Blunt traumatic rupture of the atria The case histories of 2 patients with atrial rupture from blunt chest trauma are presented, one of whom is the tenth survivor. Based on a review of these cases and the literature, important factors in the diagnosis and treatment of this easily repairable anatomic lesion are discussed. The importance of rapid recognition and early operation are emphasized. J. Marvin Smith III, M . D . , Frederick L. Grover, M . D . , Javier J. Marcos, M . D . , Kit V. Arom, M.D., and J. Kent Trinkle, M.D., San Antonio, Texas
A he case histories of two patients with right atrial rupture secondary to blunt trauma are reported to emphasize the important points of diagnosis and treatment. Both patients were transported by a new Fire Department Emergency Medical System. The efficiency of this evacuation system has resulted in more such critically injured patients reaching the hospital alive. One of our patients lived, the tenth reported to have survived atrial rupture. Case report CASE 1. A 65-year-old man was admitted to the emergency room 25 minutes after having been struck by an automobile. He was awake and alert, with a systolic blood pressure of 80 mm. Hg and a central venous pressure of zero. Chest roentgenography (Fig. 1) demonstrated a right hemothorax and fractured rib. No other injuries were found. A tube inserted into the right side of the chest yielded 400 c.c. of blood. Despite rapid infusion of 2 L. of balanced salt solution and type-specific blood, the patient remained in shock. Forty-five minutes after his arrival, the drainage from the chest tube suddenly became profuse and cardiac arrest ensued. A right anterolateral thoracotomy was immediately performed in the emergency room. There was a large amount of clotted blood in the right pleura, a longitudinal tear in the pericardium anterior to the phrenic nerve, and a 4 cm. laceration in the right atrium extending from the base of the atrial appendage inferiorly. A partially occluding clamp closed the atrial rent, cardiac massage was started, and vigorous transfusion continued. No effective cardiac activity could be obtained after 45 minutes, and the patient was pronounced dead. CASE 2. A 25-year-old woman arrived in the emergency room with a systolic blood pressure of 70 mm. Hg, 20 From the Division of Cardiothoracic Surgery, The University of Texas Health Science Center at San Antonio and the Audie Murphy Veterans Administration Hospital, 7703 Floyd Curl Drive, San Antonio, Texas 78284. Received for publication June 6, 1975.
Fig. 1. Chest film, taken with the patient supine, demonstrates right hemothorax, fracture of right eighth and ninth ribs posteriorly, and a central venous pressure line in the superior vena cava. minutes after being involved in a two-car collision. She was agitated and disoriented and had decreased strength in the right extremities. Examination revealed multiple lacerations of the forehead, a weak pulse of 120 beats per minute, normal heart sounds, and equal breath sounds bilaterally. Findings on the chest x-ray film (Fig. 2) were unremarkable except for a right rib fracture. The central venous pressure was 40 cm. of saline. A rapidly performed peritoneal lavage yielded slightly bloody fluid. The patient was moved immediately to the operating room 6 17
6 18
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Smith et al.
Table I. Surgically treated atrial rupture Location of rupture
Ref. No.
Age, sex
3 4
M 42, M
Right atrium, SVC Left atrium
5
57, F
6
21, M
7 7* 8
46, M 20, M 27, F
Right atrium, IVC, SVC Right atrial appendage, right atrium Left atrial appendage Left atrial appendage Right atrium, right atrial appendage Right atrial appendage Right atrium Right atrial appendage Right atrium Right atrium
9 10 10 UTHSCSA* UTHSCSA
21, 23, 26, 65, 25,
M M M M F
Chest x-ray
film
BP (mm. Hg)
CVP (cm. H£>)
Heart sounds
70/20 0
NR NR
Good quality Diminished
0
NR
NR
Diffuse haze on right Enlarged cardiac silhouette, fractured ribs Left hemopneumothorax
60/40
NR
Distant
Widened mediastinum
0 Shock Unobtainable
20 NR 35
Faint NR Muffled
Widened mediastinum Left hemothorax Widened superior mediastinu
Not stated 0/0 0/0 80sys 70 sys
NR 25 24 0 40
Distant NR Distant Normal Normal
Widened mediastinum Normal Normal Right hemothorax Fractured right sixth rib
Legend: BP, Blood pressure. CVP, Central venous pressure. SVC, Superior vena cava. IVC, Inferior vena cava. NR, Not recorded. ND, Not done. *The patient died. tThe patient underwent a thoracotomy in the emergency room.
