Professional Documents
Culture Documents
research-article2016
CTO0010.1177/2055552016630491Cardiovascular and Thoracic OpenMonroe et al.
Case Study
CTO
Cardiovascular and Thoracic Open
Abstract
Objective: To report two cases of cardiac injury following blunt thoracic trauma without external evidence of injury.
Design: Case report and review of the literature.
Setting: A 23-bed pediatric intensive care unit in an academic childrens hospital.
Interventions: Two children presented following significant thoracic trauma without external evidence of injury.
Cardiac injury was not initially suspected, and lack of definitive diagnostic evaluation led to a delay in diagnosis and
definitive treatment.
Results: A 4-year-old girl presented 6months after initial injury and evaluation with massive right ventricular dilatation
secondary to traumatic tricuspid regurgitation. The second patient, an 11-year-old boy, underwent a laparotomy for
suspected abdominal pathology delaying diagnosis of his traumatic ventricular septal defect and definitive repair until
clinical hemodynamic deterioration occurred.
Conclusion: Clinicians should maintain a high index of suspicion for cardiac injury in patients with a significant mechanism
of thoracic trauma despite external evidence. Standard screening tests are often inadequate and echocardiography
should be performed for any suspected cardiac trauma.
Keywords
television, trauma, tricuspid regurgitation, ventricular septal defect
Background
Cardiac injury following blunt chest trauma, while rare,1,2
may be life threatening if not detected expeditiously. It is
commonly associated with obvious external signs of tho- 1Division of Pediatric Critical Care Medicine, Phoenix Childrens
racic injury, with the majority of complications being Hospital, Phoenix, AZ, USA
described within 48h of the event.1,2 We report two pediat- 2Division of Pediatric Hematology/Oncology, Childrens Hospital San
ric cases illustrating cardiac injury without external signs of Diego, University of CaliforniaSan Diego, San Diego, CA, USA
3Department of Pediatric Cardiology, Childrens Hospital and Research
thoracic trauma, one of the cases with the cardiac complica-
Center at Oakland, Oakland, CA, USA
tion presenting temporally remote to the traumatic event. 4Department of Child Health, College of Medicine, University of
Creative Commons Non Commercial CC-BY-NC: This article is distributed under the terms of the Creative Commons
Attribution-NonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use,
reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open
Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
patient with suspected ventricular rupture. Similarly, the Working Group on Blunt Cardiac Injury. J Trauma 1996;
presence of associated defects such as right ventricular free 40(1): 6167.
wall rupture and damage to the semilunar valves must be 2. Tiao GM, Griffith PM, Szmuszkovicz JR, etal. Cardiac and
considered. great vessel injuries in children after blunt trauma: an insti-
tutional review. J Pediatr Surg 2000; 35(11): 16561660.
Optimal timing for surgical repair in the traumatic VSD
3. Smyth BT. Chest trauma in children. J Pediatr Surg 1979;
remains undetermined. Some authors recommend delay in
14(1): 4147.
repair in order to allow for stable hemodynamics and 4. Ogunkunl OO, Duru CO, Omokhodion SI, etal. Acquired
improved tissue integrity at wound edges.22,23 Attempted ventricular septal defect: a rare sequelae of blunt chest
early repair in the setting of hemodynamic instability has trauma in a 7 year-old boy. Niger J Clin Pract 2015; 18(2):
been relatively unsuccessful in previously reported pediat- 297299.
ric cases,4,5 with right ventricular dysfunction contributing 5. Harel Y, Szeinberg A, Scott WA, etal. Ruptured interven-
to poor surgical outcome in at least one patient. In the set- tricular septum after blunt chest trauma: ultrasonographic
ting of progressive clinical deterioration, our patient diagnosis. Pediatr Cardiol 1995; 16(3): 127130.
underwent successful early repair with delayed sternal clo- 6. Helling TS, Duke P, Beggs CW, etal. A prospective evalua-
sure. It is possible that delayed sternal closure in this case tion of 68 patients suffering blunt chest trauma for evidence
of cardiac injury. J Trauma 1989; 29(7): 961965; discus-
may have allowed early surgical repair without subsequent
sion 965966.
hemodynamic deterioration from right ventricular dys-
7. Steed M, Guerra V, Recto MR, etal. Ventricular septal
function. This hypothesis is supported by recent experi- avulsion and ventricula septal defect after blunt cardiac
ence with delayed sternal closure in other high-risk trauma. Ann Thorac Surg 2012; 94(5): 17141716.
pediatric cardiac surgeries.24 8. Bromberg BI, Mazziotti MV, Canter CE, etal. Recognition
and management of nonpenetrating cardiac trauma in chil-
dren. J Pediatr 1996; 128(4): 536541.
