Cardiac Contusion: A Capricious Syndrome JAMES W. JONES, M.D., ROBERT L. HEWITT, M.D., THEODORE DRAPANAS, M.D.
Cardiac contusions are being recognized with increasing frequency. Among 507 patients with non-penetrating chest injuries, 210 had serial electrocardiograms sufficient to evaluate the heart. Forty-five of these 210 patients (21%) had cardiac contusions. These 45 patients and 3 others who were confirmed to have cardiac contusions at necropsy, comprise the 48 patients in this series. Life-endangering cardiac complications occurred in 14 (29%Yo) of the 48 patients, and 4 patients died. The development of cardiac complications following cardiac contusions appears to have a significant relationship to the presence of shock, hypoxia and to factors related to the severity of multiple injuries. These observations have therapeutic implications in management of patients with cardiac contusions through prevention of hypovolemia and hypoxia and avoidance of fluid overload as well as treatment of specific cardiac complications.
From the Department of Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, Louisiana 70112
number and timing to properly evaluate the heart. Fortyfive (21%) of these 210 patients had cardiac contusions. Criteria for diagnosis included definite electrocardiographic evidence of injury which completely or partially resolved on subsequent electrocardiograms following injury. These 45 patients and three others, confirmed to have cardiac contusion at necropsy, comprised the 48 patients in this study. Patients with valvular injuries, myocardial rupture and traumatic septal defects although nonA SPECTRUM of cardiac injuries may result from also related to trauma were not included. penetrating chest trauma including rupture, chamber Results fracture, fracture of the valvular structures and contusion The frequency of the diagnosis of cardiac contusion of the myocardium. Although cardiac contusion is usually non-fatal, it may be accompanied by a variety of during the period of study is indicated in Figure 1. An potentially fatal complications.4'7'8 Furthermore, cardiac increasing awareness of this injury is apparent by the contusion may be unrecognized initially and may become increase in number of patients with myocardial contuapparent only when a serious cardiac complication de- sions admitted to the hospital during this time although velops. This retrospective study was undertaken to the diagnosis was established in 17 patients 48 hours or evaluate the frequency and type of complications in pa- more following admission to the hospital. The patients in this series were predominantly young tients with documented cardiac contusion and to determine if a high-risk subgroup likely to have serious cardiac males who were involved in automobile accidents. Thirty-nine were males, and the average age was 33 complications could be identified. years. Table 1 lists the modes of injury for the 48 paPatient Selection tients, and as indicated, vehicle accidents accounted for The records of 507 patients with non-pentrating chest injury in 45 patients. Table 2 lists the associated injuries in the 48 patients. injuries admitted to the Tulane Surgical Service, Charity Hospital of Louisiana from 1963 through 1973 were re- Most sustained multiple injuries, averaging 2.7 injuries viewed. Forty-eight patients (9.4%) of the 507 patients per patient. Evidence of moderate to severe chest trauma were identified as having cardiac contusions. Among was apparent in all patients as determined by history, those 507 patients with non-pentrating chest injuries, 210 physical examination or roentgenogram. As listed, 22 patients had serial electrocardiograms sufficient in patients had rib fractures and 13 had sternal fractures. Pulmonary contusion, hemothorax and pneumothorax v were also common. Associated non-thoracic injuries Presented at the Annual Meeting of the Southern Surgical Associa- were also common, especially injuries to the abdomen, pelvis and cranium. Auscultation of a pericardial friction tion, December 9-11, 1974, Boca Raton, Florida. 567
568
JONES, HEWITT AND DRAPANAS
Ann.
Surg. * May 1975
TABLE 2. Specific Injuries Among 48 Patients With Cardiac Contusions
Chest Rib Fractures Sternal Fracture Flail Chest Clavicle Fracture
Mediastinum; great vessel injury Pulmonary contusion Hemopneumothorax
1963
1964
96
1966
1967
1968
1969
1970
1971
1972
I is
1973 6 no.
