Blunt traumatic pericardial rupture and cardiac herniation with a penetrating twist: two case reports

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, Dec 2009

Background Blunt Traumatic Pericardial Rupture (BTPR) with resulting cardiac herniation following chest trauma is an unusual and often fatal condition. Although there has been a multitude of case reports of this condition in past literature, the recurring theme is that of a missed injury. Its occurrence in severe blunt trauma is in the order of 0.4%. It is an injury that frequently results in pre/early hospital death and diagnosis at autopsy, probably owing to a combination of diagnostic difficulties, lack of familiarity and associated polytrauma. Of the patients who survive to hospital attendance, the mortality rate is in the order of 57-64%. Methods We present two survivors of BTPR and cardiac herniation, one with a delayed penetrating cardiac injury secondary to rib fractures. With these two cases and literature review, we hope to provide a greater awareness of this injury Conclusion BTPR and cardiac herniation is a complex and often fatal injury that usually presents under the umbrella of polytrauma. Clinicians must maintain a high index of suspicion for BTPR but, even then, the diagnosis is fraught with difficulty. In blunt chest trauma, patients should be considered high risk for BTPR when presenting with: Cardiovascular instability with no obvious cause Prominent or displaced cardiac silhouette and asymmetrical large volume pneumopericardium Potentially, with increasing awareness of the injury and improved use and availability of imaging modalities, the survival rates will improve and cardiac Herniation could even be considered the 5th H of reversible causes of blunt traumatic PEA arrest.

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Blunt traumatic pericardial rupture and cardiac herniation with a penetrating twist: two case reports

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine Blunt traumatic pericardial rupture and cardiac herniation with a penetrating twist: two case reports Peter B Sherren 0 Robert Galloway 0 Marie Healy 0 0 Address: Department of Anaesthesia and Intensive care, The Royal London Hospital , Whitechapel, E1 1BB , UK Background: Blunt Traumatic Pericardial Rupture (BTPR) with resulting cardiac herniation following chest trauma is an unusual and often fatal condition. Although there has been a multitude of case reports of this condition in past literature, the recurring theme is that of a missed injury. Its occurrence in severe blunt trauma is in the order of 0.4%. It is an injury that frequently results in pre/early hospital death and diagnosis at autopsy, probably owing to a combination of diagnostic difficulties, lack of familiarity and associated polytrauma. Of the patients who survive to hospital attendance, the mortality rate is in the order of 57-64%. Methods: We present two survivors of BTPR and cardiac herniation, one with a delayed penetrating cardiac injury secondary to rib fractures. With these two cases and literature review, we hope to provide a greater awareness of this injury Conclusion: BTPR and cardiac herniation is a complex and often fatal injury that usually presents under the umbrella of polytrauma. Clinicians must maintain a high index of suspicion for BTPR but, even then, the diagnosis is fraught with difficulty. In blunt chest trauma, patients should be considered high risk for BTPR when presenting with: Cardiovascular instability with no obvious cause Prominent or displaced cardiac silhouette and asymmetrical large volume pneumopericardium Potentially, with increasing awareness of the injury and improved use and availability of imaging modalities, the survival rates will improve and cardiac Herniation could even be considered the 5th H of reversible causes of blunt traumatic PEA arrest. - Background Cardiac herniation is a significant and potentially fatal complication of BTPR. This is by no means a new problem [1,2] and its occurrence in severe blunt trauma is in the order of 0.4% [3,4]. Despite literature experience dating back to 1864 [5], it is an injury that frequently results in pre/early hospital death and diagnosis at autopsy, probably owing to a combination of diagnostic difficulties, lack of familiarity and associated polytrauma [3,6]. Of those who make it to hospital, and are later diagnosed with BTPR, the survival rate is 36.4% - 42.9% [7]. The high mortality rate is probably a reflection of not only BTPR and cardiac herniation but also the associated injuries [3]. Here, we present two interesting cases of both left and right pleuropericardial ruptures and cardiac herniation. Despite the delay in initial diagnosis, both patients survived, though with varying degrees of disability secondary to related traumatic injuries. The second patient is one of the few reported cases of cardiac herniation and a delayed penetrating cardiac injury secondary to rib fractures. The common issue echoed throughout our experience and those of others is that of missed or delayed diagnosis. With these cases and literature review we hope to provide further awareness of this injury and clues which can be sought from the clinical presentation and investigations to aid diagnosis. Case 1 A 21-year-old male was admitted to a district general hospital accident and emergency department following a moderate speed motorbike accident with the predominant vector of force through the chest and head. Initially when seen by the local ambulance service he was noted to be GCS 15/15, have a high Alveolar-arterial gradient but was cardiovascularly stable. Of note, he could not move or feel his legs. Management in the district general accident and emergency department followed standard Advanced Trauma Life Support (ATLS) practices. Chest radiograph showed pulmonary contusions on the left but nothing else of significance. He became increasingly agitated and hypoxic and was intubated prior to transfer for computed tomography (CT) scan. Head CT scans showed an interventricular haemorrhage. Spinal images showed T8/T9 fracture/dislocation with a normal cervical CT. Initial chest CT scans were reported as showing dextracardia and bilateral pneumothoraces; on the left side, the pneumothorax was reported as a possible tension pneumothorax. The possibility of a pneumopericardium was later attributed to an anterior pneumothorax. Abdominal and pelvis CT scans were essentially normal. As time progressed, persistent hypotension developed despite bilateral tube thoracostomies, fluid challenges and inotropes. The initial working diagnosis of spinal shock was made and a referral was made for further management and neurosurgical intervention for stabilisation of the T8-9 fracture/dislocation. On transfer to our trauma centre, the patient's condition deteriorated; on arrival in our department, he was found (...truncated)


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Peter B Sherren, Robert Galloway, Marie Healy. Blunt traumatic pericardial rupture and cardiac herniation with a penetrating twist: two case reports, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2009, pp. 64, 17, DOI: 10.1186/1757-7241-17-64