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(RSS) Karim's Weblog

Random snippets and thoughts - hopefully mostly trauma related!

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(RSS) Trauma Research Blog

Selected new & juicy research papers, with editorial comment.

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PubMed ID: 19680160
J Trauma. 2009 Aug 12.
Authors: Teixeira PG, Inaba K, Oncel D, Dubose J, Chan L, Rhee P, Salim A, Browder T, Brown C, Demetriades D.

Abstract:

OBJECTIVE:: Because of its rarity and high rate of mortality, traumatic blunt cardiac rupture (BCR) has been poorly studied. The objective of this study was to use the National Trauma Data Bank to review the epidemiology and outcomes associated with traumatic BCR. METHODS:: After approved by the institutional review board, the National Trauma Data Bank (version 5.0) was queried for all BCR occurring between 2000 and 2005. Demographics, clinical injury data, interventions, and outcomes were abstracted for each patient. Statistical analysis was performed using an unpaired Student's t test or Mann-Whitney U test to compare means and chi analysis to compare proportions. Stepwise logistic regression analysis was performed to identify independent predictors of inhospital mortality. RESULTS:: Of 811,531 blunt trauma patients, 366 (0.045%) had a BCR of which 334 were available for analysis, with the mean age of 45 years, 65% were men, and their mean Injury Severity Score was 58 +/- 19. The most common mechanism of injury was motor vehicle collision (73%), followed by pedestrian struck by auto (16%), and falls from height (8%). Twenty-one patients (6%) died on arrival and 140 (42%) died in the emergency room. The overall mortality for patients arriving alive to hospital was 89%. Of the patients surviving to operation, 42% survived >24 hours of which 87% were discharged. Survivors were significantly younger (39 vs. 46 years, p = 0.04), had a lower Injury Severity Score (47 vs. 56, p = 0.02), higher Glasgow Coma Scale (10 vs. 6, p < 0.001), and were more likely to present with an systolic blood pressure >/=90 mm Hg (p = 0.01). Nevertheless, none of these factors was found to be an independent risk factor for mortality. CONCLUSION:: BCR is an exceedingly rare injury, occurring in 1 of 2400 blunt trauma patients. In patients arriving alive to hospital, traumatic BCR is associated with a high mortality rate, however, is not uniformly fatal.

Notes & Commentary:

Coming shortly after our description of the patient with cardiac herniation following blunt trauma is this review of the National Trauma DataBank from the LA County group. Of course this is the tip of the iceberg as most patients will die at scene, but there's a surprisingly low (42%) mortality in the emergency department, suggesting that a significant proportion of these patients should be salvageable if identified early and managed appropriately.

As some of you have surmised this is a typical (if rare) picture of cardiac herniation.  This is not dextrocardia/situs as the anatomy of the aortic arch is normal.  Also the high vasopressor requirement suggests that this is not normal for the patient!  Similarly the picture is not typical of other postulated causes such as tension pneumothorax, tension pneumomediastinum, tension pneumopericardium etc.  The patient was taken to the operating room.  A left anterolateral thoractomy incision was performed and the pericardium opened.  The pericardium was empty which confirmed the diagnosis.  The incision was extended into a full clamshell incision.

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The heart was twisted on the SVC/IVC axis and was oedematous and engorged.  The right phrenic nerve was intact but torn free from the pericardium.  The preidcardial tear was widened and the heart relocated, with a good return in blood pressure and a decrease in vasopressor requirements.

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The right lateral tear in the pericardium was closed to avoid the heart re-twisting into the right chest.  The surgical pericardial incision was left widely open as the heart was too engorged for it to be closed.  The clamshell incision was closed and the patient taken to the intensive care unit for further management.

Cardiac herniation is rare but is a correctable cause of traumatic arrest or profound hypotension and must be considered.  There are several cases in the literature and two case reviews [PMIDs 9253902 and 16096553].  The Chest X-ray and CT findings of a right-sided herniation are clear here, although many are left-sided and the chest X-ray may be normal.

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