CASE REPORT left ventricular rupture; trauma, blunt chest
A Pediatric Survivor of Left Ventricular Rupture After Blunt Chest Trauma The case of a patient with left ventricular rupture as a result of blunt chest trauma from a motor vehicle accident is presented. This is the first reported case of a pediatric survivor of this rare and usually lethal injury and only the fourth report of a survivor. This condition can be treated if the patient survives long enough to reach a trauma center, if the diagnosis is entertained early, and if the appropriate diagnostic studies are obtained in an expeditious manner. We believe that echocardiography is the diagnostic method of choice for pericardial tamponade, whether it is the result of penetrating or blunt trauma, and that early use of this modality m a y improve survivability. [Mozzetti MD, Devin JB, Susselman MS, Lammert GR, Olshaker JS: A pediatric survivor of left ventricular rupture after blunt chest trauma. Ann Emerg Med April 1990;19:386-389.]
INTRODUCTION Blunt chest trauma resulting in pericardial tamponade is an u n c o m m o n event that usually necessitates immediate surgical intervention. Only four cases of survival after left ventricular rupture secondary to blunt chest trauma have been reported; we report the first surviving pediatric victim. In addition, the superiority of echocardiography compared with computed tomography (CT) in the diagnosis of cardiac tamponade is demonstrated.
CASE REPORT A 15-year-old girl was an unrestrained rear-seat passenger in an automobile moving at 45 m p h and was thrown into the front right seat during a collision with an embankment. At the scene of the accident, she was reported to be awake and alert but short of breath and extremely anxious. Vital signs at the scene were blood pressure of 110/58 m m Hg; pulse, 110; and respirations, 32. The patient was immobilized on a spine board in cervical-spine precautions and transported to the regional trauma center. On arrival, she was alert, complaining of shortness of breath, hyperventilating, and anxious. The medical history and review of systems were unremarkable. Her chief complaints were mild chest pain and shortness of breath, which were exacerbated by lying flat. She stated that the shortness of breath while lying flat was something she had experienced since she was a child. Vital signs on presentation were blood pressure of 120/64 m m Hg; pulse, 120 and regular; respirations, 34; and temperature, 36.7 C. She was alert and oriented to person, place, time, and situation but at times was combative, confused, and agitated. Secondary survey was then performed. Head, ear, eye, nose, and thorat examination was normal except for mild ecchymoses around the eyes and facial tenderness. The pupils were equal and reactive to light, and extraocular m o v e m e n t s were intact. There was no drainage from the ears, hem o t y m p a n u m , unusual discharge from the nose, or gross trauma or compromise of airway and mouth. The patient's neck was immobilized and tender to palpation with no soft-tissue swelling or asymmetry. She had normal neck veins and a midline trachea. Her chest had a small, tender ecchymosis at the right sternal border, fourth costochondral junction, but otherwise there was no bony tenderness. There were bilateral clear breath sounds that were louder on the right. The first and second heart sounds
19:4 April 1990
Annals of Emergency Medicine
Michael D Mozzetti, MD* Joseph B Devin, MDt Mark S Susselman, MDt Gary R Lammert, MD* Jonathan S Olshaker, MD* San Diego, California From the Departments of Emergency Medicine and Clinical Investigation, Naval Hospital;* and the Mercy Hospital Regional Trauma Center,t San Diego, California. Received for publication September 11, 1989. Accepted for publication November 1, 1989. Supported by the Clinical Investigation Program, case report no. 84-16-1968-119. The opinions expressed in this article are the views of the authors and do not represent the position or view of the Department of the Navy, the Department of Defense, or the US government. Address for reprints: LCDR MD Mozzetti, MC, USN, % Clinical Investigation Department, Naval Hospital, San Diego, California 92134-5000.