FIG. 1. Forty-eight patients with cardiac contusions admitted to Charity Hospital, 1963 through 1973; the diagnosis was established 48 hours or longer following admission in 17 patients.
rub or abnormality in heart sounds were documented in only 11 patients. Heart size usually remained normal on roentgenogram unless the injury was accompanied by pericardial effusion. Serial electrocardiograms were the most reliable method of establishing the diagnosis of cardiac contusion. Electrocardiographic changes were predominatly in the ST-segment and T-wave in 40 patients. QRS abnormalities or Q waves were observed in 9, and conduction abnormalities were observed in 7. Typical electrocardiographic changes are demonstrated in Figures 2, 3 and 4. The electrocardiographic abnormalities were temporary in most patients and usually resolved to a normal pattern within two to three weeks. Life-endangering cardiac complications occurred in 14 of the 48 patients with cardiac contusion. A number of other patients developed lesser cardiac complications which did not require treatment such as sinus tachycardia, premature ventricular contractions or conduction disturbances which were not severe such as right bundle branch block in 5 patients and left anterior hemiblock in two.
The complications considered to be life-endangering all required treatment and are listed in Table 3. The' early complications included arrhythmias which required pharmacologic treatment (atrial fibrillation, atrial flutter, supraventricular tachycardia and ventricular tachyTABLE 1. Cardiac Contusion: Mode
Mode
of Injury
Patients
Automobile Accident Pedestrian Accident Motorcycle Accident Fall
38 4 3 3
Total
48
Abdomen Liver Fracture Spleen Fracture Retroperitoneal Hematoma Diaphragmatic hernia Hepatic veins Cranial Injury G-U Injury Pelvic Fracture Long Bone Fracture Spinal Fracture Facial Injuries Total
22 13 7 4 7 18 11
6 3
14 13 3 7 3 3 133
cardia), heart failure and complete heart block. Four patients subsequently developed pericardial tamponade requiring pericardiocentesis, and 3 of them required pericardial window or pericardectomy. One patient required pericardectomy for constrictive pericarditis. The group of patients with severe cardiac complications appeared to include the more severely injured patients since these 14 patients had an average of 3.36 extracardiac injuries per patient as compared to 1.91 injuries per patient for the group without cardiac complications (P
Cardiac contusions are being recognized with increasing frequency. Among 507 patients with non-penetrating chest injuries, 210 had serial electrocardiograms sufficient to evaluate the heart. Forty-five of these 210 patients (21%) had cardiac contusions. These 45 patients and 3 others who were confirmed to have cardiac contusions at necropsy, comprise the 48 patients in this series. Life-endangering cardiac complications occurred in 14 (29%Yo) of the 48 patients, and 4 patients died. The development of cardiac complications following cardiac contusions appears to have a significant relationship to the presence of shock, hypoxia and to factors related to the severity of multiple injuries. These observations have therapeutic implications in management of patients with cardiac contusions through prevention of hypovolemia and hypoxia and avoidance of fluid overload as well as treatment of specific cardiac complications.
