterations were observed which might contribute to early myocardial damage in vivo. Multiple trauma including long-bone fracture and subsequent intramedullary reaming induces cardiac dysfunction and valvular insufficiency, which might be linked to both mechanical cardiac injury and increased systemic inflammation. 6 hours after trauma there are less differences between RIAI and RIAII treatment with regard to post-traumatic cardiac consequences in multiple injured pigs, indicating no beneficial effect of RIAII over RIAI.
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Affiliation(s)
- Ina Lackner
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Hospital Ulm, Ulm, Germany
| | - Birte Weber
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Hospital Ulm, Ulm, Germany
| | - Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, California
| | - Nina Holzwarth
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Hospital Ulm, Ulm, Germany
| | - Meike Baur
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Hospital Ulm, Ulm, Germany
| | - Florian Gebhard
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Hospital Ulm, Ulm, Germany
| | - Michel Teuben
- Department of Trauma, University Hospital of Zurich, Zurich, Switzerland
| | | | - Paolo Cinelli
- Department of Trauma, University Hospital of Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, University Hospital of Zurich, Zurich, Switzerland
| | - Miriam Lipiski
- Department of Surgical Research, University Hospital of Zurich, Zurich, Switzerland
| | - Nikola Cesarovic
- Department of Surgical Research, University Hospital of Zurich, Zurich, Switzerland
| | | | | | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Hospital Ulm, Ulm, Germany
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Gao JM, Li H, Wei GB, Liu CP, Du DY, Kong LW, Li CH, Yang J, Yang Q. Blunt Cardiac Injury: A Single-Center 15-Year Experience. Am Surg 2020. [DOI: 10.1177/000313482008600432] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In recent years, the incidence of blunt cardiac injury (BCI) has increased rapidly and is an important cause of death in trauma patients. This study aimed to explore early diagnosis and therapy to increase survival. All patients with BCI during the past 15 years were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome. The patients were divided into two groups according to the needs of their condition—nonoperative (Group A) and operative (Group B). Comparisons of the groups were performed. A total of 348 patients with BCI accounted for 18.3 per cent of 1903 patients with blunt thoracic injury. The main cause of injury was traffic accidents, with an incidence of 48.3 per cent. In Group A (n = 305), most patients sustained myocardial contusion, and the mortality was 6.9 per cent. In Group B (n = 43), including those with cardiac rupture and pericardial hernia, the mortality was 32.6 per cent. Comparisons of the groups regarding the shock rate and mortality were significant ( P < 0.01). Deaths directly resulting from BCI in Group B were greater than those in Group A ( P < 0.05). In all 348 patients, the mortality rate was 10.1 per cent. When facing a patient with blunt thoracic injury, a high index of suspicion for BCI must be maintained. To manage myocardial contusion, it is necessary to protect the heart, alleviate edema of the myocardium, and control arrhythmia with drugs. To deal with those requiring operation, early recognition and expeditious thoracotomy are essential.
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Affiliation(s)
- Jin-Mou Gao
- Department of Cardiothoracic Surgery, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Hui Li
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Gong-Bin Wei
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Chao-Pu Liu
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Ding-Yuan Du
- Department of Cardiothoracic Surgery, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Ling-Wen Kong
- Department of Cardiothoracic Surgery, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Chang-Hua Li
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Jun Yang
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Qian Yang
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
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Biddick AA, Bacek LM, Fan S, Kuo KW. Association between cardiac troponin I concentrations and electrocardiographic abnormalities in dogs with blunt trauma. J Vet Emerg Crit Care (San Antonio) 2020; 30:179-186. [PMID: 32100447 DOI: 10.1111/vec.12933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/15/2018] [Accepted: 08/09/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine whether a normal cardiac troponin I (cTnI) concentration and normal ECG on entry rule out the development of a clinically significant cardiac arrhythmia (CSCA, defined as an arrhythmia requiring anti-arrhythmic treatment) in dogs that have sustained blunt trauma. DESIGN Prospective, observational study. Client-owned dogs were enrolled between January 2015 and November 2016. SETTING University teaching hospital. ANIMALS Forty-seven client-owned dogs with a history of witnessed or suspected blunt trauma within 24 hours prior to presentation to the hospital. INTERVENTIONS On admission to the emergency service, dogs had a standard 3-lead ECG and cTnI concentration (using a veterinary point-of-care device* ) performed. Animal Trauma Triage (ATT) scores, Modified Glasgow Coma Scale (MGCS), and the details regarding the nature and timing of the injury were recorded. The patients were monitored in the ICU for a minimum of 24 hours on continuous ECG telemetry. Cardiac rhythm was monitored every hour, and any abnormalities were noted. The need for anti-arrhythmic therapy was recorded. There were no treatment interventions. MEASUREMENTS AND MAIN RESULTS Five of 47 dogs (10.6%) developed a CSCA during hospitalization after sustaining blunt trauma. A normal entry ECG and normal cardiac troponin concentration on entry had a 100% negative predictive value (NPV) for ruling out the development of a CSCA, although a normal cardiac troponin concentration alone also had an NPV of 100%. A normal entry ECG had an NPV of 95.3%. The prognosis for survival to discharge was 89.4% in this study population (42/47 dogs). CONCLUSIONS In dogs with blunt trauma, an entry cTnI concentration or a combination of cTnI and ECG on entry may be useful in determining which patients are at a higher risk for the development of CSCA during the first 12 to 24 hours after the trauma.