386/78
BLUNT CHEST TRAUMA Mozzetti et al
TIGURE 1. Supine chest radiograph
showing the normal cardiac silhouette (white arrow) and the right pulmonary contusion (black arrow). were clearly heard with a regular r h y t h m and rapid rate. Bowel s o u n d s w e r e p r e s e n t , and the a b d o m e n was n o n t e n d e r to palpation w i t h no masses, contusions, or organomegaly. T h e pelvis was nont e n d e r to c o m p r e s s i o n . G e n i t a l i a were n o r m a l w i t h o u t vaginal bleeding. There was no rectal tenderness or blood, and there was good rectal tone. The extremities were nont e n d e r w i t h no d e f o r m i t i e s and full range of motion. Cranial and spinal nerve f u n c t i o n were i n t a c t grossly. There was no ataxia. Deep tendon reflexes were n o r m a l . Babinski's sign was not present. The skin was cool, pink, and dry w i t h o u t bruises or lacerations on the back, and the spine was nontender. The patient was given 40% oxygen by facemask; a second large-bore IV line was started, and she was placed on a cardiac m o n i t o r and oximeter. A F o l e y c a t h e t e r was p l a c e d w i t h o u t d i f f i c u l t y . A c h e s t r a d i o g r a p h and cross-table lateral c e r v i c a l - s p i n e radiograph were obtained i m m e d i a t e l y . T h e c e r v i c a l - s p i n e l a t e r a l was normal. The chest radiograph showed a normal cardiac silhouette w i t h o u t a p n e u m o t h o r a x or h e m o t h o r a x , b u t there was a suggestion o'f p u l m o n a r y c o n t u s i o n (Figure 1). T h e r e were no f r a c t u r e d ribs. A d i a g n o s t i c p e r i toneal lavage was negative. The p a t i e n t became m o r e confused and combative, and her systolic blood pressure dropped to 80 m m Hg and palpable w i t h i n 20 minutes. The b l o o d p r e s s u r e was c o r r e c t e d by a r a p i d f l u i d c h a l l e n g e of 750 m L Ringer's lactate. Because of her deteriorating m e n t a l status, head trauma, and i n c r e a s i n g c o m b a t i v e n e s s , she was orally i n t u b a t e d w i t h a standard rapid sequence induction using d-Tubocurare, succinylcholine, and t h i o p e n t a l s o d i u m and in-line cervical traction. A left subclavian central IV line was placed, and the i n i t i a l central v e n o u s p r e s s u r e was 20 c m H20. She then was taken for a head CT, w h i c h was normal. W h i l e in the CT scanner, her blood p r e s s u r e dropped again, and a CT of the m e d i a s t i n u m was obtained to search for aortic disruption. Blood pressure was corrected 76/387
TABLE. Frequency of findings associated with cardiac rupture and
pericardial tamponade Percentage of Patients
Finding
Hypotension Elevated central venous pressure Tachycardia Motor vehicle accidents Distended neck veins Upper body plethora Unresponsiveness Distant heart sounds Associated other injuries Cardiomegaly on chest radiograph
w i t h a fluid bolus of 500 mL. T h e m e d i a s t i n a l C T w a s i n t e r p r e t e d as n o r m a l except for heart m o t i o n artifact (Figure 2). A diagnostic cchocardiogram was then obtained, which showed a m o d e r a t e l y large collection of p e r i c a r d i a l f l u i d (Figure 3). O n e h u n d r e d ten m i l l i l i t e r s of n o n c l o t ting blood was i m m e d i a t e l y drained by p e r i c a r d i o c e n t e s i s . T h e c a t h e t e r w a s l e f t in p l a c e to m o n i t o r t h e a m o u n t of c o n t i n u e d efflux into the pericardial sac. C o n t i n u e d b l e e d i n g into the peric a r d i u m was d e t e c t e d , a n d the paAnnals of Emergency Medicine
100 95 89 82 80 76 74 61 60 59
tient was then taken to surgery. At thoracotomy, through a median sternotomy, a 1.5-cm left v e n t r i c u l a r posterior rupture was found with oozing around the clot in the defect. This was repaired without cardiac bypass w i t h i n d i v i d u a l l y p l e d g e t t e d n o n a b s o r b a b l e p r o l e n e sutures. T h e p a t i e n t recovered uneventfully.
