sternal fractures and delayed cardiac ta”>Case Report

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

American Journal of Emergency Medicine 34 (2015) 758.e1-758.e3

Sternal fractures and Delayed cardiac tamponade due to a severe blunt chest trauma?,??

Abstract

Sternal fractures caused by blunt chest trauma are associated with an increased incidence of cardiac injury. Reports of the incidence of car- diac injury associated with sternal fracture range from 18% to 62% [1]. Delayed cardiac tamponade is a rare phenomenon that appears days or weeks after injury. Moreover, after nonpenetrating chest trauma, cardiac tamponade is very rare and occurs in less than 1 of 1000 [2]. This case describes a patient who had delayed cardiac tamponade 17 days after a severe blunt chest trauma.

A 58-year-old man, without other medical problems, was admitted with chest pain and dyspnea. He had been in previous good health, with no symptoms suggestive of cardiovascular disease, and had no his- tory of hypertension, diabetes, or coronary artery disease. Two weeks before admission, the patient had an accident during which a heavy and high-speed wood was pushed against the forward part of his chest, which resulted in strong chest pain. The pain increased with ven- tral chest compression. The patient was admitted to his local hospital for observation and simple supportive care. Computed tomography (CT) of the thorax showed the isolated sternal fractures with displaced sternum fragments. One of the fragments was so close to the pulmonary artery. Computed tomography cuts through the thorax showed minimal peri- cardial fluid without Pleural effusions. The findings on cardiac enzyme determinations and electrocardiogram (ECG) were reported normal. He was hospitalized for 1 week and also treated with analgesics due to chest pain. No cardioVascular abnormalities were observed during that period. One day before, he observed progressive shortness of breath that prevented him from performing ordinary activities; lower limbs edema and abdominal enlargement ensued. So, he went to our hospital. Clinical findings included body temperature of 36.3?C, respiratory rate of 24 per minute, an oxygen saturation level of 92%, a sinus tachycardia of 112 beats per minute, blood pressure of 120/78 mm Hg. Central venous pressure readings were 14 cm H₂O on admission. The chest examination disclosed a large region of severe bruising in front of his chest, and his con- sciousness was clear. The ECG showed sinus tachycardia. Emergency echocardiography showed a large pericardial effusion. Chest x-ray film showed enlarged cardiac silhouette and sternal fractures (Fig. 1A). Com- puted tomography showed a visible sternum fractures with displaced sternum fragment. A visible fragment was disclosed, compressing anteri-

orly both the right ventricular cavity and outflow tract (Fig. 1B).

? HML and QLC are equal first authors.

?? All above authors have nothing to disclose.

Cardiac tamponade was established; arrangements were made to perform a median sternotomy. A middle skin incision was made, follow- ed by repeat sternotomy, with some trouble. Mediastinal adhesions were tremendously thick and heavy (Fig. 2A). We gently removed the sternum fragments (Fig. 2B) and performed a pericardiotomy. More than 800 mL of dark red color fluid and thrombus was removed from the pericardial sac. No visible puncture wound on the pulmonary artery or interpericardial sac was found. We wired the proximal and distal fragments together with 2 metal wires and performed sternal closure with a Ni-Ti shape memory alloy embracing fixator.

The patient was weaned from mechanical ventilatory support the next day. pericardial fluid drainage decreased from 300 mL the first postoperative day to 25 mL on the third postoperative day. We removed the pericardial drain at that time. The patient fully recovered without complication and was discharged after 7 days.

Blunt chest trauma may lead to a wide variety of Cardiac damage ranging from nonsignificant minor contusion to fatal Cardiac rupture. It is said that cardiac injury occurs in approximately 15% of patients who give a history of severe blunt chest trauma and leads to death in half of the cases [3]. However, cardiac tamponade after blunt chest trauma is a rare event. Nonpenetrating blunt chest trauma, as in our case, causing delayed cardiac tamponade is unusual. For many years, the exact mech- anism whereby delayed cardiac tamponade occurs is unknown [4].

If in patients with isolated sternal fractures, no abnormality was found on ECG examination or anteroposterior chest radiograph, together with lateral sternal radiograph and in the absence of other in- juries, hospital admission is not indicated [5]. However in our case, tamponade may occur from extrapericardial blood collection without intrapericardial hematoma or injury and requires operative decompres- sion. Moreover, 3-dimensional CT sternum disclosed that a visible ster- num fracture, compressing anteriorly both the right ventricular cavity and outflow tract, is so close to the pulmonary artery. We performed a median sternotomy. operative fixation has been done by wiring the proximal and distal fragments together with 2 heavy wire sutures. Then we performed the sternal closure with a Ni-Ti shape memory alloy embracing fixator (Fig. 3). The shape memory alloy embracing fixator has certain advantages, such as less trauma, easy to do, and stable fixation. This method can enhance the fracture healing, and it is a better method to treat fractures of sternum [6].

This case illustrates 1 unusual sequelae of blunt chest trauma- delayed cardiac tamponade.

Huai-min Liang, MD Department Cardiovascular Surgery West China Hospital, Sichuan University

Chengdu 610064, PR China

0735-6757/(C) 2015

758.e2 H. Liang et al. / American Journal of Emergency Medicine 34 (2015) 758.e1-758.e3

Fig. 1. X-ray film and computed tomography. A, X-ray film showed enlarged cardiac silhouette and sternal fractures. B, Computed tomography showed a visible sternum fractures with displaced sternum fragments, compressing anteriorly both the right ventricular cavity and outflow tract, and a large pericardial effusion.

Fig. 2. A, Tremendously thick mediastinal adhesions. B, Sternum fractures and displaced fragments.

Fig. 3. X-ray film and computed tomography on the sixth postoperative day. A, X-ray film showed a Ni-Ti shape memory alloy embracing fixator. B, Computed tomography showed no visible sternum fragments and pericardial effusion.

H. Liang et al. / American Journal of Emergency Medicine 34 (2015) 758.e1-758.e3 758.e3

Qiu-lin Chen, MD

Department of Cardiothoracic Surgery Central Hospital of Guangyuan City, Guangyuan Sichuan Province 628000, PR China

Er-yong Zhang, MD Jia Hu, MD, PhD^?

Department of Cardiovascular Surgery, West China Hospital Sichuan University, Chengdu 610064, PR China

^?Corresponding author

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.07.075

References

1. Karmy-Jones R, Jurkovich GJ. Blunt chest trauma. Curr Probl Surg 2004;41(3):223-380.
2. Maenza RL, Seaberg D, D’Amico F. A meta-analysis of blunt cardiac trauma: ending myocardial confusion. Am J Emerg Med 1996;14(3):237-41.
3. Pretre R, Chilcott M. Blunt trauma to the heart and great vessels. N Engl J Med 1997; 336(9):626-32.
4. Collins AM, Ridgway P, McDonald K, Tolan M. Delayed cardiac tamponade following blunt Thoracic trauma. Inj Extra 2008;39(7):253-5.
5. Rashid MA, Ortenwall P, Wikstrom T. Cardiovascular injuries associated with sternal fractures. Eur J Surg 2001;167(4):243-8.
6. von Garrel T, Ince A, Junge A, Schnabel M, Bahrs C. The sternal fracture: radiographic analysis of 200 fractures with special reference to concomitant injuries. J Trauma 2004;57(4):837-44.