Traumatic bifascicular intraventricular block

Complete heart block following penetrating chest trauma in operation Iraqi freedom

We present a 30-year-old US army soldier who had penetrating chest trauma from a road side explosive with focal cardiac injury. The soldier had penetration of his right atrium and subsequent traumatic membranous ventricular septal defect and complete heart block. He was brought to a Combat Support Hospital where fortuitously the assigned trauma surgeon on-call was a cardiothoracic surgeon, and the assigned trauma intensivist on-call was a cardiac electrophysiologist. Of course, the only source they knew of a pacemaker was halfway around the world. We discuss the management of this injury in an austere combat environment.

Slow progressing cardiac complications-a case report

OBJECTIVE

This case presentation describes an uncommon development of complete heart block. Within 48 hours after a motor vehicle accident with the deployment of the air bag against the patient's chest, the patient reported exertional bradycardia and shortness of breath.

CLINICAL FEATURES

A 51-year-old man was in a motor vehicle accident. After the collision, he noticed a slow onset of chest discomfort with exertion and bradycardia. The patient experienced cardiac difficulty during a stress electrocardiogram. During the 4 months after the motor vehicle accident, symptoms progressed; and a diagnosis of vagal sympathetic reflex was suggested.

INTERVENTION AND OUTCOME

A pacemaker was finally required because of the ventricular pacing of 35 to 40 beats per minute, which was symptomatic of a complete atrioventricular block.

CONCLUSION

A gradual progression to complete atrioventricular block over a period longer than 3 weeks is unusual. This case demonstrates that a patient manifesting exertional bradycardia and shortness of breath shortly after chest trauma should be regularly monitored until all symptoms are resolved.

[Evaluation and treatment of cardiac injuries]

Cardiac injuries caused by a heart traumatism are not frequent but, of great importance given their high morbidity. Two different groups in terms of etiology, clinical picture, application of diagnostic techniques, treatment and prognosis can be considered. On one hand, there are cardiac injuries caused by a thoracal contusion, which provokes a contused lesion can affect the free wall, the interventricular septum, the valves, the subvalvular apparatus, the conduction system and the coronary vessels and, on the other hand, cardiac injuries caused by penetrating objects. Cardiac injury can lead to a life-threatening hemodynamic instability which mandates prompt and clear diagnostic and therapeutic approaches.

Immediate and persistent complete heart block following a horse kick

Nonpenetrating chest trauma has been reported to cause acute and transient disorders of impulse formation and propagation, including intraventricular conduction delay and heart block. We report a case of immediate and sustained complete heart block following blunt chest injury.

Concrete induced cardiac contusion

A previously fit 22 year old man was struck in the chest by a concrete block dropped through the windscreen of his car while he was driving on the motorway. He suffered extensive chest wall trauma and lung contusion, which subsequently precipitated acute respiratory distress. On admission ECG showed right bundle branch block and left axis deviation. Three days later QRS duration was normal but there was anterior ST segment elevation and subsequent T wave change. There was a large rise in creatine kinase, and echocardiography revealed septal and apical hyokinesis as well as a mobile mass attached to the left side of the interventricular septum, which had the echogenic texture of myocardium. The patient had fixed perfusion defects in the areas of hypokinesis on thallium scanning but the coronary arteries were unobstructed at angiography. He was treated with warfarin in the short term and an angiotensin converting enzyme inhibitor in the longer term and has made an asymptomatic recovery. Outpatient echocardiography two months after the injury demonstrated some recovery in overall left ventricular systolic function and no evidence of the intracardiac mass. This case illustrates some of the typical features of non-fatal cardiac contusion associated with non-penetrating cardiac trauma, and was complicated by partial thickness avulsion of a strip of the myocardium in the interventricular septum.

Cardiac trauma. Diagnosis, management, and current therapy

In cardiac trauma the two main mechanisms of injury are blunt and penetrating trauma. Common cardiac effects of trauma include myocardial rupture, contusion, laceration, pericardial insult, coronary injury, valvular damage, arrhythmias, and conduction abnormalities. Hemodynamic instability can develop rapidly and pose marked risk to patient survival. An adequate level of clinical awareness and timely use of diagnostic techniques such as echocardiography, aortography, and cardiac angiography are essential for rapid identification of cardiac trauma. Once the diagnosis is made, prompt surgical intervention is often the key to survival.