DISCUSSION Cardiac r u p t u r e after b l u n t chest t r a u m a is u n c o m m o n w h e n c o m pared w i t h aortic disruption, and surv i v a l a f t e r t h i s i n j u r y is rare. ~ In 19:4 April 1990
1935, Bright and Beck reported on postmortem examinations of 152 pat i e n t s w i t h b l u n t c h e s t injuries. ~ Their results s h o w e d that all four chambers of the heart ruptured with equal frequency. Because 30 patients survived at least one hour, they concluded that if rapid diagnosis and prompt definitive repair were carried out, m o r e of these patients m i g h t survive) In 1896, Rhen first reported a survivor with penetrating injury to the heart, as mentioned by Griffith. 3 The first report of a successful repair of blunt injury to the heart was reported in 1955 by DesForges et al. 4 Since this time, there have been 40 cases in the literature of patients w h o survived cardiac r u p t u r e after b l u n t trauma. 1 Of the survivors of blunt cardiac chamber rupture, only five {including our patient} have survived a left ventricular lesion. This case represents the only report of a pediatric survivor of blunt left ventricular rupture we have found in the literature. Because this entity is rare and survival is dismal, early recognition and t r e a t m e n t is of p a r a m o u n t importance. The frequency of findings associated w i t h cardiac r u p t u r e w i t h pericardial tamponade is given {Table). Fifty-six percent of the patients underwent diagnostic pericardiocentesis. Its use was primarily diagnostic, but aspiration of even a small a m o u n t of n o n c l o t t i n g blood f r o m the p e r i c a r d i u m y i e l d e d i m p r o v e d hemodynamics, which allowed time for the definitive procedure, a perieardial window, or a pericardiotomy.l First, a high index of suspicion for cardiac rupture with blunt chest trauma, in addition to aortic disrup19:4 April 1990
tion, cardiac concussion, and contusion, m u s t always be m a i n t a i n e d . 5 These entities m u s t be considered in the differential diagnosis. Whenever h y p o t e n s i o n e n s u e s , w i t h o u t arr h y t h m i a as the etiology, especially in the presence of elevated central v e n o u s pressure, a c u t e pericardial tarnponade as a result of c h a m b e r rupture m u s t be entertained as a diagnostic possibility and expeditiously ruled out. Second, while mediastinal CT m a y be considered to rule out an aortic disruption, it is a poor modality for diagnosing pericardial tamponade. In the setting of blunt chest trauma, elevated central venous pressure, and persistent or recurrent hypotension, echocardiography should be rapidly obtained. Because our patient's blood pressure deteriorated in the CT scanner, we elected to obtain a rapid series of CT cuts to see if there was aortic disruption. There was no evidence of this, and aortography was not considered to be required at this time. Echocardiography is a reliable indication of pericardial tamponade, whether it is from blunt or penetrating trauma. 6 Aortography is the appropriate diagnostic test for aortic disruption. Third, rapid diagnosis and definitive surgical repair m a y avert the disastrous consequences of this usually lethal injury. At any time during the diagnostic workup, this patient could have deteriorated abruptly, necessitating emergency thoracotomy.7, s Miller et al have r e c e n t l y r e c o m mended the use of a diagnostic pericardial window in place of the diagnostic pericardiocentesis or echocardiagram. 9 This disorder is t r e a c h e r o u s for Annals of Emergency Medicine
FIGURE 2. CT of the mediastinum. Arrow 1 shows right pulmonary contusion, and arrow 2 shows probable pericardial fluid versus m o v e m e n t artifact. FIGURE 3. Echocardiogram still photograph. Arrow shows the pericardial fluid, which was about 110 mL of nonclotting blood.
two reasons. It is rare and the diagnosis m a y not be readily considered. It is also a lethal injury, and a high index of suspicion m u s t be m a i n tained to consider this as a diagnostic possibility early on in the evaluation of t h e p a t i e n t w i t h b l u n t c h e s t trauma. The key here is recognizing that the p a t i e n t w i t h h y p o t e n s i o n has an elevated central venous pressure and that the etiology of the hypotension is not hemorrhage or tension pnuemothorax/hemothorax as it usually is in such a patient. We do not feel that pericardial window would have provided additional information or adequate exposure for the definitive repair of the defect in the ventricle.