From the Department of Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, Louisiana 70112
number and timing to properly evaluate the heart. Fortyfive (21%) of these 210 patients had cardiac contusions. Criteria for diagnosis included definite electrocardiographic evidence of injury which completely or partially resolved on subsequent electrocardiograms following injury. These 45 patients and three others, confirmed to have cardiac contusion at necropsy, comprised the 48 patients in this study. Patients with valvular injuries, myocardial rupture and traumatic septal defects although nonA SPECTRUM of cardiac injuries may result from also related to trauma were not included. penetrating chest trauma including rupture, chamber Results fracture, fracture of the valvular structures and contusion The frequency of the diagnosis of cardiac contusion of the myocardium. Although cardiac contusion is usually non-fatal, it may be accompanied by a variety of during the period of study is indicated in Figure 1. An potentially fatal complications.4'7'8 Furthermore, cardiac increasing awareness of this injury is apparent by the contusion may be unrecognized initially and may become increase in number of patients with myocardial contuapparent only when a serious cardiac complication de- sions admitted to the hospital during this time although velops. This retrospective study was undertaken to the diagnosis was established in 17 patients 48 hours or evaluate the frequency and type of complications in pa- more following admission to the hospital. The patients in this series were predominantly young tients with documented cardiac contusion and to determine if a high-risk subgroup likely to have serious cardiac males who were involved in automobile accidents. Thirty-nine were males, and the average age was 33 complications could be identified. years. Table 1 lists the modes of injury for the 48 paPatient Selection tients, and as indicated, vehicle accidents accounted for The records of 507 patients with non-pentrating chest injury in 45 patients. Table 2 lists the associated injuries in the 48 patients. injuries admitted to the Tulane Surgical Service, Charity Hospital of Louisiana from 1963 through 1973 were re- Most sustained multiple injuries, averaging 2.7 injuries viewed. Forty-eight patients (9.4%) of the 507 patients per patient. Evidence of moderate to severe chest trauma were identified as having cardiac contusions. Among was apparent in all patients as determined by history, those 507 patients with non-pentrating chest injuries, 210 physical examination or roentgenogram. As listed, 22 patients had serial electrocardiograms sufficient in patients had rib fractures and 13 had sternal fractures. Pulmonary contusion, hemothorax and pneumothorax v were also common. Associated non-thoracic injuries Presented at the Annual Meeting of the Southern Surgical Associa- were also common, especially injuries to the abdomen, pelvis and cranium. Auscultation of a pericardial friction tion, December 9-11, 1974, Boca Raton, Florida. 567
568
JONES, HEWITT AND DRAPANAS
Ann.
Surg. * May 1975
TABLE 2. Specific Injuries Among 48 Patients With Cardiac Contusions
Chest Rib Fractures Sternal Fracture Flail Chest Clavicle Fracture
Mediastinum; great vessel injury Pulmonary contusion Hemopneumothorax
1963
1964
96
1966
1967
1968
1969
1970
1971
1972
I is
1973 6 no.
FIG. 1. Forty-eight patients with cardiac contusions admitted to Charity Hospital, 1963 through 1973; the diagnosis was established 48 hours or longer following admission in 17 patients.
rub or abnormality in heart sounds were documented in only 11 patients. Heart size usually remained normal on roentgenogram unless the injury was accompanied by pericardial effusion. Serial electrocardiograms were the most reliable method of establishing the diagnosis of cardiac contusion. Electrocardiographic changes were predominatly in the ST-segment and T-wave in 40 patients. QRS abnormalities or Q waves were observed in 9, and conduction abnormalities were observed in 7. Typical electrocardiographic changes are demonstrated in Figures 2, 3 and 4. The electrocardiographic abnormalities were temporary in most patients and usually resolved to a normal pattern within two to three weeks. Life-endangering cardiac complications occurred in 14 of the 48 patients with cardiac contusion. A number of other patients developed lesser cardiac complications which did not require treatment such as sinus tachycardia, premature ventricular contractions or conduction disturbances which were not severe such as right bundle branch block in 5 patients and left anterior hemiblock in two.
The complications considered to be life-endangering all required treatment and are listed in Table 3. The' early complications included arrhythmias which required pharmacologic treatment (atrial fibrillation, atrial flutter, supraventricular tachycardia and ventricular tachyTABLE 1. Cardiac Contusion: Mode
Mode
of Injury
Patients
Automobile Accident Pedestrian Accident Motorcycle Accident Fall
38 4 3 3
Total
48
Abdomen Liver Fracture Spleen Fracture Retroperitoneal Hematoma Diaphragmatic hernia Hepatic veins Cranial Injury G-U Injury Pelvic Fracture Long Bone Fracture Spinal Fracture Facial Injuries Total
22 13 7 4 7 18 11
6 3
14 13 3 7 3 3 133
cardia), heart failure and complete heart block. Four patients subsequently developed pericardial tamponade requiring pericardiocentesis, and 3 of them required pericardial window or pericardectomy. One patient required pericardectomy for constrictive pericarditis. The group of patients with severe cardiac complications appeared to include the more severely injured patients since these 14 patients had an average of 3.36 extracardiac injuries per patient as compared to 1.91 injuries per patient for the group without cardiac complications (P