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Affiliation(s)
- Allison A Biddick
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL
| | - Lenore M Bacek
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL
| | - Shirley Fan
- Statistical Consulting Center, College of Mathematics and Statistics, Auburn University, Auburn, AL
| | - Kendon W Kuo
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL
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Maykowski P, Bae JO, Notrica DM. Isolated cardiac tamponade following blunt trauma in an infant. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2019. [DOI: 10.1016/j.epsc.2019.101294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Becerra Á, Trujillo H, Valencia L, Rodríguez-Pérez A. Looking for the reason of hemodynamic instability: a case report of the role of intraoperative ultrasound. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 30651202 PMCID: PMC9391855 DOI: 10.1016/j.bjane.2018.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background and objectives A prompt and effective management of trauma patient is necessary. The aim of this case report is to highlight the importance of intraoperative echocardiography as a useful tool in patients suffering from refractory hemodynamic instability no otherwise explained. Case report A 41 year-old woman suffered a car accident. At the emergency department, no abnormalities were found in ECG or chest X-ray. Abdominal ultrasound revealed the presence of abdominal free liquid and the patient was submitted to urgent exploratory laparotomy. Nevertheless, she persisted suffering arterial hypotension and metabolic acidosis. Looking for the reason of her hemodynamic instability, intraoperative transthoracic echocardiography was performed, finding out the presence of pericardial effusion. Once the cardiac surgeon extracted pericardial clots, patient's situation improved clinically and analytically. Conclusion Every anesthesiologist should be able to use the intraoperative echocardiography as an effective tool in order to establish the appropriate measures to promote the survival of patients suffering severe trauma.
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Affiliation(s)
- Ángel Becerra
- Hospital Universitario de Gran Canaria Dr. Negrín, Department of Anesthesiology, Las Palmas de Gran Canaria, Espanha.
| | - Héctor Trujillo
- Hospital Universitario de Gran Canaria Dr. Negrín, Department of Anesthesiology, Las Palmas de Gran Canaria, Espanha
| | - Lucía Valencia
- Hospital Universitario de Gran Canaria Dr. Negrín, Department of Anesthesiology, Las Palmas de Gran Canaria, Espanha
| | - Aurelio Rodríguez-Pérez
- Hospital Universitario de Gran Canaria Dr. Negrín, Department of Anesthesiology, Las Palmas de Gran Canaria, Espanha; Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Espanha
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Becerra Á, Trujillo H, Valencia L, Rodríguez-Pérez A. [Looking for the reason of hemodynamic instability: a case report of the role of intraoperative ultrasound]. Rev Bras Anestesiol 2019; 69:200-203. [PMID: 30651202 DOI: 10.1016/j.bjan.2018.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/10/2018] [Accepted: 09/04/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES A prompt and effective management of trauma patient is necessary. The aim of this case report is to highlight the importance of intraoperative echocardiography as a useful tool in patients suffering from refractory hemodynamic instability no otherwise explained. CASE REPORT A 41 year-old woman suffered a car accident. At the emergency department, no abnormalities were found in ECG or chest X-ray. Abdominal ultrasound revealed the presence of abdominal free liquid and the patient was submitted to urgent exploratory laparotomy. Nevertheless, she persisted suffering arterial hypotension and metabolic acidosis. Looking for the reason of her hemodynamic instability, intraoperative transthoracic echocardiography was performed, finding out the presence of pericardial effusion. Once the cardiac surgeon extracted pericardial clots, patient's situation improved clinically and analytically. CONCLUSION Every anesthesiologist should be able to use the intraoperative echocardiography as an effective tool in order to establish the appropriate measures to promote the survival of patients suffering severe trauma.