SUMMARY We report the first pediatric survivor of left ventricular rupture, presenting our opinion of the best diagnostic modality for detecting this lethal injury. Our patient survived the initial injury and recovered without sequelae. Her survivability was no doubt enhanced by her youth. This case serves to point out several important diagnostic features of this injury. In the setting of blunt chest trau o m a and i n t e r m i t t e n t h y p o t e n s i o n , 388/77
BLUNT CHEST TRAUMA Mozzetti et al
cardiac chamber rupture must be c o n s i d e r e d i n t h e d i f f e r e n t i a l diagn o s i s . E c h o c a r d i o g r a p h y is a v a i l a b l e at m o s t t r a u m a c e n t e r s ; it is a m o b i l e and reliable diagnostic modality and s h o u l d be u s e d e a r l y i n a n y s u c h resuscitation. Echocardiography should p r e c e d e o t h e r d i a g n o s t i c t e s t s s u c h as h e a d C T w h e n h y p o t e n s i o n is associated with elevated central venous pressure. The operating room should be r e a d i e d for e m e r g e n c y surgery, a n d t h e p a t i e n t s h o u l d h a v e d e f i n i t i v e rep a i r as s o o n as p o s s i b l e . P e r i c a r d i o c e n t e s i s m a y be u s e d as a d i a g n o s t i c
78/389
and temporizing therapeutic proc e d u r e w h i l e t h e p a t i e n t is b e i n g prep a r e d for surgery.
injury. N Er~gl J Med 1955;252:267.
REFERENCES
6. Whye D, Barish R, Almquist T, et ah Echocardiographic diagnosis of acute pericardial effusion in penetrating chest trauma. A m J Emerg Med 1988;6:21-23. 7. Baker CC, Thomas AN, Trunkey DD: The role of emergency room thoracotomy in trauma. Trauma 1980;20:848-855. 8. Hendel PN, Grant AI~: Blunt traumatic rupture of the heart. J Thorac Cardiovasc $urg 1981;81:574-576.
i. Leavitt BJ, Meyer JA, Morton JR, et ah Survival following nonpenetrating traumatic rupture of cardiac chambers. AnN Thorac Surg 1987;44:532-535. 2. Bright EF, Beck CS: Nonpenetrating wounds of the heart: A clinical and experimental study. Am Heart J 1935;10:293. 3. Griffith GL, Zeok JV, Mattingly WT, et ai: Right atrial rupture due to blunt chest trauma. South Med J 1984;77:715-716. 4. DesForges G, Ridder WP: Successful suture of ruptured myocardium after nonpenetrating
Annals of Emergency Medicine
5. Tenzer ML: The spectrum of myocardial contusion: A review. J Trauma 1985;25:620-627.
9. Miller FB, Bond SJ, Shumate CR, et al: Diagnostic pericardial window. Arch Surg 1987; 122:605-609.
19:4 April 1990
A Pediatric Survivor of Left Ventricular Rupture After Blunt Chest Trauma The case of a patient with left ventricular rupture as a result of blunt chest trauma from a motor vehicle accident is presented. This is the first reported case of a pediatric survivor of this rare and usually lethal injury and only the fourth report of a survivor. This condition can be treated if the patient survives long enough to reach a trauma center, if the diagnosis is entertained early, and if the appropriate diagnostic studies are obtained in an expeditious manner. We believe that echocardiography is the diagnostic method of choice for pericardial tamponade, whether it is the result of penetrating or blunt trauma, and that early use of this modality m a y improve survivability. [Mozzetti MD, Devin JB, Susselman MS, Lammert GR, Olshaker JS: A pediatric survivor of left ventricular rupture after blunt chest trauma. Ann Emerg Med April 1990;19:386-389.]
INTRODUCTION Blunt chest trauma resulting in pericardial tamponade is an u n c o m m o n event that usually necessitates immediate surgical intervention. Only four cases of survival after left ventricular rupture secondary to blunt chest trauma have been reported; we report the first surviving pediatric victim. In addition, the superiority of echocardiography compared with computed tomography (CT) in the diagnosis of cardiac tamponade is demonstrated.