where, after an endotracheal tube was inserted, she sustained a cardiac arrest. A midline laparotomy and an anterolateral thoracotomy in the fifth left intercostal space, performed simultaneously, disclosed a tense, bulging pericardium and no abdominal injury. The pericardium was opened anterior to the phrenic nerve and considerable clot was removed. Exsanguinating hemorrhage ensued from the right atrium, necessitating extension of the incision across the sternum. A 4 cm. rupture of the right atrium was found and was occluded with a vascular clamp. Following rapid transfusion of type-specific blood, cardiac massage, and intracardiac epinephrine, effective cardiac activity was obtained and the atrial rent oversewn. Isoproterenol was temporarily required to support the circulation. Additional x-ray films disclosed a fracture of the right ischium through the acetabulum. The patient remained obtunded for 3 days, but her neurologic status gradually improved to complete recovery except for paralysis of the left sixth nerve. She was discharged on the twenty-third hospital day, returned to teaching high school English one month after discharge, and is now without cardiac symptoms 9 months after the injury. Discussion
Fig. 2. Portable chest film, taken with the patient sitting, demonstrates normal-appearing cardiac silohuette, no hemothorax, fracture of the right sixth rib, and a central venous pressure line in the right atrium.
Rupture of a chamber of the heart was the most common injury found in an autopsy series of 546 cases of blunt cardiac trauma. 1 There were 67 cases of isolated atrial rupture, and 13 of the patients did not die immediately. Bright and Beck 2 reported that 30 of 168 patients with fatal heart rupture survived longer than one hour after injury. Therefore, with modern ambulance service and support measures, there is adequate time for many of these patients to arrive alive at an emergency room. The fact that only 9 previous
Volume 71 Number 4 April, 1976
Blunt traumatic rupture of atria
Improved afte pericardiocente
619
Clinical presentation
Pericardium intact
Hemorrhagic shock Tamponade
No Yes
ND Yes
Right thoracentesis twice No
9hr.
Hemorrhagic shock
No
ND
Left
1 hr.
Tamponade
Yes
ND
No
1 hr., 42 min.
Tamponade Hemorrhagic shock Tamponade
Yes No Yes
No ND Yes
No Left No
NRt > 2 hr. >8 hr.
Tamponade Tamponade Hemorrhagic shock Hemorrhagic shock Tamponade
No Yes Yes No Yes
Yes Yes ND ND ND
Right No No Right No
NR, hours 1 hr. 4 to 5 hr.
survivors of this injury are reported3-10 indicates that there is a delay in transport, diagnosis, and/or treatment, as in our patient who was in the emergency room for 45 minutes prior to death. In contrast, the successfully treated patient was undergoing operation 30 minutes after arrival. Patients with atrial rupture may present with signs of pericardial tamponade or hemorrhagic shock (Table I), depending on whether the pericardium remains intact. A laceration of the pericardium allows some decompression into either hemithorax, and the clinical presentation is more apt to be one of hemorrhagic shock. However, it is not unusual for one of the cardiac chambers to rupture with the pericardium remaining intact, as Parmley1 reported in 71 of 161 cases of isolated atrial or ventricular rupture. As in penetrating wounds of the heart, it is uncommon for all of the classic signs of tamponade to be found in any one patient,11 and the diagnosis can be difficult. An elevated central venous pressure of 20 cm. of water or greater is quite suggestive, but poor catheter placement and patient agitation can lead to misleading elevations. Heart sounds may or may not be decreased, as is demonstrated by our second patient, who had clearly audible heart sounds despite severe tamponade. Chest roentgenography is helpful in demonstrating hemothorax, associated chest injuries, and sometimes mediastinal widening, but it is not diagnostic for pericardial tamponade since the pericardium does not dilate acutely.
Chest tube
Time to surgery NR
45 min.t 30 min.
If pericardial tamponade is present, the patient should be taken immediately to the operating room. Pericardiocentesis with insertion of an indwelling catheter as suggested by Noon8 will sometimes allow additional time for transporting the unstable patient to the operating room. Pericardiocentesis is not a definitive therapeutic procedure,13 however. It is often misleading, and reliance upon it alone may result in higher mortality rates.14 Initial performance of a subxiphoid pericardial window11 under local anesthesia will confirm the diagnosis, relieve the tamponade, and may prevent immediate decompensation from the institution of positive-pressure ventilation and/or general anesthesia. If hemopericardium is found, the incision is extended to a median sternotomy, which affords the best exposure and control. If extreme hemorrhage, rapid decompensation, and/or cardiac arrest occur before the patient can be transported, immediate thoracotomy is necessary. Mattox12 has shown that this can be efficaciously performed in the emergency room. For resuscitation or control of exsanguinating hemorrhage, an anterolateral thoracotomy in the fifth intercostal space on the side of hemorrhage should be employed. The incision may be extended across the sternum for additional exposure if necessary. The left side is preferable in the event no localizing factors exist. Pump standby and autotransfusion offer increased safety, but operation should not be delayed while awaiting their availability. Hemorrhage can usually be controlled with a partially occluding
62 0 Smith et al.
