Traumatic rupture of the heart and intrapericardial structures

fFORENSIC EDITOR:

MEDICINEf HARRISON

S. MARTLAND,

M.D.

TRAUMATIC RUPTURE OF THE HEART AND INTRAPERICARDIAL STRUCTURES STUART 2. HAWKES, M.D. NEWARK, N. J.

A

STUDY of the Iiterature on traumatic injuries to the heart and great vesseIs within the pericardium reveaIs mostIy singIe case reports of deaths due to this cause. In the past the condition has been described as rare. No series of any size is on record. Reports of series of spontaneous cardiac rupture, however, are quite common. AutomobiIe injuries are so common in this country, over 36,000 deaths occurring this year and some 900,000 injuries, that Iesions which were heretofore considered rare and unusual are being encountered almost every day-. In this paper the protocoIs for the ten-year period 1925-1934 were studied in the office of the Chief MedicaI Examiner of Essex County (N. J.) as this type of death was feIt to be more common than has been suspected. INCIDENCE

TABLE

I

NO.

i---

Total.

Cardiac Injurv

Per Cent

(_____-

~708 1

70

)

2.6

Of these 70 cases onIy one was a doubtfu1 death as the resuIt of direct trauma to the body. This case wiI1 be discussed in greater detai1 Iater in the paper. When we consider that these 70 cases represent about 2.6 per cent of this type of vioIent deaths and I per cent of a11 autopsies performed during these ten years, fata trauma to the heart must be a type of injury seen quite frequentIy in MedicaI Examiners’ ofhces in the Iarger cities of this country. In TabIe II are shown the specrfic types of vioIence which caused death.

TABLE II During this ten-year period over 7000 Highway Accidents autopsies have been performed routineIy Struck by pleasure car. for medicoIega1 reasons. Picking from this Collision of two cars. Struck by train.. number the cases where fata traumatic Struck by bus.. heart injuries occurred, we find a11 the Struck by truck.. cases were due to either highway accidents, Struck by “hit and run” car. Struck by taxi.. incIuding train deaths, or faIIs from a Struck by motorcycle. considerabIe height, incIuding suicide by FalIs jumping, etc. Among these 2708 deaths From window. From roof., (TabIe I), injuries to the heart and great From poIe., vesseIs within the pericardium occurred in From scaffold. 70 cases, either directIy causing death or From elevated highway. Airplane accident.. acting as a contributory factor. 503

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A study of Table II wiII show that the individua1 was exposed to considerabIe trauma to produce the Iesion. It wiII aIso

produce or have a part in the heart injury. Any marks of injury such as brush burns, abrasions, Iacerations or any signs of

FIG. I. Traumatic rupture of aorta. Auto accident. Male, white, struck by hit-and-run driver. Dead on arriva1 at hospital. Compression of chest, muItiple fractures of ribs, rupture of aorta and hemopericardium. Note transverse rupture of aorta just above sinuses of VaIsaIva, almost encircling aortic root with tearing of R. P. commissure. (AI1 iIIustrations ‘and cases from Offme of Chief MedicaI Examiner, Essex County, N. J.)

rupture of aorta and left ventricle. Fall. Male, white, aged sixty-five. FaII from second story window. Dead on arriva1 at hospital. Compression of chest, fracture of ribs, spine and skuI1. A transverse tear in aorta, I cm. above sinuses of VaIsaIva, aImost encircIing aortic root and a rupture half way through interventricular septum may be noted.

reveal that some type of automobile accident accounts for two-thirds of a11 these deaths. The other one-third are situations where excessive trauma to the individual occurs. This type of injury apparentIy does not occur then except where great force of a compressive nature is brought to bear on the individua1. This force does not necessariIy have to produce fractures to invoIve the heart as wiI1 be shown.

bodiIy distortion were absent in over haIf the cases. This fact (Table III) is of great interest and importance as in these cases one of the most important causes of death may be masked by the apparent Iack of injury to the thorax or back.

THORACIC

INJURIES

In these cases bodiIy injury wil1 be construed as pertaining to the bony cage of the thorax and its covering integument. These wouId be the skin and subcutaneous tissues of the chest and upper back with the sternum, ribs, shoulders, and spine. Other injuries may be contributory in producing death but they could not

FIG.

2.