CASE REPORT A 15-year-old girl was an unrestrained rear-seat passenger in an automobile moving at 45 m p h and was thrown into the front right seat during a collision with an embankment. At the scene of the accident, she was reported to be awake and alert but short of breath and extremely anxious. Vital signs at the scene were blood pressure of 110/58 m m Hg; pulse, 110; and respirations, 32. The patient was immobilized on a spine board in cervical-spine precautions and transported to the regional trauma center. On arrival, she was alert, complaining of shortness of breath, hyperventilating, and anxious. The medical history and review of systems were unremarkable. Her chief complaints were mild chest pain and shortness of breath, which were exacerbated by lying flat. She stated that the shortness of breath while lying flat was something she had experienced since she was a child. Vital signs on presentation were blood pressure of 120/64 m m Hg; pulse, 120 and regular; respirations, 34; and temperature, 36.7 C. She was alert and oriented to person, place, time, and situation but at times was combative, confused, and agitated. Secondary survey was then performed. Head, ear, eye, nose, and thorat examination was normal except for mild ecchymoses around the eyes and facial tenderness. The pupils were equal and reactive to light, and extraocular m o v e m e n t s were intact. There was no drainage from the ears, hem o t y m p a n u m , unusual discharge from the nose, or gross trauma or compromise of airway and mouth. The patient's neck was immobilized and tender to palpation with no soft-tissue swelling or asymmetry. She had normal neck veins and a midline trachea. Her chest had a small, tender ecchymosis at the right sternal border, fourth costochondral junction, but otherwise there was no bony tenderness. There were bilateral clear breath sounds that were louder on the right. The first and second heart sounds
19:4 April 1990
Annals of Emergency Medicine
Michael D Mozzetti, MD* Joseph B Devin, MDt Mark S Susselman, MDt Gary R Lammert, MD* Jonathan S Olshaker, MD* San Diego, California From the Departments of Emergency Medicine and Clinical Investigation, Naval Hospital;* and the Mercy Hospital Regional Trauma Center,t San Diego, California. Received for publication September 11, 1989. Accepted for publication November 1, 1989. Supported by the Clinical Investigation Program, case report no. 84-16-1968-119. The opinions expressed in this article are the views of the authors and do not represent the position or view of the Department of the Navy, the Department of Defense, or the US government. Address for reprints: LCDR MD Mozzetti, MC, USN, % Clinical Investigation Department, Naval Hospital, San Diego, California 92134-5000.
386/78
BLUNT CHEST TRAUMA Mozzetti et al
TIGURE 1. Supine chest radiograph
showing the normal cardiac silhouette (white arrow) and the right pulmonary contusion (black arrow). were clearly heard with a regular r h y t h m and rapid rate. Bowel s o u n d s w e r e p r e s e n t , and the a b d o m e n was n o n t e n d e r to palpation w i t h no masses, contusions, or organomegaly. T h e pelvis was nont e n d e r to c o m p r e s s i o n . G e n i t a l i a were n o r m a l w i t h o u t vaginal bleeding. There was no rectal tenderness or blood, and there was good rectal tone. The extremities were nont e n d e r w i t h no d e f o r m i t i e s and full range of motion. Cranial and spinal nerve f u n c t i o n were i n t a c t grossly. There was no ataxia. Deep tendon reflexes were n o r m a l . Babinski's sign was not present. The skin was cool, pink, and dry w i t h o u t bruises or lacerations on the back, and the spine was nontender. The patient was given 40% oxygen by facemask; a second large-bore IV line was started, and she was placed on a cardiac m o n i t o r and oximeter. A F o l e y c a t h e t e r was p l a c e d w i t h o u t d i f f i c u l t y . A c h e s t r a d i o g r a p h and cross-table lateral c e r v i c a l - s p i n e radiograph were obtained i m m e d i a t e l y . T h e c e r v i c a l - s p i n e l a t e r a l was normal. The chest radiograph showed a normal cardiac silhouette w i t h o u t a p n e u m o t h o r a x or h e m o t h o r a x , b u t there was a suggestion o'f p u l m o n a r y c o n t u s i o n (Figure 1). T h e r e were no f r a c t u r e d ribs. A d i a g n o s t i c p e r i toneal lavage was negative. The p a t i e n t became m o r e confused and combative, and her systolic