Conclusion 9. Bertinchant JP, Polge A, Mohty D, etal. Evaluation of
A history of significant blunt thoracic trauma should lead incidence, clinical significance, and prognostic value of
to a high level of suspicion for cardiac injury, with hemo- circulating cardiac troponin I and T elevation in hemody-
dynamic instability, EKG abnormality, arrhythmia, or new namically stable patients with suspected myocardial con-
tusion after blunt chest trauma. J Trauma 2000; 48(5):
murmur requiring prompt echocardiographic evaluation.
924931.
Controversy exists regarding the utility of an echocardio-
10. Beggs CW, Helling TS, Evans LL, etal. Early evaluation
gram in the evaluation of the child with thoracic trauma of cardiac injury by two-dimensional echocardiography in
where the patient appears well with no external injuries but patients suffering blunt chest trauma. Ann Emerg Med 1987;
has a significant mechanism of trauma. The possibility of 16(5): 542545.
silent cardiac injury, as illustrated by these cases, warrants 11. Bertrand S, Laquay N, El Rassi I, etal. Tricuspid insuffi-
echocardiography in those patients with a history of sig- ciency after blunt chest trauma in a nine-year-old child. Eur
nificant thoracic trauma. While many cases with cardiac J Cardiothorac Surg 1999; 16(5): 587589.
injury can be managed conservatively, detailed transtho- 12. Veeragandham RS, Backer CL, Mavroudis C, etal.
racic (and when necessary transesophageal) echocardio- Traumatic left ventricular aneurysm and tricuspid insuf-
grams are mandated in order to define those cases requiring ficiency in a child. Ann Thorac Surg 1998; 66(1): 247
248.
intervention. Finally, significant cardiac defects may
13. Banning AP, Durrani A and Pillai R. Rupture of the atrial
develop over time as late sequelae of thoracic trauma and
septum and tricuspid valve after blunt chest trauma. Ann
should be considered by the primary care practitioner dur- Thorac Surg 1997; 64(1): 240242.
ing long-term follow-up care. 14. Yasuura K, Matsuura A, Maseki T, etal. Successful
repair of tricuspid regurgitation 46 years after causal blunt
Declaration of Conflicting Interests trauma. Scand J Thorac Cardiovasc Surg 1996; 30(2):
The author(s) declared no potential conflicts of interest with 105108.
respect to the research, authorship, and/or publication of this 15. Holper K, Hahnel C, Augustin N, etal. Operative correc-
article. tion of traumatic tricuspid insufficiency. Herz 1996; 21(3):
172178.
Funding 16. van Son JA, Danielson GK, Schaff HV, etal. Traumatic tri-
cuspid valve insufficiency. Experience in thirteen patients.
The author(s) received no financial support for the research,
J Thorac Cardiovasc Surg 1994; 108(5): 893898.
authorship, and/or publication of this article.
17. Dounis G, Matsakas E, Poularas J, etal. Traumatic tricuspid
insufficiency: a case report with a review of the literature.
References
Eur J Emerg Med 2002; 9(3): 258261.
1. Dowd MD and Krug S. Pediatric blunt cardiac injury: 18. Blaustein AS and Ramanathan A. Tricuspid valve disease.
epidemiology, clinical features, and diagnosis. Pediatric Clinical evaluation, physiopathology, and management.
Emergency Medicine Collaborative Research Committee: Cardiol Clin 1998; 16(3): 551572, x.
19. RuDusky BM and Cimochowski G. Traumatic tricuspid insuf- review of the surgical literature. Angiology 1973; 24(4):
ficiencya case report. Angiology 2002; 53(2): 229233. 222229.
20. Kleikamp G, Schnepper U, Kortke H, etal. Tricuspid valve 23. Knapp JF, Sharma V, Wasserman G, etal. Ventricular sep-
regurgitation following blunt thoracic trauma. Chest 1992; tal defect following blunt chest trauma in childhood: a case
102(4): 12941296.
report. Pediatr Emerg Care 1986; 2(4): 242243.
21. Maisano F, Lorusso R, Sandrelli L, etal. Valve repair for
traumatic tricuspid regurgitation. Eur J Cardiothorac Surg 2 4. McElhinney DB, Reddy VM, Parry AJ, etal. Management
1996; 10(10): 867873. and outcomes of delayed sternal closure after cardiac sur-
22. Moraes CR, Victor E, Arruda M, etal. Ventricular septal gery in neonates and infants. Crit Care Med 2000; 28(4):
defect following nonpenetrating trauma. Case report and 11801184.