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Luxatio cordis—surgical treatment followed by venovenous extracorporal membrane oxygenation
American Journal of Emergency Medicine 33 (2015) 1109.e1–1109.e2
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Luxatio cordis—surgical treatment followed by venovenous extracorporal membrane oxygenation
We report about a 54-year-old male patient who was involved in a motorcycle accident. On day 15 after trauma, a tension pneumothorax was suspected based on radiography because of the right-side shift of the heart. A computer tomographic scan detected a pneumothorax on the left side and pneumopericardium. A chest drain was inserted on the left side. The postinterventional radiograph showed a further dislocation of the heart to the right side. The diagnosis of luxatio cordis was suspected. The patient was taken into the operating theater in a hemodynamic stable state. Severe pericardial rupture was diagnosed intraoperatively, and bovine pericardial patch plastic reconstruction was performed. Because of systemic inflammatory response syndrome, degrading gas exchange, and the impossibility of providing protective ventilation 24 hours after surgery, venovenous extracorporal membrane oxygenation (ECMO) was indicated. venovenous ECMO was continued for 7 days. Eighteen days after removing the ECMO cannulas, the spine was stabilized using internal fixation. After 8 months of rehabilitation, he was able to move his legs and is still in the spine cord injury rehabilitation program. We report about a 54-year-old male patient who was involved in a motorcycle accident. At the accident site, cardiopulmonary resuscitation was necessary, and the patient was transferred to the nearest hospital for a primary survey. Computer tomographic (CT) scans showed instable fractures of the second and third thoracic vertebrae, a transection of the myelin down to thoracic vertebrae 2, serial rib fractures on the right and left side accompanied with a hemothorax on the left side, and a femur fracture in the left limb. The patient presented with hemoglobin levels of 5.4 mmol/L and a troponin T level of 94 ng/L (reference norm b0.04 ng/L). Vasopressors were needed up to 6 days posttrauma. The femur fracture was treated with a T2 retrograde nail. When presented for a secondary survey to our level 1 trauma center, antibiotic therapy was started (penicillin/tazobactam) due to ventilation-associated pneumonia. A dilative tracheotomy was performed. While weaning, a pendular breathing pattern was detected. We suspected functional tetraplegia. On day 15 posttrauma, a tension pneumothorax was suspected based on radiography because of the right side shift of the heart (Fig. 1). A CT scan detected a pneumothorax on the left side and pneumopericardium. A chest drain was inserted on the left side. The postinterventional radiograph showed a further dislocation of the heart to the right side. The diagnosis of luxatio cordis was suspected. The patient was taken into the operating theater in a hemodynamic
0735-6757/© 2015 Elsevier Inc. All rights reserved.
stable state. Severe pericardial rupture was diagnosed intraoperatively and bovine pericardial patch plastic reconstruction (9 × 14 cm) was performed (Table). Because of systemic inflammatory response syndrome, high-dose vasopressors were needed postoperatively. There were no pathological signs either in transesophageal echocardiography or in thoracic CT scans. Because of the degrading gas exchange and the impossibility of providing protective ventilation 24 hours after surgery, venovenous extracorporal membrane oxygenation (v.v. ECMO) was indicated. A few hours later, cardiopulmonary resuscitation was necessary. Venovenous ECMO was continued for 7 days. After decannulation, the patient remained stable. Eighteen days after removing the ECMO cannulas, the spine was stabilized using internal fixation. Nevertheless, the patient showed a prolonged period of awakening and weaning from the ventilator, but was eventually successfully transferred to the rehabilitation facility with a portable ventilator. After 8 months of rehabilitation, he was able to move his legs and is still in the spine cord injury rehabilitation program. Despite his severe trauma, our patient was stabilized in a normal time span until the mediastinal shift occurred. The treatment of this condition led to a severe and unexpected aggravation postoperatively, which we were able to treat by v.v. ECMO. The recovery after spinal surgery was without complications. The treatment was successful; however, luxatio cordis should have been suspected in the first chest x-ray at the time of the primary survey (Fig. 2). In this case of luxatio cordis, the injury was found with delay while treating adjourning injuries surgically as an incidental finding in a stable patient. There is one case in the literature where pericardial rupture presented 3 weeks after trauma and was detected via video-assisted thoracoscopy, but in this case, the patient was mobilized for the first time after trauma [1,2]. The ventilation of our patient with positive end-expiratory pressure of 8 mm H2O and higher might have prevented the heart from shifting [3]. Furthermore, he needed a longer time to adapt to the stabilized position of the heart and pericardium compared with earlier detected cases [3,4]. With this rare and potentially lethal disease [4,5], our patient was stabilized using v.v. ECMO. We compared our scans with thorax scans of the patient while healthy, where a slightly to-the-right transferred mediastinum was observed. This, as well as the whole body CT scan, ruled out a situs inversus and a cor mobile. The surgical technique (patch plastic) is typical for pericardial rupture [3]. As potential causes for the prolonged regeneration, we suspect the adjourning injuries to be the cause as well as an extended period before the diagnosis was made.
