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Right atrial rupture after road traffic accident Accidents and post-traumatic injuries are one of the most important health and social problems. Non-penetrating chest trauma with injury to the heart has become increasingly common particularly as a result of acceleration/deceleration injuries in modern, high speed, vehicular accidents. Most of them require immediate medicosurgical intervention. The classic clinical presentation is not universal and a subset of patients may present asymptomatically. In blunt chest trauma, cardiac chamber rupture is uncommon although associated with high mortality rate.1 Blunt traumatic atrial rupture has better prognosis than ventricular tear.2 Rapid transportation to medical care, accurate timely diagnosis and emergent operative intervention are essential for successful outcome. A 28-year-old male with history of road traffic accident presented to the emergency department with severe shortness of breath, tachycardia and left leg injury. This gentleman had a head-on collision with a car while he was riding a motor bike. He sustained injury on his chest due to the handle of the motorbike. When he was received in the resuscitation room, he was tachypneic, tachycardic and hypotensive. He was resuscitated as per Advanced Trauma Life Support protocols. On chest X-ray he had a widened mediastinum. Ultrasound focused assessment with sonography for trauma (FAST) was negative and showed a moderate pericardial effusion on echocardiogram. On being haemodynamically stable after initial resuscitation, he had chest and abdomen computed tomography scan that showed significant pericardial effusion. On the suspicion of major vessel or myocardial injury, he was taken for emergency surgery. At the time of sternotomy the patient became hypotensive and required cardiopulmonary resuscitation from which he revived. The pericardium was seen bulging with clots and blood, which was opened, and careful evacuation of blood clots was performed. Venous blood was seen gushing from the superior aspect of the right atrium that was controlled by packing. It was found that there was a near total transection of superior vena cava (SVC) from the right atrium junction above the sinoatrial node. Using inflow occlusion technique, SVC and inferior vena cava were occluded with vascular clamps, and rent was repaired using 4/0 Prolene in continuous doublelayered fashion (Fig. 1). Clamps were removed on completion of the first layer of suture, which was no more than 1 min of inflow occlusion time and then the second layer was performed, with no significant haemodynamic instability or rhythm disturbance. Thorough irrigation was performed. Mediastinal drains were placed and the chest closed using sternal wires. The patient was extubated on the first post-operative day; however, his post-operative course was eventful with requirement of non-invasive positive pressure ventilation and diuretics. His serial post-operative chest X-rays showed bilateral opacification probably due to blunt lung parenchymal © 2015 Royal Australasian College of Surgeons
injury. After a complete resolution of symptoms, he was discharged home with mediastinal drains. In blunt trauma, cardiovascular injuries are second only to central nervous system injuries as the most frequent cause of death. Out of them 75% are road traffic accidents.3 Fulda et al. reported in a retrospective review of 59 patients requiring emergency surgery for blunt heart trauma. Majority had vehicular accidents (68%), and overall mortality rate was 76%. Rapid transportation and expeditious surgical treatment can save many patients.2 Right atrium is thin walled and anteriorly located so it is more prone to rupture.1 The mechanism of various blunt cardiac injuries can be explained as compression of the heart between the anterior chest wall, and the vertebral direct transmission of increased intrathoracic pressure to the cardiac chambers transmitted hydraulic effect from the abdominal or extremity veins to the right atrium (the so-called hydraulic ram effect),4 cardiac laceration from fractured ribs or sternal fragments, and deceleration junctions of fixed and mobile portions of the heart, such as the disruption of the atrial junction with either the vena cava or the pulmonary vein.5 Early identification of cardiac tamponade, using FAST and focused echocardiographic evaluation in life support, is the new horizon for rapid management of blunt thoracic trauma with sensitivity and specificity for cardiac tamponade 93 and 99%, respectively.6 Various techniques have been used to control bleeding from SVC and right atrium injury, inflow occlusion, side biting clamps, vascular shunts, cardiopulmonary bypass and even circulatory arrest depending on the extent and nature of injury.7 Cardiac chamber injuries can be repaired by simple suture with or without the use of
Fig. 1. Intraoperative picture of right atrium injury repair.