Traumatic

TABLE INJURY

TO

ENCLOSING

III STRUCTURES

ExternaI marks of injury (chest, back, shoulders) None.. 39 Present. 31 Chest waI1 injury Fractured ribs, biIatera1. 36 Fractured ribs, left side.. 14 Fractured ribs, right side.. 8 Fractured sternum (only). 2 No fractures., IO No fractures and no externa1 marks.. 7

In some of these cases a11 sorts of cIinica1 measures were attempted on the unfortunate individua1, viz: active treatment of shock, major operations on other parts, treatment of isoIated fractures,

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without the apparent realization that any heart injury was present. The more careful study of the patient with heart injury in mind, in whom there has been compression and who has no signs of violence, may lead to saving the Iives of some of these unfortunates. Operations on the heart are becoming one of the procedures of modern surgery. If the condition is recognized the treatment of the patient shouId center on the heart Iesion and the injury of other vita1 structures. Any Iife-saving measures wiI1 be possibIe in onIy a very smaII percentage of the tota as wiI1 be shown Iater. The most important fact, however, is the reaIization of the existence of this masked condition, which may simuIate extreme surgica1 shock. MuItipIe fractures may occur but in IO cases there were none and in 7 of these no externa1 marks of which facts often compIeteIy vioIence, misIead the cIinician. To be sure many of these individuals did show injury, compression on examination, fractures, and were in extremis or were dead, but this fact does not detract from the importance of carefuI clinica observations on the smaIIer number which might have benefited from an exact understanding of the pat hoIogy present. HEART

INJURY

The intrapericardia1 structures are so cIoseIy reIated anatomicaIIy and functionaIIy that a Iesion of one of the great vesseIs as we11 as the heart seems to have the same mechanics of production. As has been noted, in IO cases there were no fractures of the ribs, sternum, or spine. In the minds of many a traumatic heart injury is only present when the heart has been lacerated by a piercing bony structure. This couId not have been the fact in these IO instances. The contents of the chest function normaIIy with a negative pressure present. The aIternate sucking and pumping action of this subatmospheric the heart requires environment to carry out its work with maximum e&iency. If we then add a sudden highIy positive as we11 as compressive pressure, no matter what phase the

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heart is caught in, the result should be a hydrostatic pressure rupture. If the heart be caught whiIe fiIIing or when nearIy

FIG. 3. Traumatic

rupture of heart and aorta. Auto accident. MaIe, colored, aged forty. Struck by auto truck. Instant death. Compression of chest, muItipIe fractures of ribs, Iaceration of heart and Iungs. I-Ieart was torn free through auricIes and aortic root found in Ieft pIeural cavity.,

fIIIed, in late diastoIe, the force wiI1 be even greater. We have then a true “blowout” of a closed ffuid pressure system with the outIet, in this case the Iarger arteries, unabIe to carry off the sudden pressure increase. To substantiate this view it may be cited that the pericardium was not torn in 27 of the total cases. This membrane must first be punctured by any bony structure before the heart or great vesseIs can be damaged. The parieta1 pericardium may possibly be ruptured with the heart and at the same time. This point cannot be concIusiveIy made in this series as there

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are no definite grounds to substantiate the facts. Hamilton’ however, reported a case of a seven-year-old gir1 who was run over

of bIebs and bIisters on the viscera1 pIeura of the Iung, especiaIIy near the free borders (acute interstitia1 emphysema denoting

FIG. 4. Traumatic

FIG. 5. Posterior surface of heart shown in Figure 4. GIobuIar traumatic aneurysm with Iinear rupture on summit, 0.5 cm. in length, located posterior to papiIIary muscles. Microscopic examination showed no evidence of rheumatic, syphititic or other specific lesions.

aneurysm of left ventricle. Auto accident. Male, white, aged six. Came home from school sick. WhiIe eating supper fell off chair dead. Three months ago was in hospital for one week suffering from compression of chest and muItipIe abrasions of body foIIowing auto accident. Discharged cured. A globular, thin-waIled aneurysm on posterior surface of left ventricle, 4 cm. in diameter, may be noted. This had ruptured producing hemopericardium with “tamponage” of heart.

by an automobiIe, the front whee1 passing across the chest. Death took pIace immediateIy. Aside from a sIight abrasion on the forehead, no other externa1 injuries were found. Autopsy showed no fractured ribs, there was a Ieft hemothorax, a tear in the parieta1 pericardium on the Ieft side, and both ventricIes were ruptured. With crushing of the bony cage there is undoubtedIy direct Iaceration of the pericardium and its contained structures but the expIanation of the injury has rested too much on this mechanism and too IittIe or nothing has been said of the compressive factor. Other evidence of compression of the chest in this type of injury is the frequent occurrence 1Hamilton, J. A. Traumatic rupture of the heart without external injuries. &it. M. J. (Dee. 15) 1934.

sudden increase in intra-aIveoIar pressure). Of the tota cases 3 deaths occurred in chiIdren under ten years of age. In none of these were any fractures present. The pIiabiIity and eIasticity of the thorax aIlowed the vioIence to occur with the bony structures springing back into position after the damage had been done. Proof of this fact may be obtained by pressing on the sternum of a chiId on the postmortem table. The sternum and spine can be approximated easiIy and when the force is reIeased norma anatomica relations are re-estabIished. This fact is Iess true of the average aduIt chest due to a stiffening of the Iigaments and caIcification of the costochondra1 junctions. A study of TabIe IV wiI1 show that no one part of the heart is injured, in any appreciabIe number of cases, more than any other.