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Affiliation(s)
- Ángel Becerra
- Hospital Universitario de Gran Canaria Dr. Negrín, Department of Anesthesiology, Las Palmas de Gran Canaria, Espanha.
| | - Héctor Trujillo
- Hospital Universitario de Gran Canaria Dr. Negrín, Department of Anesthesiology, Las Palmas de Gran Canaria, Espanha
| | - Lucía Valencia
- Hospital Universitario de Gran Canaria Dr. Negrín, Department of Anesthesiology, Las Palmas de Gran Canaria, Espanha
| | - Aurelio Rodríguez-Pérez
- Hospital Universitario de Gran Canaria Dr. Negrín, Department of Anesthesiology, Las Palmas de Gran Canaria, Espanha; Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Espanha
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20
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Braun CK, Schaffer A, Weber B, Huber-Lang M, Kalbitz M, Preßmar J. The Prognostic Value of Troponin in Pediatric Polytrauma. Front Pediatr 2019; 7:477. [PMID: 31824896 PMCID: PMC6879657 DOI: 10.3389/fped.2019.00477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/30/2019] [Indexed: 12/17/2022] Open
Abstract
Introduction: Severe trauma accounts for a great number of deaths among children and adolescents. The diagnostic value of troponin serum levels of severely injured patients has been reported for adults, but data on pediatric polytrauma (PT) are scarce. Therefore, we conducted a retrospective monocentered study analyzing the prognostic value of troponin T (TnT) in pediatric trauma patients at the time point of hospital admission. Methods: Data of 88 polytraumatized pediatric patients admitted to the emergency room of the University Hospital of Ulm, Germany, between 2007 and 2016 were analyzed retrospectively. The data source was the written and digital patient records. Interleukin-6 (IL-6), creatine kinase activity (CK activity), and lactate and TnT levels were measured by a certified clinical diagnostic laboratory; and patients were stratified for the Injury Severity Score (ISS). The prognostic value for lung contusion, organ dysfunction, and fatal outcome was statistically explored. The study was approved by the independent ethical committee of the University of Ulm (#44/18). Results: TnT levels were significantly increased in patients after severe PT compared with mild or moderate trauma severity as assessed by ISS values. Patients with TnT levels above the cutoff showed significantly increased levels of IL-6 and CK activity and a significantly prolonged stay in the intensive care unit. However, TnT levels did not correlate with absolute ISS values. TnT levels were significantly increased in patients with chest trauma and lung contusion. The incidence of lung contusion was associated with elevation of TnT. So was the onset of organ dysfunction, defined as a Sequential Organ Failure Assessment (SOFA) score ≥ 2 and fatal outcome, with a significant enhancement of plasma levels in children with organ dysfunction and in non-survivors. Conclusion: These descriptive data suggest that evaluation of TnT on admission of multiply injured children may help in predicting severity of injury and mortality in the clinical course after trauma and thus may be a useful addition to established prognostic parameters in the future.
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Affiliation(s)
- Christian Karl Braun
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Annika Schaffer
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University Hospital of Ulm, Ulm, Germany
| | - Birte Weber
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University Hospital of Ulm, Ulm, Germany
| | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University Hospital of Ulm, Ulm, Germany
| | - Jochen Preßmar
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University Hospital of Ulm, Ulm, Germany
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21
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Chen X, Miao Q, Yu Y, Zhang F, Sun L, Meng Y, Wang H, Li D. Blunt Trauma-Induced Pericardial Tamponade After Video-Assisted Thoracoscopic Surgery. Ann Thorac Surg 2018; 107:e381-e383. [PMID: 30481520 DOI: 10.1016/j.athoracsur.2018.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/09/2018] [Accepted: 10/13/2018] [Indexed: 11/19/2022]
Abstract
This report describes a case of blunt cardiac injury and pericardial tamponade after video-assisted thoracoscopic surgery in a patient with lung cancer, hypertension, and cardiac hypertrophy. Anatomic findings included massive hemorrhage in the pericardium, cardiac hypertrophy, and a superficial contusion with a ruptured blood vessel on the epicardium at the lateral wall of the left ventricle. The patient died of pericardial tamponade secondary to blunt trauma from the tip of the thoracoscopic instrument. This case suggests that detailed assessment of the cardiovascular system, especially cardiac hypertrophy, careful preoperative preparation, and careful monitoring of postoperative conditions are important.