1109.e2
F. Rademacher et al. / American Journal of Emergency Medicine 33 (2015) 1109.e1–1109.e2
Fig. 1. Chest x-ray: tension pneumothorax was suspected because of the right-side shift of the heart.
Table Timeline of the course Day posttrauma
Intervention
0 0 4 8 9 15 15 15 16 23 41
Admitted to a primary hospital Left thoracic drain Osteosynthesis of the femur via a T2 nail Transfer to our facility Percutaneous tracheostomy Bilateral thoracic drain Diagnosis of luxatio cordis Sternotomy and pericardial patch plastic Cannulation for v.v. ECMO ECMO removal Stabilization of the spine
F. Rademacher Department of Surgery, BG University Hospital Bergmannsheil, Bochum, Germany J. Reichert Department of Cardiac and Thoracic Surgery BG University Hospital Bergmannsheil, Bochum, Germany
Fig. 2. Retrospectively, the abnormality (luxatio cordis) should have been suspected in the first chest x-ray at the time of the primary survey.
T.A. Schildhauer, MD J. Swol Department of Surgery, BG University Hospital Bergmannsheil, Bochum, Germany ⁎ Corresponding author. University Hospital Bergmannsheil Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany Tel.:+49 234 302 3604; fax: +49 234 302 6880. E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.01.008 References [1] Thomas P, Saux P, Lonjon T, Viggiano M, Denis JP, Giudicelli R, et al. Diagnosis by video-assisted thoracoscopie of traumatic pericardial rupture with delayed luxation of the heart: case report. J Trauma 1995;38:967–70. [2] Levine AJ, Collins FJ. Blunt traumatic pericardial rupture. J Accid Emerg Med 1995;12: 55. [3] Fulda G, Rodriguez A, Turney SZ, Cowley RA. Blunt traumatic pericardial rupture. A ten year experience 1979-1989. J Cardiovasc Surg (Torino) 1990;31:525–30. [4] Kerins M, Maguire E, Lacy C. Cardiac luxation: an unusual complication of a log roll. Emerg Med J 2005;22:913–5. [5] Galindo Gallego M, Lopez-Cambra MJ, Fernandez-Acenero MJ, Alvarez Perez TL, Tadeo Ruiz G, Vazquez Santos P, et al. Traumatic rupture of the pericardium. Case report and literature review. J Cardiovasc Surg (Torino) 1996;37:187–91.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Luxatio cordis—surgical treatment followed by venovenous extracorporal membrane oxygenation
We report about a 54-year-old male patient who was involved in a motorcycle accident. On day 15 after trauma, a tension pneumothorax was suspected based on radiography because of the right-side shift of the heart. A computer tomographic scan detected a pneumothorax on the left side and pneumopericardium. A chest drain was inserted on the left side. The postinterventional radiograph showed a further dislocation of the heart to the right side. The diagnosis of luxatio cordis was suspected. The patient was taken into the operating theater in a hemodynamic stable state. Severe pericardial rupture was diagnosed intraoperatively, and bovine pericardial patch plastic reconstruction was performed. Because of systemic inflammatory response syndrome, degrading gas exchange, and the impossibility of providing protective ventilation 24 hours after surgery, venovenous extracorporal membrane oxygenation (ECMO) was indicated. venovenous ECMO was continued for 7 days. Eighteen days after removing the ECMO cannulas, the spine was stabilized using internal fixation. After 8 months of rehabilitation, he was able to move his legs and is still in the spine cord injury rehabilitation program. We report about a 54-year-old male patient who was involved in a motorcycle accident. At the accident site, cardiopulmonary resuscitation was necessary, and the patient was transferred to the nearest hospital for a primary survey. Computer tomographic (CT) scans showed instable fractures of the second and third thoracic vertebrae, a transection of the myelin down to thoracic vertebrae 2, serial rib fractures on the right and left side accompanied with a hemothorax on the left side, and a femur fracture in the left limb. The patient presented with hemoglobin levels of 5.4 mmol/L and a troponin T level of 94 ng/L (reference norm b0.04 ng/L). Vasopressors were needed up to 6 days posttrauma. The femur fracture was treated with a T2 retrograde nail. When presented for a secondary survey to our level 1 trauma center, antibiotic therapy was started (penicillin/tazobactam) due to ventilation-associated pneumonia. A dilative tracheotomy was performed. While weaning, a pendular breathing pattern was detected. We suspected functional tetraplegia. On day 15 posttrauma, a tension pneumothorax was suspected based on radiography because of the right side shift of the heart (Fig. 1). A CT scan detected a pneumothorax on the left side and pneumopericardium. A chest drain was inserted on the left side. The postinterventional radiograph showed a further dislocation of the heart to the right side. The diagnosis of luxatio cordis was suspected. The patient was taken into the operating theater in a hemodynamic
0735-6757/© 2015 Elsevier Inc. All rights reserved.
