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Cureus May 2019Blunt cardiac injury (BCI), also referred to in the literature as a cardiac contusion, is a known cause of myocardial injury. It is often challenging to diagnose this...
Blunt cardiac injury (BCI), also referred to in the literature as a cardiac contusion, is a known cause of myocardial injury. It is often challenging to diagnose this condition in the absence of clear diagnostic criteria. Furthermore, its clinical presentation is highly variable depending on the severity, type, and duration of the trauma, as well as the timing from the initial insult. The clinical manifestation of BCI ranges from none to fatal arrhythmias to cardiac wall rupture seen on post-mortem examination. Cardiac biomarkers and electrocardiograms (EKG) are usually helpful in identifying cardiac trauma but are not necessarily abnormal in all cases. Falls by slipping on ice are common in the winter, but rarely do people present with a myocardial injury with these mechanical events. We describe the case of a cardiac contusion with an unusual presentation and an unusual cause, whereby both the initial EKG and troponin level were normal, and the patient presented with an atrioventricular (AV) block two weeks after "slipping on ice".
PubMed: 31312575
DOI: 10.7759/cureus.4650 -
Nan Fang Yi Ke Da Xue Xue Bao = Journal... Dec 2018To analyze the morphological features and forensic pathological characteristics of cardiac ruptures of different causes for their differential diagnosis.
OBJECTIVE
To analyze the morphological features and forensic pathological characteristics of cardiac ruptures of different causes for their differential diagnosis.
METHODS
We analyzed the data of 44 autopsy cases of cardiac rupture from 2014 to 2017 in our institute, including 11 cases caused by blunt violence with intact pericardium, 4 caused by cardiopulmonary resuscitation (CPR), 9 by myocardial infarction, and 20 by aorta dissection rupture.The gross features and histopathological characteristics of cardiac rupture and pericardial effusion were analyzed and compared.
RESULTS
Cardiac ruptures caused by blunt violence varied in both morphology and locations, and multiple ruptures could be found, often accompanied with rib or sternum fractures; the volume of pericardial effusion was variable in a wide range; microscopically, hemorrhage and contraction band necrosis could be observed in the cardiac tissue surrounding the rupture.Cardiac ruptures caused by CPR occurred typically near the apex of the right ventricular anterior wall, and the laceration was often parallel to the interventricular septum with frequent rib and sternum fractures; the volume of pericardial blood was small without blood clots; microscopic examination only revealed a few hemorrhages around the ruptured cardiac muscular fibers.Cardiac ruptures due to myocardial infarction caused massive pericardial blood with blood clots, and the blood volume was significantly greater than that found in cases of CPR-induced cardiac rupture ( < 0.05);lacerations were confined in the left ventricular anterior wall, and the microscopic findings included myocardial necrosis, inflammatory cell infiltration, and mural thrombus.Cardiac tamponade resulting from aorta dissection rupture was featured by massive pericardial blood with blood clots, and the blood volume was much greater than that in cases of cardiac ruptures caused by blunt violence, myocardial infarction and CPR ( < 0.05).
CONCLUSIONS
Hemorrhage, inflammatory cell infiltration, and lateral thrombi around the cardiac rupture, along with pericardial blood clots, are all evidences of antemortem injuries.
Topics: Aortic Dissection; Aortic Aneurysm; Cardiopulmonary Resuscitation; Forensic Pathology; Heart Rupture; Heart Rupture, Post-Infarction; Humans; Myocardial Contusions
PubMed: 30613023
DOI: 10.12122/j.issn.1673-4254.2018.12.19 -
Fa Yi Xue Za Zhi Oct 2018Commotio cordis (CC) is the acute death caused by the cardiac rhythm disorder after a sudden blunt external force to the precordium of a healthy person without... (Review)
Review
Commotio cordis (CC) is the acute death caused by the cardiac rhythm disorder after a sudden blunt external force to the precordium of a healthy person without previous heart disease. As one type of violent heart damage, CC is rare with relatively small external force and sudden death, therefore causing disputes. This paper reviews the epidemiology, mechanisms and the key points in forensic identification of CC, discusses the identification and antidiastole of CC, myocardial contusion, sudden cardiac death and death from inhibition, and provides assistance to forensic pathologists to identify such causes of death.
Topics: Commotio Cordis; Death, Sudden, Cardiac; Forensic Pathology; Heart; Humans; Wounds, Nonpenetrating
PubMed: 30468059
DOI: 10.12116/j.issn.1004-5619.2018.05.020 -
Journal of Emergencies, Trauma, and... 2018The patient was a 60-year-old male fell whose head and left chest hit the ground after falling from a height of 2 m. He complained of the left shoulder and chest pain...
