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Cardiac contusion confusion
CORRESPONDENCE Cardiac Contusion Confusion
m a n i f e s t e d solely by t h e p r e s e n c e of r i g h t b u n d l e branch block.
To the Editor:
Case Repo~
We believe t h a t the recent case report: '
A 19-year-old m a n was b r o u g h t t o the emergency
Jerris R. Hedges, MD Dennis Price, MD Section of Emergency Medicine The Medical College of Pennsylvania Philadelphia, Pennsylvania 1. Parmley LF, Manion WC, Mattingly TW: Non-penetrating traumatic injury of the heart. Circulation 28:371-396, 1958.
To the Editor: In <
7:3 (Mar) 1978
F i g s . 1 & 2. Right bundle branch block.
JACEP
122/73
Discussion
department, h a v i n g been involved in a n automobile accident d u r i n g which he struck his chest a g a i n s t the steering wheel. At the time of examination, he w a s experiencing mild anterior chest pain, but otherwise had no complaints. The vital signs were w i t h i n normal l i m i t s and there were no a b n o r m a l i t i e s p r e s e n t on physical e x a m i n a t i o n . The electrocardiogram (Figures 1 and 2) revealed right bundle branch block. There were no previous electrocardiographic tracings available for comparison. X-ray films revealed no fractures of the bony thorax, b u t chest x-ray films disclosed a left p u l m o n a r y i n f i l t r a t e , c o n s i s t e n t in a p p e a r a n c e with p u l m o n a r y contusion. ' ' The p a t i e n t was a d m i t t e d to the h o s p i t a l a n d monitored. A n electrocardiogram t a k e n the next day revealed normal i n t r a v e n t r i c u l a r conduction (Figures 3 and 4). The p a t i e n t displayed no a r r h y t h m i a s or any other findings i n d i c a t i v e of cardiac contusion. The p u l m o n a r y infiltrate resolved over the course of the next four days. The p a t i e n t had a n u n e v e n t f u l hospital course and was discharged.
Right b u n d l e b r a n c h block r e s u l t i n g from nonp e n e t r a t i n g thoracic injury is an entity t h a t h a s been adequately documented. 1.The anterior location of the right ventricle undoubtedly renders this c h a m b e r vuln e r a b l e to i n j u r y w h e n t h e a n t e r i o r t h o r a x is traumatized. T r a n s i e n t right b u n d l e branch block may result. 2 Right bundle branch block has been found to occur in n o r m a l males aged 20 to 40 with a frequency of 1.5/1,000. 3 It may, therefore, represent a normal electrographic p a t t e r n in the t r a u m a t i z e d patient. Previous electrocardiograms are useful for establishing this fact.
George L. Sternbach, MD Michael Eliastam, MD Stanford University Medical Center Stanford, California 1. Parmley LF, Manion WC, Mattingly TW: Non-penetrating traumatic injury of the heart. Circulation 18"371-396, 1958. 2. Freidberg CK: Diseases of the Heart. Philadelphia, W B Saunders Company, 1967, p 1702. 3. Johnson RL. Averill KH, Lamb LE: Electrocardiographic findings in 67,375 asymptomatic subjects. IV. Right bundle branch block. Am J Cardiol 6:143-152, 1960.
Author's Reply We wish to re-emphasize the clinical n a t u r e of our report. I n a n automobile accident victim who has received a n o n p e n e t r a t i n g blow to the chest, a n abnormal e l e c t r o c a r d i o g r a m should a l e r t the e m e r g e n c y p h y s i c i a n to a possible m y o c a r d i a l injury. A rigid definition of cardiac contusion at this stage of triage would not help a p a t i e n t at risk for later cardiac complications. We believe t h a t a definition of cardiac contusion strictly based on isoenzyme elevations or scan abnormalities - - let alone necropsy studies - - will of necessity exclude m a n y patients at risk of t r a u m a t i c cardiac contusion and its possible sequelae. Despite his disclaimer t h a t conduction disturbances are not ~'... necessarily benign," we infer that Dr. Hedges assigns patients without infarct patterns or isoenzyme elevations to a category of lesser risk. This thesis cannot be proven by retrospective reviews or necropsy studies and we hope t h a t the prospective analysis of The Medical College of P e n n s y l v a n i a will define the accuracy of this proposition. Dr. S t e r n b a c h a n d Dr. E l i a s t a m p o i n t out the a n a t o m i c v u l n e r a b i l i t y of the r i g h t ventricle. One m i g h t hypothesize t h a t t r a n s i e n t right bundle branch block m a y represent true myocardial cell i n j u r y occurring at a threshold below t h a t detectable by conventional isoenzyme techniques. The purpose of our report was to alert clinicians to the possibility t h a t m i n i m a l electrocardiogram changes may a u g u r later cardiac complications. U n t i l the n a t u r a l history of conduction disturbances following chest t r a u m a can be defined in a prospective study, we believe these patients should be treated for presumed cardiac contusion.
Michael S. Miller, MD Frederick C. Scott, MD Maryvale Samaritan Hospital Phoenix, Arizona
Figs. 3 & 4. Normal intraventricular conduction. 74/123
JACEP
7:3 (Mar) 1978
m a n i f e s t e d solely by t h e p r e s e n c e of r i g h t b u n d l e branch block.