blood pressure dropped to 80 m m Hg and palpable w i t h i n 20 minutes. The b l o o d p r e s s u r e was c o r r e c t e d by a r a p i d f l u i d c h a l l e n g e of 750 m L Ringer's lactate. Because of her deteriorating m e n t a l status, head trauma, and i n c r e a s i n g c o m b a t i v e n e s s , she was orally i n t u b a t e d w i t h a standard rapid sequence induction using d-Tubocurare, succinylcholine, and t h i o p e n t a l s o d i u m and in-line cervical traction. A left subclavian central IV line was placed, and the i n i t i a l central v e n o u s p r e s s u r e was 20 c m H20. She then was taken for a head CT, w h i c h was normal. W h i l e in the CT scanner, her blood p r e s s u r e dropped again, and a CT of the m e d i a s t i n u m was obtained to search for aortic disruption. Blood pressure was corrected 76/387
TABLE. Frequency of findings associated with cardiac rupture and
pericardial tamponade Percentage of Patients
Finding
Hypotension Elevated central venous pressure Tachycardia Motor vehicle accidents Distended neck veins Upper body plethora Unresponsiveness Distant heart sounds Associated other injuries Cardiomegaly on chest radiograph
w i t h a fluid bolus of 500 mL. T h e m e d i a s t i n a l C T w a s i n t e r p r e t e d as n o r m a l except for heart m o t i o n artifact (Figure 2). A diagnostic cchocardiogram was then obtained, which showed a m o d e r a t e l y large collection of p e r i c a r d i a l f l u i d (Figure 3). O n e h u n d r e d ten m i l l i l i t e r s of n o n c l o t ting blood was i m m e d i a t e l y drained by p e r i c a r d i o c e n t e s i s . T h e c a t h e t e r w a s l e f t in p l a c e to m o n i t o r t h e a m o u n t of c o n t i n u e d efflux into the pericardial sac. C o n t i n u e d b l e e d i n g into the peric a r d i u m was d e t e c t e d , a n d the paAnnals of Emergency Medicine
100 95 89 82 80 76 74 61 60 59
tient was then taken to surgery. At thoracotomy, through a median sternotomy, a 1.5-cm left v e n t r i c u l a r posterior rupture was found with oozing around the clot in the defect. This was repaired without cardiac bypass w i t h i n d i v i d u a l l y p l e d g e t t e d n o n a b s o r b a b l e p r o l e n e sutures. T h e p a t i e n t recovered uneventfully.
DISCUSSION Cardiac r u p t u r e after b l u n t chest t r a u m a is u n c o m m o n w h e n c o m pared w i t h aortic disruption, and surv i v a l a f t e r t h i s i n j u r y is rare. ~ In 19:4 April 1990
1935, Bright and Beck reported on postmortem examinations of 152 pat i e n t s w i t h b l u n t c h e s t injuries. ~ Their results s h o w e d that all four chambers of the heart ruptured with equal frequency. Because 30 patients survived at least one hour, they concluded that if rapid diagnosis and prompt definitive repair were carried out, m o r e of these patients m i g h t survive) In 1896, Rhen first reported a survivor with penetrating injury to the heart, as mentioned by Griffith. 3 The first report of a successful repair of blunt injury to the heart was reported in 1955 by DesForges et al. 4 Since this time, there have been 40 cases in the literature of patients w h o survived cardiac r u p t u r e after b l u n t trauma. 1 Of the survivors of blunt cardiac chamber rupture, only five {including our patient} have survived a left ventricular lesion. This case represents the only report of a pediatric survivor of blunt left ventricular rupture we have found in the literature. Because this entity is rare and survival is dismal, early recognition and t r e a t m e n t is of p a r a m o u n t importance. The frequency of findings associated w i t h cardiac r u p t u r e w i t h pericardial tamponade is given {Table). Fifty-six percent of the patients underwent diagnostic pericardiocentesis. Its use was primarily diagnostic, but aspiration of even a small a m o u n t of n o n c l o t t i n g blood f r o m the p e r i c a r d i u m y i e l d e d i m p r o v e d hemodynamics, which allowed time for the definitive procedure, a perieardial window, or a pericardiotomy.l First, a high index of suspicion for cardiac rupture with blunt chest trauma, in addition to aortic disrup19:4 April 1990