ANZ J Surg •• (2015) ••–••
2
pledgets using vascular clamps (inflow occlusion technique for right atrium). Small tears can be repaired primarily without using cardiopulmonary bypass machine; care should be taken to avoid injury to coronary vessels and conduction system during repair.1
References 1. Gajjar AH, Atherton JT. Isolated right atrial tear following blunt trauma. J. Surg. Case Rep. 2011; 2011: 8. 2. Fulda G, Brathwaite CEM, Rodriguez A, Turney SZ, Dunham CM, Cowley RA. Blunt traumatic rupture of the heart and pericardium: a ten-year experience (1979–1989). J. Trauma 1991; 31: 167–73. 3. Teixeira PG, Inaba K, Oncel D et al. Blunt cardiac rupture: a 5-year NTDB analysis. J. Trauma 2009; 67: 788–91. 4. Parmley LF, Manion WC, Mattingly TW. Nonpenetrating traumatic injury of the heart. Circulation 1958; 18: 371–96. 5. Chaer RA, Doherty JC, Merlotti G, Salzman SL, Fishman D. A case of blunt injury to the superior vena cava and right atrial appendage: mechanisms of injury and review of the literature. Injury Extra 2005; 36: 341–5.
Images for surgeons
6. Campo dell’ Orto M, Kratz T, Wild C et al. Pre-hospital ultrasound detects pericardial tamponade in young patients with occult blunt trauma: time for preparation? Case report and review of literature. Clin. Res. Cardiol. 2014; 103: 409–11. 7. Pascual JL, Holena D, Portal D, Schwab CW. Blunt intrapericardial superior vena cava injury – a trap for the unwary. Injury Extra 2010; 41: 4–6.
Fazal Wahab Khan,* MBBS, MD Benish Fatima,* MBBS Nashrah Bukhari,† Taimur Asif Ali,* MBBS, FCPS Saulat H. Fatimi,* MBBS *Section of Cardiothoracic Surgery, Department of Surgery, Aga Khan University, Karachi, Pakistan and †Department of Surgery, Medical College, Aga Khan University, Karachi, Pakistan doi: 10.1111/ans.12996
© 2015 Royal Australasian College of Surgeons
Right atrial rupture after road traffic accident Accidents and post-traumatic injuries are one of the most important health and social problems. Non-penetrating chest trauma with injury to the heart has become increasingly common particularly as a result of acceleration/deceleration injuries in modern, high speed, vehicular accidents. Most of them require immediate medicosurgical intervention. The classic clinical presentation is not universal and a subset of patients may present asymptomatically. In blunt chest trauma, cardiac chamber rupture is uncommon although associated with high mortality rate.1 Blunt traumatic atrial rupture has better prognosis than ventricular tear.2 Rapid transportation to medical care, accurate timely diagnosis and emergent operative intervention are essential for successful outcome. A 28-year-old male with history of road traffic accident presented to the emergency department with severe shortness of breath, tachycardia and left leg injury. This gentleman had a head-on collision with a car while he was riding a motor bike. He sustained injury on his chest due to the handle of the motorbike. When he was received in the resuscitation room, he was tachypneic, tachycardic and hypotensive. He was resuscitated as per Advanced Trauma Life Support protocols. On chest X-ray he had a widened mediastinum. Ultrasound focused assessment with sonography for trauma (FAST) was negative and showed a moderate pericardial effusion on echocardiogram. On being haemodynamically stable after initial resuscitation, he had chest and abdomen computed tomography scan that showed significant pericardial effusion. On the suspicion of major vessel or myocardial injury, he was taken for emergency surgery. At the time of sternotomy the patient became hypotensive and required cardiopulmonary resuscitation from which he revived. The pericardium was seen bulging with clots and blood, which was opened, and careful evacuation of blood clots was performed. Venous blood was seen gushing from the superior aspect of the right atrium that was controlled by packing. It was found that there was a near total transection of superior vena cava (SVC) from the right atrium junction above the sinoatrial node. Using inflow occlusion technique, SVC and inferior vena cava were occluded with vascular clamps, and rent was repaired using 4/0 Prolene in continuous doublelayered fashion (Fig. 1). Clamps were removed on completion of the first layer of suture, which was no more than 1 min of inflow occlusion time and then the second layer was performed, with no significant haemodynamic instability or rhythm disturbance. Thorough irrigation was performed. Mediastinal drains were placed and the chest closed using sternal wires. The patient was extubated on the first post-operative day; however, his post-operative course was eventful with requirement of non-invasive positive pressure ventilation and diuretics. His serial post-operative chest X-rays showed bilateral opacification probably due to blunt lung parenchymal © 2015 Royal Australasian College of Surgeons
