Download Cardiac and Great Vessel Injuries

Cardiac and Great Vessel Injuries in Children following Blunt Trauma: An Institutional Review
Tiao GM, Griffith PM, Szmuszkovicz JR*, Mahour GH. The Division of Pediatric Surgery and Cardiology*,
Childrens Hospital of Los Angeles and the University of Southern California – Keck School of Medicine, Los Angeles, California
The purpose of this study was to review the incidence of
cardiac and great vessel injury following blunt trauma in
children at a single institution.
Method: A retrospective review from the trauma registry
encompassing 2744 patients with injuries from blunt
mechanisms was performed.
Results: Eleven patients sustained cardiac injury. Four
patients had clinically evident cardiac contusions. All
recovered uneventfully. Another four patients who died from
CNS injury were found to have cardiac contusions on
autopsy but none had clinical evidence of contusion.
One patient had a traumatic ventricular septal defect
(VSD) that required operative repair. Autopsy demonstrated
an unsuspected VSD in another patient. A third patient was
diagnosed with a ventricular septal aneurysm that was treated
medically.
Two patients had great vessel injuries. One patient had a
contained disruption of the superior vena cava that was
managed non-operatively and another patient had a midthoracic periaortic hematoma without intimal disruption
found at autopsy.
One patient had both cardiac and great vessel injuries.
Discrete aneurysms of two coronary artery septal branches
and a pulmonary outflow tract aneurysm were identified by
cardiac catheterization. The patient was treated nonoperatively without complications.
Conclusions: Cardiac and great vessel injury following blunt
trauma is uncommon in children. Cardiac contusion is the
most common injury encountered but had minimal clinical
significance. Non-contusion cardiac injury is rare but may
require surgical intervention. No patient with aortic
transection was identified in our review.
Cardiac and great vessel injury following blunt trauma can
have significant morbidity and potential mortality. The spectrum
of blunt cardiac injury ranges from myocardial contusion to
anatomic disruption such as valve dysfunction or myocardial
rupture. In the adult population, blunt cardiac injury was once
considered the most under-diagnosed traumatic injury. A recent
review suggests the incidence of cardiac trauma to be as high as
20% following blunt chest trauma.
The incidence of great vessel injury following blunt trauma
in the adult population has been estimated to be as high as 15%.
Aortic transection is the most common great vessel injury.
Injuries to other great vessels including the pulmonary and
innominate arteries have been reported in the literature. Most
individuals who sustain aortic injury expire at the incident
scene; however, with improved emergency medical services it is
possible that more patients with this injury may reach medical
attention. As a result, there has been heightened awareness of
great vessel injury.
In the pediatric age group, the incidence of cardiac and great
vessel injury following blunt trauma has not been clearly
established. Several recent series report a low incidence. In
contrast, a study that reviewed the post-mortem examination
results of children who expired because of traumatic causes
found a 15% incidence of cardiac injury. The purpose of the
present study was to determine the incidence of blunt cardiac
and great vessel injury at a single institution and to review the
method of diagnosis and the subsequent clinical course of these
patients.
CARDIAC CONTUSIONS
Fourteen patients with injuries
A retrospective review of the trauma registry at
Childrens Hospital of Los Angeles from 1992-1998
was performed
There were 2744 blunt trauma victims enrolled in the
registry:
• 1409 admissions - 486 to the intensive care unit
• 87 patients expired, 66 post-mortem exams were
available for review
Eleven patients sustained cardiac injury
Eight cardiac contusions (Table)
1 ventricular septal defect and ventricular
aneurysm (case 1)
1 ventricular septal aneurysm (case 2)
1 ventricular septal defect (case 3)
Two patients had great vessel injury (Table)
1 superior vena cava intimal disruption
1 periaortic hematoma with intact intima
One patient had a combined great vessel & cardiac
injury
Coronary artery and pulmonary outflow tract
aneurysm (case )
14 patients with cardiac or great vessel injury:
• 9 patient’s cardiac or great vessel injury were
identified clinically
• 5 patient’s injuries were identified at autopsy
Incidence among admissions
The 14 patient’s charts were analyzed for the
mechanism of injury, the type of injury, the clinical
course and the subsequent outcome.