tion, cardiac concussion, and contusion, m u s t always be m a i n t a i n e d . 5 These entities m u s t be considered in the differential diagnosis. Whenever h y p o t e n s i o n e n s u e s , w i t h o u t arr h y t h m i a as the etiology, especially in the presence of elevated central v e n o u s pressure, a c u t e pericardial tarnponade as a result of c h a m b e r rupture m u s t be entertained as a diagnostic possibility and expeditiously ruled out. Second, while mediastinal CT m a y be considered to rule out an aortic disruption, it is a poor modality for diagnosing pericardial tamponade. In the setting of blunt chest trauma, elevated central venous pressure, and persistent or recurrent hypotension, echocardiography should be rapidly obtained. Because our patient's blood pressure deteriorated in the CT scanner, we elected to obtain a rapid series of CT cuts to see if there was aortic disruption. There was no evidence of this, and aortography was not considered to be required at this time. Echocardiography is a reliable indication of pericardial tamponade, whether it is from blunt or penetrating trauma. 6 Aortography is the appropriate diagnostic test for aortic disruption. Third, rapid diagnosis and definitive surgical repair m a y avert the disastrous consequences of this usually lethal injury. At any time during the diagnostic workup, this patient could have deteriorated abruptly, necessitating emergency thoracotomy.7, s Miller et al have r e c e n t l y r e c o m mended the use of a diagnostic pericardial window in place of the diagnostic pericardiocentesis or echocardiagram. 9 This disorder is t r e a c h e r o u s for Annals of Emergency Medicine
FIGURE 2. CT of the mediastinum. Arrow 1 shows right pulmonary contusion, and arrow 2 shows probable pericardial fluid versus m o v e m e n t artifact. FIGURE 3. Echocardiogram still photograph. Arrow shows the pericardial fluid, which was about 110 mL of nonclotting blood.
two reasons. It is rare and the diagnosis m a y not be readily considered. It is also a lethal injury, and a high index of suspicion m u s t be m a i n tained to consider this as a diagnostic possibility early on in the evaluation of t h e p a t i e n t w i t h b l u n t c h e s t trauma. The key here is recognizing that the p a t i e n t w i t h h y p o t e n s i o n has an elevated central venous pressure and that the etiology of the hypotension is not hemorrhage or tension pnuemothorax/hemothorax as it usually is in such a patient. We do not feel that pericardial window would have provided additional information or adequate exposure for the definitive repair of the defect in the ventricle.
SUMMARY We report the first pediatric survivor of left ventricular rupture, presenting our opinion of the best diagnostic modality for detecting this lethal injury. Our patient survived the initial injury and recovered without sequelae. Her survivability was no doubt enhanced by her youth. This case serves to point out several important diagnostic features of this injury. In the setting of blunt chest trau o m a and i n t e r m i t t e n t h y p o t e n s i o n , 388/77
BLUNT CHEST TRAUMA Mozzetti et al
cardiac chamber rupture must be c o n s i d e r e d i n t h e d i f f e r e n t i a l diagn o s i s . E c h o c a r d i o g r a p h y is a v a i l a b l e at m o s t t r a u m a c e n t e r s ; it is a m o b i l e and reliable diagnostic modality and s h o u l d be u s e d e a r l y i n a n y s u c h resuscitation. Echocardiography should p r e c e d e o t h e r d i a g n o s t i c t e s t s s u c h as h e a d C T w h e n h y p o t e n s i o n is associated with elevated central venous pressure. The operating room should be r e a d i e d for e m e r g e n c y surgery, a n d t h e p a t i e n t s h o u l d h a v e d e f i n i t i v e rep a i r as s o o n as p o s s i b l e . P e r i c a r d i o c e n t e s i s m a y be u s e d as a d i a g n o s t i c
78/389
and temporizing therapeutic proc e d u r e w h i l e t h e p a t i e n t is b e i n g prep a r e d for surgery.
injury. N Er~gl J Med 1955;252:267.
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i. Leavitt BJ, Meyer JA, Morton JR, et ah Survival following nonpenetrating traumatic rupture of cardiac chambers. AnN Thorac Surg 1987;44:532-535. 2. Bright EF, Beck CS: Nonpenetrating wounds of the heart: A clinical and experimental study. Am Heart J 1935;10:293. 3. Griffith GL, Zeok JV, Mattingly WT, et ai: Right atrial rupture due to blunt chest trauma. South Med J 1984;77:715-716. 4. DesForges G, Ridder WP: Successful suture of ruptured myocardium after nonpenetrating
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9. Miller FB, Bond SJ, Shumate CR, et al: Diagnostic pericardial window. Arch Surg 1987; 122:605-609.
19:4 April 1990