To the Editor:
Case Repo~
We believe t h a t the recent case report: '
A 19-year-old m a n was b r o u g h t t o the emergency
Jerris R. Hedges, MD Dennis Price, MD Section of Emergency Medicine The Medical College of Pennsylvania Philadelphia, Pennsylvania 1. Parmley LF, Manion WC, Mattingly TW: Non-penetrating traumatic injury of the heart. Circulation 28:371-396, 1958.
To the Editor: In <
7:3 (Mar) 1978
F i g s . 1 & 2. Right bundle branch block.
JACEP
122/73
Discussion
department, h a v i n g been involved in a n automobile accident d u r i n g which he struck his chest a g a i n s t the steering wheel. At the time of examination, he w a s experiencing mild anterior chest pain, but otherwise had no complaints. The vital signs were w i t h i n normal l i m i t s and there were no a b n o r m a l i t i e s p r e s e n t on physical e x a m i n a t i o n . The electrocardiogram (Figures 1 and 2) revealed right bundle branch block. There were no previous electrocardiographic tracings available for comparison. X-ray films revealed no fractures of the bony thorax, b u t chest x-ray films disclosed a left p u l m o n a r y i n f i l t r a t e , c o n s i s t e n t in a p p e a r a n c e with p u l m o n a r y contusion. ' ' The p a t i e n t was a d m i t t e d to the h o s p i t a l a n d monitored. A n electrocardiogram t a k e n the next day revealed normal i n t r a v e n t r i c u l a r conduction (Figures 3 and 4). The p a t i e n t displayed no a r r h y t h m i a s or any other findings i n d i c a t i v e of cardiac contusion. The p u l m o n a r y infiltrate resolved over the course of the next four days. The p a t i e n t had a n u n e v e n t f u l hospital course and was discharged.
Right b u n d l e b r a n c h block r e s u l t i n g from nonp e n e t r a t i n g thoracic injury is an entity t h a t h a s been adequately documented. 1.The anterior location of the right ventricle undoubtedly renders this c h a m b e r vuln e r a b l e to i n j u r y w h e n t h e a n t e r i o r t h o r a x is traumatized. T r a n s i e n t right b u n d l e branch block may result. 2 Right bundle branch block has been found to occur in n o r m a l males aged 20 to 40 with a frequency of 1.5/1,000. 3 It may, therefore, represent a normal electrographic p a t t e r n in the t r a u m a t i z e d patient. Previous electrocardiograms are useful for establishing this fact.
George L. Sternbach, MD Michael Eliastam, MD Stanford University Medical Center Stanford, California 1. Parmley LF, Manion WC, Mattingly TW: Non-penetrating traumatic injury of the heart. Circulation 18"371-396, 1958. 2. Freidberg CK: Diseases of the Heart. Philadelphia, W B Saunders Company, 1967, p 1702. 3. Johnson RL. Averill KH, Lamb LE: Electrocardiographic findings in 67,375 asymptomatic subjects. IV. Right bundle branch block. Am J Cardiol 6:143-152, 1960.
Author's Reply We wish to re-emphasize the clinical n a t u r e of our report. I n a n automobile accident victim who has received a n o n p e n e t r a t i n g blow to the chest, a n abnormal e l e c t r o c a r d i o g r a m should a l e r t the e m e r g e n c y p h y s i c i a n to a possible m y o c a r d i a l injury. A rigid definition of cardiac contusion at this stage of triage would not help a p a t i e n t at risk for later cardiac complications. We believe t h a t a definition of cardiac contusion strictly based on isoenzyme elevations or scan abnormalities - - let alone necropsy studies - - will of necessity exclude m a n y patients at risk of t r a u m a t i c cardiac contusion and its possible sequelae. Despite his disclaimer t h a t conduction disturbances are not ~'... necessarily benign," we infer that Dr. Hedges assigns patients without infarct patterns or isoenzyme elevations to a category of lesser risk. This thesis cannot be proven by retrospective reviews or necropsy studies and we hope t h a t the prospective analysis of The Medical College of P e n n s y l v a n i a will define the accuracy of this proposition. Dr. S t e r n b a c h a n d Dr. E l i a s t a m p o i n t out the a n a t o m i c v u l n e r a b i l i t y of the r i g h t ventricle. One m i g h t hypothesize t h a t t r a n s i e n t right bundle branch block m a y represent true myocardial cell i n j u r y occurring at a threshold below t h a t detectable by conventional isoenzyme techniques. The purpose of our report was to alert clinicians to the possibility t h a t m i n i m a l electrocardiogram changes may a u g u r later cardiac complications. U n t i l the n a t u r a l history of conduction disturbances following chest t r a u m a can be defined in a prospective study, we believe these patients should be treated for presumed cardiac contusion.
Michael S. Miller, MD Frederick C. Scott, MD Maryvale Samaritan Hospital Phoenix, Arizona
Figs. 3 & 4. Normal intraventricular conduction. 74/123
JACEP
7:3 (Mar) 1978