Cardiac luxation is a rare but potentially fatal consequence of blunt thoracic trauma. We present a case of a pericardial tear with cardiac luxation following blunt chest trauma. It is hypothesised that the cardiac luxation occurred while log rolling the patient during the initial assessment. This report stresses the need to be aware of the potential for such a complication.
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A 21 year old man was brought by ambulance to the emergency department. He had been travelling by motorcycle at approximately 30 miles per hour when he was hit on the left side by a car.
On initial examination, the patient’s airway was intact, his cervical spine adequately immobilised, and his trachea central. He was breathing spontaneously, with good bilateral air entry. His oxygen saturation was 94% on 15 l/min of oxygen, pulse rate 120 beats/min, heart sounds normal, and blood pressure 110/60 with warm peripheries and no evidence of external haemorrhage. He responded well to 2 litres of intravenous crystalloid. His chest x ray (CXR) showed a right basal pulmonary contusion and a prominent right heart border. Other injuries found on examination were mild left upper quadrant abdominal tenderness, a poorly palpable left brachial pulse, reduced sensation and muscular paralysis in the left arm, and a slowly expanding haematoma at the base of the left anterior triangle of his neck.
During assessment, the patient was log rolled to the right, after which he became intermittently hypotensive, requiring further bolus fluid administration and 2 units of packed red cells. Reassessment of his chest revealed reduced air entry bilaterally with oxygen saturation of 90% on pulse oximetry. Bilateral needle thoracocenteses were performed followed by chest drain insertion, resulting in improvement in air entry and oxygen saturation, and yielding 100 millilitres of blood immediately from the left side.
A repeat CXR showed marked displacement of the cardiac silhouette to the right (fig 1). ECG showed ST segment elevation in the anterolateral and inferior leads. Transthoracic echocardiography demonstrated no abnormality, although the views obtained were suboptimum. This was suspected to be due to a possible anterior mediastinal haematoma.
The fluctuating blood pressure, cardiac silhouette displacement, poor cardiac views on echocardiography, neurovascular compromise of the left arm, and expanding haematoma at the base of his neck led us to consider the possibility of great vessel injury. The patient therefore underwent contrast enhanced CT scanning of his chest, neck, and abdomen. The scans revealed an anterior mediastinal haematoma, fractured left scapula, extensive bilateral lower lobe contusions, fracture of the transverse process of the sixth cervical vertebra, and a ruptured spleen with contained haematoma, but no abnormality of the great or subclavian vessels. The patient underwent laparotomy and splenectomy, and was subsequently transferred to the intensive care unit (ICU).
In ICU, his apex beat became increasingly visible on the right side of his chest with obvious mediastinal displacement on CXR. Initial cardiothoracic opinion suggested that this was caused by hyperinflation of the left lung with associated collapse of the right, and positional changes were advised. However, the mediastinal shift persisted despite repositioning the patient. A repeat echocardiogram (transoesophageal) on day 3 showed his heart had rotated 90° to the right. He returned to the operating theatre for an exploratory thoracotomy and was found to have a large pericardial tear extending from the superior vena cava to the inferior vena cava with cardiac luxation to the right. His heart was repositioned into the sac and the defect repaired with bovine pericardium. He made a good postoperative recovery and at review, 3 months postinjury, he was well, with normal cardiac position on a transthoracic ultrasound examination. His brachial plexus injury was improving with conservative management.
Pericardial rupture represents a rare but potentially fatal consequence of serious thoracic trauma.1,2 Cases of traumatic rupture may involve the diaphragmatic pericardium, pleuropericardium or both and can be right (36%) or left sided (64%).2 A pericardial tear 8–12 cm long is the most dangerous type of tear, as it exposes the heart to luxation and the luxated heart may then become incarcerated by the edges of the pericardial tear, leading to sudden deterioration.3
The diagnosis of acute pericardial rupture is generally very difficult,1 and is rarely made preoperatively.4 It is suggested intraoperatively by ongoing cardiovascular instability after repair of abdominal or other injuries. Some diagnostic clues have been described, such as absent heart sounds, an abnormal ECG pattern, pericardial tamponade,3 or a characteristic murmur described by Morel-Lavallee in 1864,5bruit de Moulin, which is thought to occur as a result of a haemopneumopericardium.
There has also been a report of a case presenting almost 3 weeks after the precipitating injury.6 This patient had a pelvic fracture requiring him to lie supine for 2 weeks. When he was first allowed to sit up, he developed sudden chest pain, which was subsequently proven to be due to herniation of the heart through the pleuropericardium.
Radiologically, rupture can be suggested by a pneumopericardium or pericardial effusion. The heart may be displaced or simply enlarged.7 Angiography may be used to study an abnormal mediastinum and is more often diagnostic when pericardial rupture is associated with cardiac luxation than without.2,8,9 In the presence of diaphragmatic pericardial tears, computed tomography may further aid in diagnosis by identification of any abnormal gas distribution or organ positioning caused by herniation of viscera that contains air into the pericardium.
Our case involved a patient with a right sided pleuropericardial tear. We believe that our patient sustained a pericardial tear as a consequence of blunt thoracic trauma and that he subsequently developed cardiac luxation during a log roll to the right side. This is supported by the change in cardiac silhouette on CXR and his fluctuating haemodynamic profile following the log roll. Intermittent luxation with associated hypotension has been described previously,10 but not as a consequence of a log roll.
Our case highlights the need to have a high index of suspicion of pericardial rupture with cardiac luxation in patients with blunt chest trauma whose haemodynamic status deteriorates following a log roll.
Competing interests: none declared
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