injury. After a complete resolution of symptoms, he was discharged home with mediastinal drains. In blunt trauma, cardiovascular injuries are second only to central nervous system injuries as the most frequent cause of death. Out of them 75% are road traffic accidents.3 Fulda et al. reported in a retrospective review of 59 patients requiring emergency surgery for blunt heart trauma. Majority had vehicular accidents (68%), and overall mortality rate was 76%. Rapid transportation and expeditious surgical treatment can save many patients.2 Right atrium is thin walled and anteriorly located so it is more prone to rupture.1 The mechanism of various blunt cardiac injuries can be explained as compression of the heart between the anterior chest wall, and the vertebral direct transmission of increased intrathoracic pressure to the cardiac chambers transmitted hydraulic effect from the abdominal or extremity veins to the right atrium (the so-called hydraulic ram effect),4 cardiac laceration from fractured ribs or sternal fragments, and deceleration junctions of fixed and mobile portions of the heart, such as the disruption of the atrial junction with either the vena cava or the pulmonary vein.5 Early identification of cardiac tamponade, using FAST and focused echocardiographic evaluation in life support, is the new horizon for rapid management of blunt thoracic trauma with sensitivity and specificity for cardiac tamponade 93 and 99%, respectively.6 Various techniques have been used to control bleeding from SVC and right atrium injury, inflow occlusion, side biting clamps, vascular shunts, cardiopulmonary bypass and even circulatory arrest depending on the extent and nature of injury.7 Cardiac chamber injuries can be repaired by simple suture with or without the use of
Fig. 1. Intraoperative picture of right atrium injury repair.
ANZ J Surg •• (2015) ••–••
2
pledgets using vascular clamps (inflow occlusion technique for right atrium). Small tears can be repaired primarily without using cardiopulmonary bypass machine; care should be taken to avoid injury to coronary vessels and conduction system during repair.1
References 1. Gajjar AH, Atherton JT. Isolated right atrial tear following blunt trauma. J. Surg. Case Rep. 2011; 2011: 8. 2. Fulda G, Brathwaite CEM, Rodriguez A, Turney SZ, Dunham CM, Cowley RA. Blunt traumatic rupture of the heart and pericardium: a ten-year experience (1979–1989). J. Trauma 1991; 31: 167–73. 3. Teixeira PG, Inaba K, Oncel D et al. Blunt cardiac rupture: a 5-year NTDB analysis. J. Trauma 2009; 67: 788–91. 4. Parmley LF, Manion WC, Mattingly TW. Nonpenetrating traumatic injury of the heart. Circulation 1958; 18: 371–96. 5. Chaer RA, Doherty JC, Merlotti G, Salzman SL, Fishman D. A case of blunt injury to the superior vena cava and right atrial appendage: mechanisms of injury and review of the literature. Injury Extra 2005; 36: 341–5.
Images for surgeons
6. Campo dell’ Orto M, Kratz T, Wild C et al. Pre-hospital ultrasound detects pericardial tamponade in young patients with occult blunt trauma: time for preparation? Case report and review of literature. Clin. Res. Cardiol. 2014; 103: 409–11. 7. Pascual JL, Holena D, Portal D, Schwab CW. Blunt intrapericardial superior vena cava injury – a trap for the unwary. Injury Extra 2010; 41: 4–6.
Fazal Wahab Khan,* MBBS, MD Benish Fatima,* MBBS Nashrah Bukhari,† Taimur Asif Ali,* MBBS, FCPS Saulat H. Fatimi,* MBBS *Section of Cardiothoracic Surgery, Department of Surgery, Aga Khan University, Karachi, Pakistan and †Department of Surgery, Medical College, Aga Khan University, Karachi, Pakistan doi: 10.1111/ans.12996
© 2015 Royal Australasian College of Surgeons
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