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TABLE ANALYSIS

OF

Hawkes-Rupture

No. 3

SITE

OF

Iv INJURY

AXD

Heart Left ventrick.. . Right ventrick.. .. Left auricle. . Right auricle.. . Both ventricles. Both auricles. Split from apex to base. Interventricular septum.. Traumatic aneurysm, Ieft ventrick.. Maceration.. Abrasion.................................... Site not mentioned. Associated Strucfures Pericardium torn. Pericardium not torn.. Aortaonly.................................. Aorta and heart. Inferior vena cava only..

TYPE

. .

8 8

4 4 3 3

. .

7 3 2 2 I 8 43

27 16

5 I

In one case an abrasion at the left base without DericardiaI injury caused death tamponade.” This apparentIy by “Herz individual might have well been a candidate for surgery had the condition recognized. In 16 cases the aorta was ruptured. The site of this injury to be aImost constant, occurring in the cases within the first inch of the above the aortic cusps (Figs. I and

been alone seems 14 of aorta 2). In

some of the specimens the laceration practicaIIy encircIed the vesseI, whiIe in one the heart was compIeteIy detached with a stub of aorta and was found Iying in the Ieft pIeura1 cavity (Fig. 3). Of the

two remaining cases one occurred aortic arch, whiIe the other perhaps not be incIuded in this study.

in the shouId

It is the case of a white male, aged fortynine, who was hit by a truck. There n-as no chest injury found. He had a compound comminuted fracture of the right Icg bclo\v the knee which necessitated amputation because of gas baciIIus infection. On the fourth day after the accident and the second day postoperative, he began to complain of chest pain and pain in the back. CIinicaIIy he graduaIIy went into shock. He responded to no stimuIi. He died eight days after the accident. At autopsy a ruptured aneurysm of the third portion of the aorta was found. The Ieak was smaI1 and the bIeeding had been slow but continuous with bloody infiItration of the surrounding structures. The evidence is not compIete in this case that the truck caused a rupture of the aneurysm. One

other

case

deserves

mention:

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A boy six years old was hit by a truck. Hospital diagnosis was compression of the chest and multiple abrasions of the body. He u-as discharged after one week as cured. He continued his usua1 Iife at home until three months after the accident when he came home from school complaining of feeIing sick. While eating his supper he feI1 off his chair dead. At autopsy a ruptured traumatic aneurysm of the left ventricle with hemopericardium was found. The aneurysm was gIobuIar, thin-walled, on the posterior surface of the left ventricIe. It measured 4 cm. in diameter with a. rupture on the summit 0.5 cm. in diameter (Figs. 4 and 3). The aneurysm started posterior to the papillary muscles. No rheumatic or syphiIitic lesions were found. There was no chest waI1 injury or fracture. A simiIar

case

has been

reported:2

A boy nine years old who \vas eaught bet\\-een a waI1 and a buIIock cart. Examination after the accident showed no evidence of externa1 He event to schoo1 the or interna injuries. folIowing day. Ten days later whiIe pIaying at school he complained of precordia1 pain and feI1 down dead. Autopsy showed a rupture of the Ieft ventricle with hemopericardium, the rupture definiteIy being reIated to a contusion of the heart muscIe in this area. ANALYSlS

OF

DEATHS

In these 70 deaths there were but 4 cases where the heart injury aIone was responsibIe for the death. In the other 66 there were associated other morta1 injuries such as rupture of Iungs, liver, spleen, hoIIow viscus, or fracture of the skuI1 or spine. 'rABLE DUKATIOK

01: LIFE

1' 4ITER

INJI:KY

Dead on arriva1. Within one hour.. Within tweIvc hours.. Within six days. Within eight hays.. \Vithin ninety- days.

ji

8 1 I I I

A study of TabIe v wiI1 show that 6~ of these individuaIs died within twentyfour hours, and that 3 Iived six, eight, and ninety days respectiveIy. The author \\ishes to thank Dr. IIarrison S. Martland, Chief Medica Examiner of Essex County, for the privilege of reporting the cases.

1 Gunewardenc, I I. 0. Traumatic heart. Brif. M. J. INOV. 24) 1934.

rupture

of the