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Заболевания → Blunt cardiac rupture: the utility of emergency department ultrasound

Background . Rupture of the heart is usually a fatal injury in patients sustaining blunt trauma. Those arriving in the emergency department alive can be saved with prompt diagnosis and treatment.
Methods . We describe the cases of 4 consecutive patients with rupture of the free cardiac wall whom we treated at Grady Hospital. Two had a tear of the right ventricle, 1 had a tear of the right atrium, and 1 had two tears of the left atrium. All patients were involved in motor vehicle accidents. The diagnosis was made by ultrasound in 3 patients and during exploratory surgical intervention in the other. All tears were repaired primarily without the aid of cardiopulmonary bypass.
Results . Three of the patients survived, and 1 died.
Conclusions . Rarely are patients with rupture of the free cardiac wall seen in an emergency department. The improvements in the prehospital care and the transportation may result in an increase in the numbers of such patients. Physicians treating patients with blunt trauma must suspect the presence of cardiac rupture. Immediate use of ultrasonography will establish the diagnosis and prompt repair of the injury may improve overall survival.
Blunt rupture of the heart has been estimated to cause 2,500 motor vehicle fatalities per year [1] . The majority of these patients die shortly after the injury, but a subset survives 30 minutes or longer [2] . Improvements in the prehospital care and the transportation of trauma victims may result in a greater number of patients with such an injury being delivered alive to the emergency department. We report the cases of 4 consecutive patients sustaining blunt trauma seen at Grady Hospital during the last 3 years. The diagnosis of hemopericardium in 3 of the patients was made during ultrasound examination in the emergency department. All patients underwent repair without cardiopulmonary bypass.
Material and methods
The case reports that follow concern 4 consecutive patients with blunt chest trauma who were seen at Grady Hospital. All 4 were involved in motor vehicle accidents and had rupture of the free cardiac wall.
Patient 1
A 35−year-old woman was involved in a motor vehicle accident and was admitted to the emergency department with complaints of dyspnea and left chest pain. Blood pressure was 130/70 mm Hg, pulse rate was 140 beats per minute, and respirations were 40/min. During the examination, she became diaphoretic and hypotensive. Two units of packed red blood cells and 2 units of crystalloid solution were given, and a chest tube was inserted, which drained 700 mL of blood. The hypotension improved, but the neck veins became markedly distended. Echocardiography showed fluid in the pericardial space with impending tamponade, and the patient was taken to the operating room.
Through a median sternotomy, the pericardium was opened, and a large volume of blood was evacuated. There was bleeding through a rupture of the right ventricular wall just to the right of the left anterior descending coronary artery. The ventricular wound was repaired with two pledgeted, interrupted horizontal mattress sutures. Echocardiography prior to discharge from the hospital and a year later showed good ventricular function with no noticeable cardiac abnormality.
Patient 2
A 7−year-old boy was admitted to the emergency department after a motor vehicle accident. Pulse rate was 150 beats per minute, blood pressure was 80/50 mm Hg, and the Glasgow coma score was 14. Shortly after arrival, he became agitated and then unresponsive, and blood pressure dropped to 60/30 mm Hg. He was intubated and given 900 mL of fluid, which resulted in hemodynamic improvement. Echocardiography revealed fluid in the pericardial space.
The patient was transferred to the operating room, and a median sternotomy was performed. When the pericardium was opened, 200 mL of blood drained under pressure, and two small tears were noted, one at the left atrial appendage and the other at the junction of the left pulmonary veins and the left atrium. Both wounds were repaired with pledgeted, interrupted horizontal mattress sutures. An echocardiogram made on the fourth postoperative day showed no abnormality, and the patient was discharged on the tenth hospital day. A repeat echocardiogram 1 year later was normal.
Patient 3
A 45−year-old man was involved in a motor vehicle accident. When he was seen at the emergency department, systolic blood pressure was 90 mm Hg, heart rate was 110 bpm, respirations were 30 min, and the Glasgow coma score was 14. Soon after his arrival, systolic blood pressure dropped to 60 mm Hg, and the patient became lethargic. Two units of packed red blood cells were given.
The patient was taken to the operating room for exploratory laparotomy. No abnormality was found in the abdomen, but when a small incision was made on the membranous portion of the diaphragm, blood from the pericardial space drained under pressure, resulting in marked hemodynamic improvement. A median sternotomy was performed, and a 2−cm tear was found in the outflow tract of the right ventricle next to the left anterior descending coronary artery. The tear was repaired with pledgeted, interrupted horizontal mattress sutures. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day.