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Affiliation(s)
- Xuebing Chen
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Qi Miao
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Yangeng Yu
- Department of Guangdong Public Security, Key Laboratory of Forensic Pathology, Guangzhou, China
| | - Fu Zhang
- Department of Guangdong Public Security, Key Laboratory of Forensic Pathology, Guangzhou, China
| | - Leping Sun
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Yunle Meng
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Huijun Wang
- School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Dongri Li
- School of Forensic Medicine, Southern Medical University, Guangzhou, China.
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Boriani G, Fauchier L, Aguinaga L, Beattie JM, Blomstrom Lundqvist C, Cohen A, Dan GA, Genovesi S, Israel C, Joung B, Kalarus Z, Lampert R, Malavasi VL, Mansourati J, Mont L, Potpara T, Thornton A, Lip GYH, Gorenek B, Marin F, Dagres N, Ozcan EE, Lenarczyk R, Crijns HJ, Guo Y, Proietti M, Sticherling C, Huang D, Daubert JP, Pokorney SD, Cabrera Ortega M, Chin A. European Heart Rhythm Association (EHRA) consensus document on management of arrhythmias and cardiac electronic devices in the critically ill and post-surgery patient, endorsed by Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin American Heart Rhythm Society (LAHRS). Europace 2018; 21:7-8. [DOI: 10.1093/europace/euy110] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/26/2018] [Indexed: 02/05/2023] Open
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | | | - James M Beattie
- Cicely Saunders Institute, King’s College London, London, UK
| | | | | | - Gheorghe-Andrei Dan
- Cardiology Department, University of Medicine and Pharmacy “Carol Davila”, Colentina University Hospital, Bucharest, Romania
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano and Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - Carsten Israel
- Evangelisches Krankenhaus Bielefeld GmbH, Bielefeld, Germany
| | - Boyoung Joung
- Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Zbigniew Kalarus
- SMDZ in Zabrze, Medical University of Silesia, Katowice; Department of Cardiology, Silesian Center for Heart Diseases, Zabrze, Poland
| | | | - Vincenzo L Malavasi
- Cardiology Division, Department of Nephrologic, Cardiac, Vascular Diseases, Azienda ospedaliero-Universitaria di Modena, Modena, Italy
| | - Jacques Mansourati
- University Hospital of Brest and University of Western Brittany, Brest, France
| | - Lluis Mont
- Arrhythmia Section, Cardiovascular Clínical Institute, Hospital Clinic, Universitat Barcelona, Barcelona, Spain
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | | | | | - Radosław Lenarczyk
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Harry J Crijns
- Cardiology Maastricht UMC+ and Cardiovascular Research Institute Maastricht, Netherlands
| | - Yutao Guo
- Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Marco Proietti
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy
| | | | - Dejia Huang
- Cardiology Division, Department of Medicine, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | | | - Sean D Pokorney
- Electrophysiology Section, Division of Cardiology, Duke University, Durham, NC, USA
| | - Michel Cabrera Ortega
- Department of Arrhythmia and Cardiac Pacing, Cardiocentro Pediatrico William Soler, Boyeros, La Havana Cuba
| | - Ashley Chin
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, South Africa
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Kerr H, Bowen B, Light D. Thoracoabdominal Injuries. CONTEMPORARY PEDIATRIC AND ADOLESCENT SPORTS MEDICINE 2018. [PMCID: PMC7123492 DOI: 10.1007/978-3-319-56188-2_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Trauma to the thorax and abdomen can occur during participation in sports. This chapter reviews some of the more common presentations of such injuries and how such injuries should be best managed. Thoracic injuries reviewed include internal injuries such as pneumothorax, pulmonary contusion, hemothorax, commotio cordis, and cardiac contusion. Chest wall injuries are also reviewed such as rib fractures, costochondritis, and slipping rib syndrome plus sternal and scapular fractures. Abdominal injuries reviewed are focused on internal organ trauma to the spleen and liver, kidney, pancreas, and bowel. There is attention to the effect of Epstein-Barr virus and infectious mononucleosis, seen very frequently in high school and collegiate athletes. Finally, groin pain and athletic pubalgia are described. In addition to anatomy and clinical presentation, imaging modalities that characterize such trauma are reviewed for each diagnosis. Prevention of thoracoabdominal injuries and return-to-play decisions are described at the chapter conclusion.