Bifascicular block complicating blunt cardiac injury. A case report and review of the literature

A thirty-five-year-old horse trainer presented to the emergency room of the authors' hospital with minimal nonpenetrating chest injury after having been kicked by a horse. No rib or sternum fractures were demonstrated. The admission ECG demonstrated a right bundle branch block and a left anterior hemiblock that were previously absent. The authors are aware of only two similar reports, but analogous conduction disturbances might have been classified as intraventricular conduction defects. The rarity of these defects may be explained by the anatomic pathways of the bundle of His and its bifurcations.

Evaluation of noninvasive tests of cardiac damage in suspected cardiac contusion

Nonpenetrating trauma to the chest can result in cardiac damage that may be overlooked because of associated injuries and the lack of obvious thoracic injury. The clinical diagnosis of important cardiac damage in this setting is difficult. We evaluated noninvasive tests for detecting myocardial damage in 100 patients with severe, nonpenetrating chest trauma. The noninvasive tests included serial ECG, serial total CPK and CPK-MB enzymes, continuous Holter monitor recording to detect dysrhythmia, and technetium-99m pyrophosphate scintigraphy. Peak CPK-MB elevations occurred in 72 patients. ECG abnormalities were noted in 70 patients, and 27 patients had Lown grade 3 or greater dysrhythmias. Fifteen patients died and all had autopsies. The noninvasive abnormalities were nonspecific and did not reflect myocardial contusion that led to clinically important cardiac complications.

Traumatic sinus node dysfunction

A 50-year-old man exhibited sinus node dysfunction following non-penetrating chest trauma. Transiently elevated cardiac isoenzymes, together with normal past electrocardiograms, support the contention that the blunt chest trauma was responsible for the sinus node dysfunction. This case suggests that this condition may occur more frequently than expected and remain unrecognized. Temporary and subsequent permanent pacing may be necessary. Also emphasized is the potential for liability issues.

CPK-MB isoenzyme determinations: diagnostic and prognostic value in evaluation of blunt chest trauma

The incidence of myocardial contusion in patients with blunt chest trauma was examined. The criterion used for diagnosing contusion--actual cellular injury--was based on detection of the MB-isoenzyme of creatine phosphokinase, a sensitive and specific marker for cardiac cellular injury. Forty-nine patients with blunt chest trauma were evaluated using this diagnostic approach. Twenty-six demonstrated measurable serum levels of MB-CPK. Electrocardiographic (ECG) evaluation of this subgroup revealed that 85% exhibited anatomically localized ST-T wave abnormalities while 15% showed nonlocalized and nonspecific changes. Sixty-eight percent of those with localized abnormalities demonstrated ST segment changes depicting injury, most of which were localized to the anterior septal leads. The remaining 23 patients demonstrated non-detectable serum levels of MB-CPK and were classified as cardiac concussion on the basis of other clinical criteria. Twenty-six percent with concussion exhibited anatomically localized ECG changes. The remaining 74% had nonlocalized and nonspecific ECG changes.

Electrocardiographic changes in traumatized patients

Traumatized patients who sustain a severe physical or psychological insult may develop myocardial ischemic changes, espicially those patients over the age of 40 years. The electrocardiogram (EKG) findings in 34 chest injury patients out of 200 multiple injury cases over a period of two years were studied. Two types of myocardial changes were found: injury pattern (of a permanent character) and ischemic pattern (of a transient nature). The first type was more frequent in the penetrating noncardiac chest injury cases, and the second more common in the blunt chest injury cases. It is necessary to make early and serial EKG tracings on traumatized patients in order to detect myocardial changes.

Cardiac Injuries

It is not always true to assume that all cardiac injuries have uniformly bad progno sis. If diagnosed early and treated properly, the results are rewarding. Four different types of cardiac injuries managed success fully are reported.