The patient was a 60-year-old male fell whose head and left chest hit the ground after falling from a height of 2 m. He complained of the left shoulder and chest pain after regaining consciousness. On arrival, he showed left bloody otorrhea, left chest tenderness, and a limited range of motion due to the left shoulder pain. Emergency chest roentgenography revealed multiple left rib fractures, left clavicular fracture with decreased radiolucency in the left lung field, suggesting lung contusion. When the patient was being transported for computed tomography, he suddenly displayed ventricular tachycardia with pulse and subsequently became VF storm, which required percutaneous cardiopulmonary support. The coronary angiogram showed complete obstruction of the branch of the anterior descending artery. Coronary angioplasty resulted in recanalization; however, massive hemorrhage from the left ear was recognized. Computed tomography revealed traumatic subarachnoid hemorrhage and left massive hemothorax requiring thoracostomy. Massive hemorrhage from the left ear and left thoracic cavity continued after the patient was transported to the coronary care unit. He underwent massive transfusion; however, he died on the same day.
PubMed: 30429635
DOI: 10.4103/JETS.JETS_39_18 -
Intensive Care Medicine Experimental Oct 2018Both the hydrogen sulfide/cystathionine-γ-lyase (HS/CSE) and oxytocin/oxytocin receptor (OT/OTR) systems have been reported to be cardioprotective. HS can stimulate OT...
BACKGROUND
Both the hydrogen sulfide/cystathionine-γ-lyase (HS/CSE) and oxytocin/oxytocin receptor (OT/OTR) systems have been reported to be cardioprotective. HS can stimulate OT release, thereby affecting blood volume and pressure regulation. Systemic hyper-inflammation after blunt chest trauma is enhanced in cigarette smoke (CS)-exposed CSE mice compared to wildtype (WT). CS increases myometrial OTR expression, but to this point, no data are available on the effects CS exposure on the cardiac OT/OTR system. Since a contusion of the thorax (Txt) can cause myocardial injury, the aim of this post hoc study was to investigate the effects of CSE and exogenous administration of GYY4137 (a slow release HS releasing compound) on OTR expression in the heart, after acute on chronic disease, of CS exposed mice undergoing Txt.
METHODS
This study is a post hoc analysis of material obtained in wild type (WT) homozygous CSE mice after 2-3 weeks of CS exposure and subsequent anesthesia, blast wave-induced TxT, and surgical instrumentation for mechanical ventilation (MV) and hemodynamic monitoring. CSE animals received a 50 μg/g GYY4137-bolus after TxT. After 4h of MV, animals were exsanguinated and organs were harvested. The heart was cut transversally, formalin-fixed, and paraffin-embedded. Immunohistochemistry for OTR, arginine-vasopressin-receptor (AVPR), and vascular endothelial growth factor (VEGF) was performed with naïve animals as native controls.
RESULTS
CSE was associated with hypertension and lower blood glucose levels, partially and significantly restored by GYY4137 treatment, respectively. Myocardial OTR expression was reduced upon injury, and this was aggravated in CSE. Exogenous HS administration restored myocardial protein expression to WT levels.
CONCLUSIONS
This study suggests that cardiac CSE regulates cardiac OTR expression, and this effect might play a role in the regulation of cardiovascular function.
PubMed: 30341744
DOI: 10.1186/s40635-018-0207-0 -
International Journal of Surgery Case... 2018Systemic arterial air embolism (SAAE) is a rare but fatal condition, with only a few cases reported, and the detailed etiology underlying SAAE remains unknown. We report...
INTRODUCTION
Systemic arterial air embolism (SAAE) is a rare but fatal condition, with only a few cases reported, and the detailed etiology underlying SAAE remains unknown. We report a first case of massive SAAE after blunt chest injury, wherein the presence of traumatic air shunt was confirmed by direct observation during surgery. We also summarize our experience with six other SAAE cases.
PRESENTATION OF CASE
A 68-year-old woman was admitted in a state of cardiac arrest after a fall. Emergency room thoracotomy determined complete transection of left main bronchus and left superior pulmonary vein. Postmortem computed tomography (CT) revealed full of air in the aortic arch, the descending aorta, and the great vessels. Therefore, one of the cause of death might be SAAE.
DISCUSSION
An air shunt after blunt chest trauma can cause SAAE, and clinical signs and operative findings can provide clues for possible SAAE. The bronchopulmonary vein fistula, the aortic injury and full-thickness myocardial injury have the potential to become traumatic air shunts. In cases with a coexisting air shunt, pneumothorax, lung contusions and positive-pressure ventilation can be risk factors for SAAE, as sources of air continually entering the systemic arterial circulation.