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Ding M, Ning J, Feng N, Li Z, Liu Z, Wang Y, Wang Y, Li X, Huo C, Jia X, Xu R, Fu F, Wang X, Pei J. Dynamin-related protein 1-mediated mitochondrial fission contributes to post-traumatic cardiac dysfunction in rats and the protective effect of melatonin. J Pineal Res 2018; 64. [PMID: 29024001 DOI: 10.1111/jpi.12447] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 08/30/2017] [Indexed: 12/28/2022]
Abstract
Mechanical trauma (MT) causes myocardial injury and cardiac dysfunction. However, the underlying mechanism remains largely unclear. This study investigated the role of mitochondrial dynamics in post-traumatic cardiac dysfunction and the protective effects of melatonin. Adult male Sprague Dawley rats were subjected to 5-minute rotations (200 revolutions at a rate of 40 rpm) to induce MT model. Melatonin was administrated intraperitoneally 5 minute after MT. Mitochondrial morphology, myocardial injury, and cardiac function were determined in vivo. There was smaller size of mitochondria and increased number of mitochondria per μm2 in the hearts after MT when the secondary myocardial injury was induced. Melatonin treatment at the dose of 30 mg/kg reduced serine 616 phosphorylation of Drp1 and inhibited mitochondrial Drp1 translocation and mitochondrial fission in the hearts of rats subjected to MT, which contributed to the reduction of myocardial injury and the improvement of cardiac function. In vitro, H9c2 cells cultured in 20% traumatic plasma (TP) for 12 hour showed enhanced mitochondrial fission, mitochondrial membrane potential (∆Ψm) loss, mitochondrial cytochrome c release, and decreased mitochondrial complex I-IV activities. Pretreatment with melatonin (100 μmol/L) efficiently inhibited TP-induced mitochondrial fission, ∆Ψm loss, cytochrome c release, and improved mitochondrial function. Melatonin's protective effects were attributed to its role in suppressing plasma TNF-α overproduction, which was responsible for Drp1-mediated mitochondrial fission. Taken together, our results demonstrate for the first time that abnormal mitochondrial dynamics is involved in post-traumatic cardiac dysfunction. Melatonin has significant pharmacological potential in protecting against MT-induced cardiac dysfunction by preventing excessive mitochondrial fission.
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Affiliation(s)
- Mingge Ding
- Department of Geriatrics, Xi'an Central Hospital, Xi'an Jiaotong University, Xi'an, China
- Department of Physiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jiao Ning
- Department of Physiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Na Feng
- Department of Physiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zeyang Li
- Department of Physiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhenhua Liu
- Department of Physiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yuanbo Wang
- Department of Physiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yueming Wang
- Department of Physiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xing Li
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Cong Huo
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xin Jia
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Rong Xu
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Feng Fu
- Department of Physiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiaoming Wang
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jianming Pei
- Department of Physiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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25
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Pesenti-Rossi D, Allouch P, Gibault-Genty G, Augusto S, Dib JC, Squara P. Post-resuscitation myocardial injury: MRI and MDCT patterns. Ann Cardiol Angeiol (Paris) 2017; 66:354-355. [PMID: 29029773 DOI: 10.1016/j.ancard.2017.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 09/12/2017] [Indexed: 06/07/2023]
Affiliation(s)
- D Pesenti-Rossi
- Department of cardiology, Versailles Hospital, 177, rue de Versailles, 78150 Le-Chesnay, France; Ambroise-Paré clinic, department of cardiology and cardiac surgery, 27, boulevard Victor-Hugo, 92200 Neuilly/Seine, France.