Incidence of concomitant organ injury - 93%
Patient
Clinical
Manifestation
ECHO
Clinical Course
1
Arrhythmia
Normal
Unremarkable
2
Arrhythmia
Normal
Unremarkable
3
Arrhythmia
Dilated left
ventricle
Transient use of
antiarrhythmic
medication
4
Unexplained
hypotension
Wall motion
abnormalities
Transient use of
inotropic medication
4 cardiac contusions found at autopsy – no clinical manifestations
of arrhythmia or hypotension
Cardiac injury 0.4%
Great vessel injury 0.2%
CNS injuries (10 out of 14)
Intra-abdominal solid organ injury (4 out of 14)
Pulmonary contusion (3 out of 14)
Extremity fracture (1 out of 14)
GREAT VESSEL INJURIES
Patient M echanism
Mortality - 42% (6 deaths)
CNS injury was the cause of death in five of the six
patients 83.3%
One patient expired due to an anatomic cardiac injury
1
2
MVC
Injury
Mid-Thoracic periaortic
hematoma
(No Intimal Injury)
Auto-Ped
Bilat Pulmonary Contusions
(Moderate
Sup. Vena Cava Tear
Speed)
Treatment
Outcome
Non-Operative
Died from
Neurologic
Injury
Non-Operative
Alive at 6
year Followup
(No Image)
Case 1 – A 3-year old male was struck by
an automobile. He sustained a
pulmonary contusion and a grade II
liver laceration. He was noted to have a
Grade IV/VI systolic murmur on
physical exam. An ECHO demonstrated
a ventricular septal defect (VSD).
Initially, it was unclear if this was a
traumatic or a congenital abnormality.
He was admitted to the ICU where he
developed adult respiratory distress
syndrome (ARDS) and congestive heart
failure. Repeat ECHO showed the VSD
and a ventricular aneurysm (figure 1).
The patient underwent surgical intervention where
a traumatic VSD was repaired and the aneurysm
was resected. The patient recovered postoperatively and was discharged home. Subsequent
follow-up identified a recurrence of the aneurysm
by ECHO, which was confirmed by cardiac
catheterization (figure 2). One-year post-initial
injury, the recurrent aneurysm was resected. He
recovered post-operatively and at follow-up has
demonstrated no new abnormalities.
Case 3 -- A 4-year old male was found
trapped beneath a 70lb barbell. The patient
had arrested. Vital signs were restored at
the scene with endotracheal intubation and
resuscitation with intravenous fluid. En
route to the hospital, the patient’s vital
signs were lost. Despite maximal
intervention in the emergency room
including bilateral tube thoracostomy and
pericardiocentesis, the patient expired.
Post-mortem examination revealed a 4.5cm
laceration of the intra-ventricular septum.
Case 2 – An 11-year old female was involved in an auto versus pedestrian
accident where she was struck and thrown 15 feet. A head CT scan
demonstrated a cerebral contusion resulting in an admission to the
pediatric intensive care. An abdominal CT scan was normal. Unexplained
persistent hypotension in the ICU despite stable hemoglobin levels
prompted an ECHO that demonstrated a dyskinetic intraventricular
septum, a ventricular septal aneurysm and a shortening fraction of 14%
(figure 3). The patient required inotropic support for 72 hours when her
hypotension resolved. Follow-up ECHO post-discharge demonstrated
complete resolution of her cardiac abnormalities
Case - A 5-year old female was a restrained
passenger in a high-speed motor vehicle accident
(5). She sustained a cerebral contusion, bilateral
first rib fractures, a pulmonary contusion, a grade
IV liver laceration and a pubic rami fracture. She
developed ARDS requiring maximal ventilatory
support. A CXR showed a widened mediastinum
prompting a chest CT scan. The CT scan showed
blood in the mediastinum. ECHO was nondiagnostic therefore she underwent cardiac
catheterization, which showed a pulmonary outflow
tract aneurysm and multiple discrete aneurysms of
septal perforators off the left anterior descending
coronary artery (figure 4 and 5).
The child was managed non-operatively and
recovered. The patient underwent cardiac
catheterization at 8 months post-discharge that
demonstrated resolution of her injury.
• Cardiac and great vessel
injury following blunt
trauma is uncommon in
children
• Cardiac contusion is the
most common injury
encountered but had
minimal clinical
significance
• Non-contusion cardiac
injury is rare but may
require surgical
intervention
• No patient with aortic
transection was identified
in our review
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