clamp. Blood volume can then be restored, effective cardiac activity obtained, and the tear can be closed with a running vascular suture. Summary The case histories of 2 patients with atrial rupture secondary to blunt trauma are reported. One patient was treated successfully, the tenth reported survivor. Correct management is contingent upon rapid recognition of the injury and expeditious surgical repair. Rapid diagnosis can be difficult because of the variability of clinical signs from pure cardiac tamponade to hemorrhagic shock. In any patient with blunt chest trauma who presents with signs of pericardial tamponade, unexplained shock, or profuse thoracic hemorrhage, a rupture of one of the heart chambers should be suspected. It is hoped that by efficient transportation, rapid recognition, and aggressive treatment, this injury can more often be managed successfully. Addendum Since submission of this paper, another patient who had had a motor vehicle accident presented with profound shock, hemoperitoneum, and a central venous pressure of 32 cm. of water. Because of the previous experiences, the diagnosis of pericardial tamponade was rapidly made and the patient underwent immediate (within 15 minutes after admission) stemotomy and closure of a right atrial rupture. Although this immediately stabilized the patient's condition, he died later as the result of uncontrollable hemorrhage during hepatic lobectomy. REFERENCES 1 Parmley, L. F., Manion, W. C , and Mattingly, T. W.: Nonpenetrating Traumatic Injury of the Heart, Circulation 18: 371, 1958.
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2 Bright, E. F., and Beck, C. S.: Nonpenetrating Wounds of the Heart: A Clinical and Experimental Study, Am. Heart J. 10: 292, 1934. 3 Desforges, G., Ridder, W. P., and Lenoci, R. J.: Successful Suture of Ruptured Myocardium After Nonpenetrating Injury, N. Engl. J. Med. 252: 567, 1955. 4 Bogedain, W., Carpathios, I., Van Suu, D., and Moots, M. F.: Traumatic Ruptured Myocardium, J. A. M. A. 197: 1102, 1966. 5 Miller, G. E., and Rueb, A. E.: Blunt Thoracic Trauma Producing Heart Laceration, Ann. Surg. 166: 852, 1967. 6 Borja, A. R., and Lansing, A. M.: Traumatic Rupture of the Heart, Ann. Surg. 171: 438, 1970. 7 Noon, G. P., Boulafendis, D., and Beall, A. C : Rupture of the Heart Secondary to Blunt Trauma, J. Trauma 11: 122, 1971. 8 Siderys, H., and Strange, P. S.: Rupture of the Heart Due to Blunt Trauma, J. THORAC. CARDIOVASC. SURG. 62:
84, 1971. 9 O'Sullivan, M. J., Ir., Spagna, P. M., Bellinger, S. B., and Doohen, D. J.: Rupture of the Right Atrium Due to Blunt Trauma, J. Trauma 12: 208, 1972. 10 Trueblood, H. W., Wuerflein, R. D., and Angell, W. W.: Blunt Traumatic Rupture of the Heart, Ann. Surg. 177: 66, 1973. 11 Trinkle, J. K., Marcos, J., Grover, F. L., and Cuello, L. M.: Management of the Wounded Heart, Ann. Thorac. Surg. 17: 230, 1974. 12 Mattox, K. L., Beall, A. C , Jr., Jordan, G. L., and De Bakey, M. E.: Cardiorrhaphy in the Emergency Center, J. THORAC. CARDIOVASC. SURG. 68: 886,
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13 Liedtke, A. J., and DeMuth, W. E., Jr.: Nonpenetrating Cardiac Injuries: A Collective Review, Am. Heart J. 86: 687, 1973. 14 Sugg, W. L., Rea, W. J., Ecker, R. R., Webb, W. R., Rose, E. F., and Shaw, R. R.: Penetrating Wounds of the Heart: An Analysis of 459 Cases, J. THORAC. CARDIOVASC. SURG. 56: 531, 1968.