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.
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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)