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Mon May 12 22:20:10 BST 2008

Blunt cardiac injury, with injury to the valves, ventricular septum, atrial  
septum, coronary arteries, free wall rupture, and muscular hematomas have been 
 described.  The term "cardiac contusion" is so broad and non-descript as to  
be totally worthless.   Cardiac herniation via a tear in the  pericardium is 
well described.    Routine garden variety  myocardial infarction is rare in a 
37 year old patient.   Systemic  (coronary artery and CNS) air embolism 
requires a lung tear and endobronchial  pressures in excess of 60 TORR.   The arrest 
from such a lesion lead  to abrupt V-Fib and arrest, not progressive 
hypotension.    I  think you are going to be surprised by the final findings at  
autopsy.   It is possible that they also find NOTHING  new.     

k

In a message dated 5/12/2008 3:55:52 P.M. Central Daylight Time,  
johan.malmgren at vgregion.se writes:

Dr Mattox, thanks for answering

I basically have the same concerns as you do regarding target BP and that  
the thoracic surgeon did not open the chest. Regarding stent or not, I have no  
personal opinion, we've done a few and it has worked out fine, but this  
patient would possibly have been alive if he had gone to surgery instead.  
Would you please elaborate on 1. why you don't believe in cardiac  contusion 
and 2. how would coronary air embolism present? I'm guessing like a  plain old 
MI?

Johan Malmgren 
Resident, Anaesthesia, Critical Care & Traumatology
Dept of Anaesthesia and Critical Care
Sahlgrenska University Hospital
Gothenburg, Sweden
+46313428073 [Work]
+46707696961 [Mobile]

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As presented, a number of concerns exist.     

As  presented I would give NO crystalloid fluids in the ambulance or  
emergency room.   Once you saw the suspicious chest X-ray, I  would  have 
started 
Esmolol.   My target BP would have been  80/-.      He sounds more like fluid 
overload  rather  than cardiac contusion (I do not really believe this 
diagnosis  
exists), or  systemic air embolism.    Atrial  fibrillation in a 37 year old 
is  
rare, although with ETOH and drug  use, it does occur.    His  hypotension in 
the CT scanner  could be secondary to spinal cord injury as well  as bleeding 
in  
the abdomen, with rebleeding caused by popping of the  clot.    I am 
concerned 
that the thoracic surgeon did not open  the  chest, as pericardial tear with 
herniation of the heart is also a real  possibility and the thoracic surgeon 
could address that.  I  too believe  that the general surgeon could have 
easily 
have done  the  thoracotomy.    As presented, I WOULD NOT have  considered a 
STENT  of the aorta and I do not believe that the  thoracic aorta popped its 
clot 
as  your chest tube would have  filled up with blood.   The pathology  
leading 
to the  hypotension in this case is outside the left  chest.      

k mattox

In a message dated 5/12/2008 1:51:09 P.M.  Central Daylight Time,  
johan.malmgren at vgregion.se  writes:

Opinions please about a case from this morning. Please excuse  the lack of  
details, I was only partially involved

37 y/o  patient on amphetamine and benzo drives his motorcycle in 70 km/h  
right into a truck. Stable in all ways prehosp apart from a atrial  
fibrillation, 
130 bpm.
Arrives in ER and is diagnosed with  small hemo-/pneumothx right side,  subQ 
air right side, suspicious  widened mediastine, left humerusfx. Still AFib  
with 
pressure  around 130/70. BG shows hgb about 95, lactate and pH  normal.
Recieves a chest tube which drain some 100-200 ml blood.  He's having some  
problems keeping his saturation up and is  intubated. Surgeon wants to have a 
 CT.
Once on CT the head and neck  are fine, but just as the thx/abd is about  to 
start his BP is down  to 95/50. So now everyone including the surgeon are  
convinced that  something is happening inside him, and a renewed BP is 65/30. 
 By  
this time he has by some way still recieved his CT and it shows a  ruptured  
thoracic aorta at the ductus level, subQ air right side  and in mediastine,  
mediastinal hematoma, lunglaceration, rib fx x4  and a contained splenic  
hematoma.

Decision is made to stent the  aortic rupture on the trauma OR. Stenting  is 
going fine although  circulatory unstable. His abdomen is becoming more  
distended and  opened, and the splenic hematoma is no longer contained... 
Fast  
splenectomy, but about the same time anesthesia has more and more  trouble. 
It  turns 
out CVP is rising from 15 to 55-60, and the  patient jumps between  this afib 
in 140 to bradycardia to and fro.  Thoracic surgeons are called in  while the 
surgeon opens a  diaphragmatic window, no tamponade. ECG turns into  widened 
QRS 
and  then asystole. CPR is started without effect. TEE shows no  tamponade,  
and thoracic surgeon refuses to open chest with the argument that  "there's 
nothing we can do, only more harm".
Patient  dies...

So, apart from so many other things to comment, I'm curious  to what you  
think actually killed the pt. The anesthesiology  professor that handled him  
thinks that his myocardial contusion  was more devastating than they first  
thought, 
and that he went  into failure from transfusion overload. 
The surgeon also thinks that it  was a plain myocardial contusion.
I'm thinking that if he had a contusion  that actually killed him,  wouldn't 
you want at least a sternal fx  and flail chest? How about coronary  air 
embolism that gave him a  plain MI?

Suggestions and opinions please!

Johan Malmgren  
Resident, Anaesthesia, Critical Care & Traumatology
Dept of  Anaesthesia and Critical Care
Sahlgrenska University  Hospital
Gothenburg, Sweden
+46313428073 [Work]
+46707696961  [Mobile]

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