| | - P Allouch
- Ambroise-Paré clinic, department of cardiology and cardiac surgery, 27, boulevard Victor-Hugo, 92200 Neuilly/Seine, France
| | - G Gibault-Genty
- Department of cardiology, Versailles Hospital, 177, rue de Versailles, 78150 Le-Chesnay, France; Ambroise-Paré clinic, department of cardiology and cardiac surgery, 27, boulevard Victor-Hugo, 92200 Neuilly/Seine, France
| | - S Augusto
- Department of cardiology, Versailles Hospital, 177, rue de Versailles, 78150 Le-Chesnay, France
| | - J-C Dib
- Ambroise-Paré clinic, department of cardiology and cardiac surgery, 27, boulevard Victor-Hugo, 92200 Neuilly/Seine, France
| | - P Squara
- Ambroise-Paré clinic, department of cardiology and cardiac surgery, 27, boulevard Victor-Hugo, 92200 Neuilly/Seine, France
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26
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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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27
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Abstract
Head trauma is a common cause of significant morbidity and mortality in dogs and cats. Traumatic brain injury may occur after head trauma. Understanding the pathophysiology of primary and secondary injury after head trauma is essential for management. This article reviews the pathophysiology of head trauma, patient assessment and diagnostics, and treatment recommendations.
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Affiliation(s)
- Kendon W Kuo
- Emergency and Critical Care, Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, 1220 Wire Road, Auburn, AL 36849- 5540, USA.
| | - Lenore M Bacek
- Emergency and Critical Care, Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, 1220 Wire Road, Auburn, AL 36849- 5540, USA
| | - Amanda R Taylor
- Neurology/Neurosurgery, Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, 1220 Wire Road, Auburn, AL 36849- 5540, USA
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28
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Clinical and electrocardiographic features of complete heart block after blunt cardiac injury: A systematic review of the literature. Heart Rhythm 2017; 14:1561-1569. [DOI: 10.1016/j.hrthm.2017.05.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Indexed: 11/21/2022]
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29
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Tegethoff AM, Raney E, Mendelson J, Minckler MR. Paediatric chest wall trauma causing delayed presentation of ventricular arrhythmia. BMJ Case Rep 2017; 2017:bcr-2017-220498. [PMID: 28739617 PMCID: PMC5623198 DOI: 10.1136/bcr-2017-220498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This report describes a paediatric patient presenting with haemodynamically stable non-sustained ventricular tachycardia 1 day after minor blunt chest trauma. Initial laboratory studies, chest X-ray and echocardiography were normal; however, cardiac MRI revealed precordial haematoma, myocardial contusion and small pericardial effusion. Throughout her hospital course, she remained asymptomatic aside from frequent couplets and triplets of premature ventricular contractions. Ectopy was controlled with oral verapamil. This case highlights how significant cardiac injury may be missed with standard diagnostic algorithms.
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Affiliation(s)
- Angela M Tegethoff
- Department of Emergency Medicine, Banner-University Medical Center Tucson, Tucson, Arizona, USA
| | - Emerald Raney
- Department of Emergency Medicine, Banner-University Medical Center Tucson, Tucson, Arizona, USA
| | - Jenny Mendelson
- Department of Emergency Medicine, Banner-University Medical Center Tucson, Tucson, Arizona, USA
| | - Michael R Minckler
- Department of Emergency Medicine, Banner-University Medical Center Tucson, Tucson, Arizona, USA
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30
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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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31
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Lamela Domenech AE, Lopez-Menendez F, López-Candales A. Tricuspid Papillary Muscle Rupture Due to Blunt Chest Trauma. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:2733-2736. [PMID: 27872424 DOI: 10.7863/ultra.15.12058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | | | - Angel López-Candales
- Cardiovascular Medicine Division, University of Puerto Rico School of Medicine, Medical Sciences, Campus San Juan, Puerto Rico
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32
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Greene CL, Boyd JH. Successful Operative Repair of Delayed Left Ventricle Rupture From Blunt Trauma. Ann Thorac Surg 2016; 102:e101-3. [PMID: 27449439 DOI: 10.1016/j.athoracsur.2016.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 12/15/2015] [Accepted: 01/06/2016] [Indexed: 11/16/2022]
Abstract
A 21-year-old female was found to have an enlarging pericardial effusion 10 days after a 40-foot fall. Initial cardiac evaluation was negative. Ten days after presentation she developed hemodynamic compromise and chest computed tomography was concerning for cardiac rupture. The patient was taken to the operating room where the ruptured posterior ventricle was repaired, perforation in the P1 leaflet was identified and the mitral valve was replaced. The patient survived. To our knowledge, this is the first report of survival after delayed presentation of atrioventricular rupture at the level of the mitral valve.
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Affiliation(s)
- Christina L Greene
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk Cardiovascular Research Building, Stanford, California
| | - Jack H Boyd
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk Cardiovascular Research Building, Stanford, California.
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33
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Anesthetic Considerations and Ventilation Strategies in Cardiothoracic Trauma. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0149-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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