stable state. Severe pericardial rupture was diagnosed intraoperatively and bovine pericardial patch plastic reconstruction (9 × 14 cm) was performed (Table). Because of systemic inflammatory response syndrome, high-dose vasopressors were needed postoperatively. There were no pathological signs either in transesophageal echocardiography or in thoracic CT scans. Because of the degrading gas exchange and the impossibility of providing protective ventilation 24 hours after surgery, venovenous extracorporal membrane oxygenation (v.v. ECMO) was indicated. A few hours later, cardiopulmonary resuscitation was necessary. Venovenous ECMO was continued for 7 days. After decannulation, the patient remained stable. Eighteen days after removing the ECMO cannulas, the spine was stabilized using internal fixation. Nevertheless, the patient showed a prolonged period of awakening and weaning from the ventilator, but was eventually successfully transferred to the rehabilitation facility with a portable ventilator. After 8 months of rehabilitation, he was able to move his legs and is still in the spine cord injury rehabilitation program. Despite his severe trauma, our patient was stabilized in a normal time span until the mediastinal shift occurred. The treatment of this condition led to a severe and unexpected aggravation postoperatively, which we were able to treat by v.v. ECMO. The recovery after spinal surgery was without complications. The treatment was successful; however, luxatio cordis should have been suspected in the first chest x-ray at the time of the primary survey (Fig. 2). In this case of luxatio cordis, the injury was found with delay while treating adjourning injuries surgically as an incidental finding in a stable patient. There is one case in the literature where pericardial rupture presented 3 weeks after trauma and was detected via video-assisted thoracoscopy, but in this case, the patient was mobilized for the first time after trauma [1,2]. The ventilation of our patient with positive end-expiratory pressure of 8 mm H2O and higher might have prevented the heart from shifting [3]. Furthermore, he needed a longer time to adapt to the stabilized position of the heart and pericardium compared with earlier detected cases [3,4]. With this rare and potentially lethal disease [4,5], our patient was stabilized using v.v. ECMO. We compared our scans with thorax scans of the patient while healthy, where a slightly to-the-right transferred mediastinum was observed. This, as well as the whole body CT scan, ruled out a situs inversus and a cor mobile. The surgical technique (patch plastic) is typical for pericardial rupture [3]. As potential causes for the prolonged regeneration, we suspect the adjourning injuries to be the cause as well as an extended period before the diagnosis was made.
1109.e2
F. Rademacher et al. / American Journal of Emergency Medicine 33 (2015) 1109.e1–1109.e2
Fig. 1. Chest x-ray: tension pneumothorax was suspected because of the right-side shift of the heart.
Table Timeline of the course Day posttrauma
Intervention
0 0 4 8 9 15 15 15 16 23 41
Admitted to a primary hospital Left thoracic drain Osteosynthesis of the femur via a T2 nail Transfer to our facility Percutaneous tracheostomy Bilateral thoracic drain Diagnosis of luxatio cordis Sternotomy and pericardial patch plastic Cannulation for v.v. ECMO ECMO removal Stabilization of the spine
F. Rademacher Department of Surgery, BG University Hospital Bergmannsheil, Bochum, Germany J. Reichert Department of Cardiac and Thoracic Surgery BG University Hospital Bergmannsheil, Bochum, Germany
Fig. 2. Retrospectively, the abnormality (luxatio cordis) should have been suspected in the first chest x-ray at the time of the primary survey.
T.A. Schildhauer, MD J. Swol Department of Surgery, BG University Hospital Bergmannsheil, Bochum, Germany ⁎ Corresponding author. University Hospital Bergmannsheil Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany Tel.:+49 234 302 3604; fax: +49 234 302 6880. E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.01.008 References [1] Thomas P, Saux P, Lonjon T, Viggiano M, Denis JP, Giudicelli R, et al. Diagnosis by video-assisted thoracoscopie of traumatic pericardial rupture with delayed luxation of the heart: case report. J Trauma 1995;38:967–70. [2] Levine AJ, Collins FJ. Blunt traumatic pericardial rupture. J Accid Emerg Med 1995;12: 55. [3] Fulda G, Rodriguez A, Turney SZ, Cowley RA. Blunt traumatic pericardial rupture. A ten year experience 1979-1989. J Cardiovasc Surg (Torino) 1990;31:525–30. [4] Kerins M, Maguire E, Lacy C. Cardiac luxation: an unusual complication of a log roll. Emerg Med J 2005;22:913–5. [5] Galindo Gallego M, Lopez-Cambra MJ, Fernandez-Acenero MJ, Alvarez Perez TL, Tadeo Ruiz G, Vazquez Santos P, et al. Traumatic rupture of the pericardium. Case report and literature review. J Cardiovasc Surg (Torino) 1996;37:187–91.