Blunt Cardiac Rupture: A Diagnostic Challenge

Abstract

A 22-year-old unidentified male was brought to the emergency room with history of road traffic crash, with no witnesses to the accident. At presentation, patient was agitated, drowsy and diaphoretic with tachycardia of 130/min and Blood Pressure (BP) of 78mmHg systolic. There was bilaterally equal air entry, mild abdominal tenderness and blood tinged urine on inserting Foley catheter.On fluid resuscitation, BP transiently rose and patient became responsive and obeyed commands. BP showed downward trend to 70 mmHg systolic over next ten minutes and Central Venous Pressure (CVP) was found to be 20cm of H 2 O. Heart sounds were muffled on auscultation. Chest radiograph was suggestive of a widened mediastinum [Table/ Fig-1]. Pelvic radiograph was suspicious of pubic diastasis suggestive of open book pelvic fracture. The hospital ultrasound machine was out of order and patient was unstable to be shifted to radiology suite for Focused Assessment by Sonography in Trauma (FAST) or Trans Thoracic Echocardiography (TTE).A primary diagnosis of cardiac tamponade was considered and urgent cardiac surgery consultation was sought. The patient was intubated in view of progressive hypotension. On reassessment, air entry was reduced bilaterally, hence, bilateral intercostal drains were inserted and pneumothorax was drained bilaterally. Subsequently, air entry improved bilaterally. CVP persisted to be 20cm of H 2 O and patient continued to be hypotensive. Blind pericardiocentesis was attempted unsuccessfully. Patient was shifted into the operation theatre and subxiphoid pericardial window revealed a bulging pericardium. Diagnostic Peritoneal Lavage (DPL) was also done which showed haemoperitoneum. Median sternotomy was done and 250ml of clots and blood was evacuated on opening pericardium, following which BP showed an upward trend. A 0.5 cm actively bleeding rent was identified on right atrial appendage [Table /Fig-2]. The rent was closed with 5-0 polypropylene suture in two layers. Laparotomy was done and 600ml haemoperitoneum was evacuated. Splenectomy was done for grade four laceration. Large non-expanding pelvic and retroperitoneal hematoma and a small non-bleeding liver laceration were left untouched. Patient was transfused four units of blood and fresh frozen plasma each. Patient made an uneventful recovery. A postoperative TTE showed no abnormality. Patient also had a tibial spine avulsion fracture Blunt Cardiac Rupture (BCR) is a life threatening injury. Majority of patients do not reach the hospital and in those who reach the emergency department, timely diagnosis and treatment is a challenge. The case is about a patient with multiple blunt injuries who presented in shock. Cardiac tamponade was suspected on clinical grounds and on evidence of mediastinal widening on radiograph. In the absence of songography, the diagnosis was confirmed by subxiphoid pericardial window. Emergency thoracotomy revealed a right atrial appendage rupture which was surgically corrected. The patient also underwent splenectomy for grade IV splenic ...

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