Secondary left ventricular injury with haemopericardium caused by a rib fracture after blunt chest trauma

Abstract

Trauma is the third most common cause of death in the West. In the US, approximately 90,000 deaths annually are traumatic in nature and over 75% of casualties from blunt trauma are due to chest injuries. Cardiac injuries from rib fractures following blunt trauma are extremely rare. We report the unusual case of a patient who fell from a height and presented with haemopericardium and haemothorax as a result of left ventricular and lingular lacerations and was sucessfully operated upon. Case reportA 55 year old man presented to the accident and emergency department of a district general hospital after having fallen 3 metres from a ladder while cutting his garden hedge. He complained of left sided chest pain and worsening shortness of breath and dizziness. On examination, HR was 155/min, RR 37/min, BP 99/66 mm Hg, and JVP 5 cms above sternal angle. 5 th and 6 th ribs were tender but there was no obvious crepitus. Breath sounds were diminished in the left base. Chest x-ray revealed fractures of 5 th and 6 th ribs, a large left hemothorax and enlarged cardiac silhouette (Fig 1a). An intercostal drain was inserted which drained 1 lit of fresh blood but a follow up chest xray continued to show a large cardiac shadow (Fig 1b). A CT scan of chest revealed a 2 cm hemopericardium (2a) and residual left pleural blood and clot (Fig 2b). He was transferred to our regional cardiothoracic centre for further management. A transthoracic echocardiogram on arrival confirmed a global pericardial effusion with early tamponade.Patient was urgently taken to the operation theatre and a median sternotomy performed with bypass standby. The pericardium was tense. It was widely opened and 250 mls of old blood evacuated. There was a 1.5 cm non bleeding superficial left ventricular laceration posterolateral to the apex within a large area of contused left ventricle with a bleeding superficial vein. There was a corresponding 1 cm tear of the pericardium posterior to the phrenic nerve. Left pleura was widely opened and lung inspected. There was a non bleeding laceration of the superior segment of the lingula and about 500 mls of residual clot and blood in the pleural cavity. There were fractures of 5 th and 6 th ribs with wide displacement of the two segments of the fractured 5 th rib. The sharp jagged posterior end of the fractured rib had been displaced medially inside the pleural cavity and had lacerated the lingula and punctured the pericardium and the left ventricle.The sharp end of the fractured rib was excised, the bleeding ventricular vein was diathermised, the left ventricular contusion and nonbleeding laceration as well as the lingular tear were covered with a generous application of Tis-

Supporting the early use of echocardiography in blunt chest trauma

“…The initial chest X-ray (Figure 1) is also of particular interest as it shows an essentially normal anteroposterior film with perhaps a globular or enlarged cardiac silhouette, a feature noted more clearly in other reports [16]. However, the difficultly in determining acute cardiac sizing when only a single anteroposterior film is used and how the increased sensitivity of echocardiography immediately clinched the diagnosis must again be acknowledged.…”

A case report of blunt cardiac rupture

“…It is understandable, therefore, that survival after blunt cardiac rupture is extremely low. In fact, a literature review between 1957 and 2017 revealed that there were only 15 reports of patients surviving after sustaining blunt cardiac rupture in the past 60 years [ [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] ]. To the best of our knowledge, this is now the 16th survivor of blunt cardiac rupture.…”

“…Our case was interesting because, this injury was due to a low velocity injury - an uncommon injury mechanism that has only been reported three times in the medical literature [ [20] , [21] , [22] ]. In 1968, Suszoko et al reported a similar injury after a man fell over onto a chair [ 20 ].…”

“…In 1968, Suszoko et al reported a similar injury after a man fell over onto a chair [ 20 ]. Then in 2006, Kaul et al reported a 55-year-old gardener who sustained a left ventricular laceration from a fifth rib fracture after falling from a ladder at a height of 10 feet [ 21 ]. And in 2015, Udayakumara et al reported a 56-year-old carpenter who fell onto a wooden stump and sustained left ventricular injury from a fractured xiphisternum [ 22 ].…”

Penetrating Heart Injuries Due to Puncture by Fractured Sternum or Ribs Following Blunt Trauma

“…Penetrating heart injuries should be considered in cases where there is hemopneumopericardium noted in the thorax CT, injuries present in the front side of the chest wall, especially parasternal rib detachments, flail chest, sternal fracture, massive hemothorax and in patients who are unresponsive to the fluid-blood replacement therapy [5][6][7].…”