CONCLUSION
SAAE is caused by an air shunt following trauma. Clinical signs and operative findings summarized in this case should aid in the recognition of possible SAAE.
PubMed: 30268062
DOI: 10.1016/j.ijscr.2018.09.014 -
International Journal of Surgery Case... 2018Blunt cardiac trauma covers a spectrum of injuries from clinically insignificant myocardial contusions to lethal ruptures of cardiac valves and chambers. Traumatic...
INTRODUCTION
Blunt cardiac trauma covers a spectrum of injuries from clinically insignificant myocardial contusions to lethal ruptures of cardiac valves and chambers. Traumatic coronary artery-cameral fistulas (TCAF) are a rare sequelae of blunt chest trauma.
CASE PRESENTATION
A 53-year-old male developed a TCAF after a motor vehicle collision. He was found on admission to be in cardiogenic shock with an elevated troponin and intermittent bifascicular block. An echocardiogram revealed hypokinesis of the mid-anteroseptal myocardium with an ejection fraction of 50%. Cardiac catheterization revealed a pseudoaneurysm of the left anterior descending artery (LAD) with a fistulous connection to the right ventricle, shown to be associated with reversible anterior wall ischemia from distal LAD coronary steal phenomenon on a nuclear perfusion scan. Given the ischemic burden, he was treated with operative revascularization via a single vessel coronary artery bypass graft (CABG) using the left internal mammary artery to LAD.
DISCUSSION
Early repair of TCAF can halt the progression of complications like left-to-right shunting, pulmonary hypertension, and heart failure. The two best described operative approaches to surgical closure of the fistula are either via external ligation or direct repair from within the recipient chamber, possibly with bypass grafting distal to the fistula site. Transcatheter closure and conservative management has been described for select patients with iatrogenic fistulas in recent literature.
CONCLUSION
High levels of clinical suspicion are necessary for the early detection and intervention of TCAF. Surgical or transcatheter interventions including fistula ligation and CABG can prevent later complications of heart failure.
PubMed: 30142600
DOI: 10.1016/j.ijscr.2018.08.017 -
Trauma Surgery & Acute Care Open 2018A 53-year-old man was admitted to our trauma center after sustaining thoracoabdominal injuries, secondary to a rear-end motor vehicle collision. As he stepped out of his...
UNLABELLED
A 53-year-old man was admitted to our trauma center after sustaining thoracoabdominal injuries, secondary to a rear-end motor vehicle collision. As he stepped out of his vehicle, he was struck by a tractor trailer at 55 mph. The following were the initial vital signs on his arrival: heart rate 140 beats/min, blood pressure 142/80 mm Hg, respiratory rate 28 breaths/min, temperature 36.8°C, and oxygen saturation 93%. The Glasgow Coma Scale score was 15 and the Injury Severity Score was 59. He was evaluated and resuscitated per the advanced trauma life support protocols. The focused assessment with sonography for trauma examination was negative. Initial findings included bilateral chest wall and thoracic spine tenderness, subcutaneous emphysema in the chest and neck, and an unstable pelvis. He required bilateral chest tubes and a pelvic binder. CT imaging revealed a left temporal epidural hematoma, multiple facial fractures, a sternal fracture, a left scapula fracture, acromioclavicular fractures, bilateral hemopneumothoraces, pulmonary contusions, extensive pneumomediastinum compressing the right atrium, multiple rib fractures (2-10 on the left with a flail segment and 2-8 on the right) (figure 1), an unstable open-book pelvic fracture which included bilateral superior and inferior pubic rami fractures, sacral and left iliac wing fractures, and symphysis pubis diastasis.Figure 1Three-dimensional CT scan reconstruction demonstrating left-sided flail chest.The patient developed hypotension and severe respiratory distress, and was intubated. ECG revealed no dysrhythmias. Echocardiogram revealed significant left ventricular wall dysfunction consistent with myocardial contusion and right atrial compression. His troponins were also significantly elevated. He required significant resuscitation with crystalloids, blood products and vasopressors. He underwent bronchoscopy, esophagram and upper endoscopy to exclude tracheoesophageal injury, and these were negative. On hospital day 2, the patient was hemodynamically stable, and pressors were discontinued. His pelvic fractures were repaired using external fixation and sacral screws. Given his extensive left flail chest, he underwent reconstruction of his left chest wall on hospital day 5. Open reduction and internal fixation of his left ribs, 3 to 6 anteriorly and 4 to 7 posteriorly, with titanium plates was performed (figure 2). He had an epidural catheter inserted for analgesia. On postoperative day 2 after chest wall reconstruction, the patient was extubated and resumed enteral feeds. Overnight, the output from the left-sided chest tube changed from serosanguinous to milky. A sample was sent for triglycerides and lymphocyte counts confirming the diagnosis of chylothorax. His chest tube output increased to approximately 2000 mL/day. A lymphangiogram was performed with Lipiodol to diagnose the location of the chylous leak. It revealed contrast extravasation at the level of T3 to T4. An MRI was also performed to better define the anatomic course of the thoracic duct.Figure 2Postoperative chest X-ray demonstrating left chest wall reconstruction.