Patient 4
A 50−year-old man was involved in a motor vehicle accident. When he arrived at the emergency department, blood pressure was 115/70 mm Hg, pulse rate was 90 beats per minute, and the Glasgow coma score was 12. Shortly thereafter, he became hypotensive. Ultrasound examination of the heart showed fluid in the pericardial space as well as in the peritoneal cavity. A left anterolateral thoracotomy was performed immediately. The tense pericardium was opened, and after blood clots were evacuated, a 4−cm tear was found in the right atrial appendage.
The patient was transferred to the operating room. A Satinsky clamp was placed across the base of the atrial appendage, and the tear was repaired with a continuous running suture. Laparotomy was performed, and several large, deep lacerations of the right lobe of the liver were found. The patient became hypothermic and coagulopathic. After closure, the patient was taken to the surgical intensive care unit where resuscitative efforts continued. He died 6 hours after operation.
The clinical manifestations of rupture of the free cardiac wall are dependent on the presence or absence of a tear in the pericardium and on whether it is sealed. The majority of patients with rupture of the free cardiac wall and intact pericardium are seen with signs of cardiac tamponade, whereas patients with a concomitant tear in the pericardium usually manifest hemothorax and hemorrhagic shock. Pevec and associates [3] reviewed the cases of the 61 known survivors of blunt cardiac rupture up to 1989. Of them, 78% had central venous pressure equal to or greater than 20 mm Hg or distended neck veins, and 70% had systolic blood pressure of less than 80 mm Hg at admission. Of the 10 patients discussed by Calhoon and colleagues [1] , 6 were seen with cardiac tamponade, 3 were in hemorrhagic shock, and 1 had combined symptoms. Only 1 of our patients had signs of cardiac tamponade, and the other 3 became severely hypotensive shortly after admission to the emergency room. This suggests that patients who sustain blunt trauma and have signs of hypovolemia as well as those with signs of tamponade should be suspected of having cardiac rupture.
Patients with cardiac rupture who arrive alive in the emergency department are a select group of patients. Fulda and coauthors [4] reported a series of 59 patients with blunt rupture of the heart or pericardium. Fifty-one percent of patients alive at the accident scene died during transport, and 24% sustained arrest in the emergency department. Prompt diagnosis and treatment are vital to save these patients. Ultrasonography is the diagnostic modality with the most potential to quickly identify hemopericardium and to strongly indicate a diagnosis of cardiac rupture.
Ultrasound has been immediately available in our emergency department for the last 5 years. Ultrasonography is performed by a surgical resident or a faculty member from the trauma service. All patients with a penetrating wound of the precordial area and all patients with blunt injury and signs of cardiac tamponade or unexplained hypotension undergo ultrasonography of the heart during resuscitation efforts [5] . Ultrasound has clinically been demonstrated to be both sensitive and specific in detecting pericardial effusion in a trauma setting [6] . In 3 of our patients, hemopericardium was detected by echocardiography in the emergency department. In 1 of them, ultrasound was used because of signs suggestive of cardiac tamponade and in the other 2 because of unexplained hypotension. Kato and associates [7] reported a Japanese series of patients with blunt trauma in which a total of 1,424 ultrasound examinations were performed between 1985 and 1995. Pericardial effusion was detected in 9 patients, 8 of whom had blunt cardiac rupture and 1, a benign cause of the effusion.
The majority of patients with rupture of the heart have other more common and glaring injuries. Therefore, the emergency room physician must suspect the presence of cardiac rupture in patients with severe blunt trauma, particularly in those manifesting signs suggestive of cardiac tamponade or unexplained hypotension and hemothorax. The immediate use of echocardiography to detect the presence of fluid in the pericardial space and the prompt repair of these injuries may lead to a higher survival among these patients.
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2.Bright E.B., Beck C.S.. Nonpenetrating wounds of the heart. Am Heart J 1935;10:293−321.
3.Pevec W.C., Udekwu A.O., Peitzman A.B.. Blunt rupture of the myocardium. Ann Thorac Surg 1989;48:139−142.
4.Fulda G., Brathwaite C.E.M., Rodriguez A., Turney S.Z., Dunham C.M., Cowley R.A.. Blunt traumatic rupture of the heart and pericardium. J Trauma 1991;31:167−173.
5.Rozycki G.S., Feliciano D.V., Schmidt J.A.. The role of surgeon-performed ultrasound in patients with possible cardiac wounds. Ann Surg 1996;223:737−744.
6.Rozycki G.S., Ochsner M.G., Jaffin J.H., Champion H.R.. Prospective evaluation of surgeons' use of ultrasound in the evaluation of trauma patients. J Trauma 1993;34:516−526.
7.Kato K., Kushimoto S., Mashiko K.. Blunt traumatic rupture of the heart. J Trauma 1994;36:859−864.
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