WHAT WOULD YOU DO?
Conservative management: placing the patient nulla per os (NPO), and starting total parenteral nutrition (TPN), octreotide and midodrine.Thoracic duct embolization by interventional radiology.CT-guided thoracic duct disruption.Thoracotomy with thoracic duct ligation.
PubMed: 30023436
DOI: 10.1136/tsaco-2018-000183 -
Journal of Cardiothoracic Surgery Jun 2018Blunt cardiac trauma is diagnosed in less than 10% of trauma patients and covers the range of severity from clinically insignificant myocardial contusions to lethal...
BACKGROUND
Blunt cardiac trauma is diagnosed in less than 10% of trauma patients and covers the range of severity from clinically insignificant myocardial contusions to lethal multi-chamber cardiac rupture. The most common mechanisms of injury include: motor vehicle collisions (MVC), pedestrians struck by motor vehicles and falls from significant heights. A severe complication from blunt cardiac trauma is cardiac chamber rupture with pericardial tear. It is an exceedingly rare diagnosis. A retrospective review identified only 0.002% of all trauma patients presented with this condition. Most patients with atrial rupture do not survive transport to the hospital and upon arrival diagnosis remains difficult.
CASE PRESENTATION
We present two cases of atrial and pericardial rupture. The first case is a 33-year-old female involved in a MVC, who presented unresponsive, hypotensive and tachycardic. A left sided hemothorax was diagnosed and a chest tube placed with 1200 mL of bloody output. The patient was taken to the OR emergently. Intraoperatively, a laceration in the right pericardium and a 3 cm defect in the anterior, right atrium were identified. Despite measures to control hemorrhage and resuscitate the patient, the patient did not survive. The second case is a 58-year-old male involved in a high-speed MVC. Similar to the first case, the patient presented unresponsive, hypotensive and tachycardic with a left sided hemothorax. A chest tube was placed with 900 mL of bloody output. Based on the output and ongoing resuscitation requirements, the patient was taken to the OR. Intraoperatively, a 15 cm anterior pericardial laceration was identified. Through the defect, there was brisk bleeding from a 1 cm laceration on the left atrial appendage. The injury was debrided and repaired using a running 3-0 polypropylene suture over a Satinsky clamp. The patient eventually recovered and was discharged home.
CONCLUSIONS
We present two cases of uncontained atrial and pericardial rupture from blunt cardiac trauma. Contained ruptures with an intact pericardium present as a cardiac tamponade while uncontained ruptures present with hemomediastinum or hemothorax. A high degree of suspicion is required to rapidly diagnose and perform the cardiorrhaphy to offer the best chance at survival.
Topics: Accidents, Traffic; Adult; Cardiac Tamponade; Fatal Outcome; Female; Heart Atria; Heart Injuries; Heart Rupture; Hemothorax; Humans; Male; Middle Aged; Pericardium; Retrospective Studies; Wounds, Nonpenetrating
PubMed: 29914563
DOI: 10.1186/s13019-018-0753-2 -
International Heart Journal Jul 2018Blunt chest trauma may lead to cardiac involvement such as myocardial contusion, coronary artery dissection, cardiac rupture, or myocardial infarction. Early detection...
Blunt chest trauma may lead to cardiac involvement such as myocardial contusion, coronary artery dissection, cardiac rupture, or myocardial infarction. Early detection and treatment of complications such as these are essential. We describe a case status post collision with an iron ball and discuss how to detect myocardial infarction. We emphasize the importance of careful interview, physical examination, and electrocardiogram even in seemingly healthy patients. A severe blow, such as that described, can impair coronary artery flow and may potentially cause myocardial infarction.
Topics: Aged; Coronary Angiography; Diagnosis, Differential; Electrocardiography; Humans; Magnetic Resonance Imaging, Cine; Male; Medical History Taking; Myocardial Contusions; Myocardial Infarction; Physical Examination; Thoracic Injuries
PubMed: 29794383
DOI: 10.1536/ihj.17-345