A 33-year-old patient was hospitalized after a blunt chest trauma with a left flail chest. Six hours after admission to the intensive care unit the patient suddenly developed hypotension and tachycardia. His left chest tube drained 1.5 l of blood within minutes. Immediate resuscitation and emergency sternotomy with left anterolateral extension was performed for pericardial tamponade secondary to left ventricular perforation due to a sharp rib fragment. Outcome was favourable and the patient was operated on for his flail chest by internal stabilization the next da

Kipfer, Beat

Roth, Thierry

Schmid, Ralph A.

Takala, Jukka

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Case reportDelayed heart perforation after blunt traumaThierry Rotha, Beat Kipferb, Jukka Takalac, Ralph A. Schmida,*aDivision of General Thoracic Surgery, University Hospital, 3010 Berne, SwitzerlandbDivision of Cardiovascular Surgery, University Hospital, Berne, SwitzerlandcDivision of Intensive Care Medicine, University Hospital, Berne, SwitzerlandReceived 30 April 2001; received in revised form 21 September 2001; accepted 14 October 2001AbstractA 33-year-old patient was hospitalized after a blunt chest trauma with a left flail chest. Six hours after admission to the intensive care unitthe patient suddenly developed hypotension and tachycardia. His left chest tube drained 1.5 l of blood within minutes. Immediate resuscita-tion and emergency sternotomy with left anterolateral extension was performed for pericardial tamponade secondary to left ventricularperforation due to a sharp rib fragment. Outcome was favourable and the patient was operated on for his flail chest by internal stabilizationthe next day. q 2002 Elsevier Science B.V. All rights reserved.Keywords: Heart perforation; Ventricle laceration; Lung perforation; Blunt chest trauma; Flail chest1. IntroductionTraumatic injuries, following cardiovascular disease andcancer, are the third most common cause of death in occi-dental countries. In the United States approximately 90 000accidental deaths and 9 million disabling injuries arecommitted annually, and 75% of the casualties from blunttrauma are due to chest injuries [1].2. Case reportA 33-year-old man was referred from a regional hospitalto our centre after a blunt chest trauma. At work, he wascrushed between a tractor and a tree. He complained of leftthoracic pain without dyspnea. The chest X-ray disclosedmultiple rib fractures from the fourth to the eighth rib on theleft side, with subcutaneous emphysema (Fig. 1a). Thepatient’s previous medical history was uneventful. Onadmission, 3 h after the accident, he was conscious andstable with arterial blood pressure of 150/90 mmHg andheart rate of 109/min, saturation was 94% with 6 l/minoxygen. Clinically a paradoxal motion of the left chestwall could be observed. Blood analysis showed a hyperleu-cocytosis of 20.8 g/l, creatine kinase elevation of 861 IU/lbut troponin , 0:6 mg/l. A left lateral chest tube was imme-diately inserted which drained 150 ml blood. A computedtomography (CT) scan of the thorax and abdomen wasperformed confirming a left haemothorax and the rib frac-tures which were moderately displaced. In addition, adiffuse contralateral lung contusion was present (Fig. 2).An antibiotic prophylaxis with amoxicillin/clavulanic acidwas initiated. The operative indication for flail chest stabi-lization was considered and planned for the next day. Aperidural analgesia (with bupivacaine 1 mg/ml, fentanyl 2mg/ml and adrenaline 2 mg/ml) was initiated and the patientwas transferred to the intensive care unit (ICU) with mini-mal chest pain. Six hours after admission, he turned in hisbed and immediately complained of transfixiant chest pain,the arterial blood pressure fell abruptly to non-measurablelevels, and the chest tube drained 1500 ml blood withinminutes. Immediate resuscitation with volume perfusion,vasoactive drugs (adrenaline) i.v., intubation and heartmassage was instituted while the patient was transferredto the adjacent operative room. An emergency sternotomywith left anterolateral extension (hemi-clamshell) wasperformed. After drainage of a pericardial blood tamponade,systemic blood pressure rose immediately. A left ventricularperforation of 15 mm length close to the apex was quicklydiscovered and controlled by finger pressure, then closedwith non-absorbable monofilament suture reinforced byTeflon felt. The pericardium was partially closed. A lungperforation of the lingula with air leak was resected using anendo-GIA 45-mm stapler. Two sharp, distal, rib fragmentswere removed, including the one responsible for the heartperforation. A pericardial tube and two thoracic tubes wereEuropean Journal of Cardio-thoracic Surgery 21 (2002) 121–1231010-7940/02/$ - see front matter q 2002 Elsevier Science B.V. All rights reserved.PII: S1010-7940(01)01054-5www.elsevier.com/locate/ejcts* Corresponding author. Tel.:141-31-632-2330; fax:141-31-632-2327.E-mail address: ralph.schmid@insel.ch (R.A. Schmid).inserted. After completion of surgery the patient washaemodynamically stable, after receiving 11 blood concen-trates, 6 fresh frozen plasmas and 4000 ml colloid.On the next day the patient showed no neurological defi-cit and was operated on as planned for his left flail cheststabilization, with reconstruction plates and 4.0-mm cancel-lous screws. The patient did not develop any post-operativerespiratory failure and was immediately extubated. Thepost-operative chest X-ray disclosed no relevant findings(Fig. 1b), and post-operative echocardiography demon-strated good left ventricle function (ejection fraction 70%)with slight pericardial effusion. After removal of chestdrains, the patient was discharged from hospital on the12th post-operative day.3. DiscussionRib fractures occur frequently after any chest trauma andare also often disclosed after some abdominal or pelvicmajor trauma. Surgical treatment is usually not required,merely good analgesia to avoid any occurrence of lungatelectasis or pneumonia. Flail chest with paradoxal respira-tion or thoracic deformity may be considered for an opera-tive rib stabilization.Heart perforation occurs very exceptionally after bluntchest trauma. In most cases it results from penetrating inju-ries such as stab wound (69%), gun shot (26%) or others(5%), but less than 20% of the injured patients reach thehospital alive [1]. Most frequently the right ventricle ispenetrated (46%), followed by the left ventricle (30%) andthe right atrium (11%). Heart perforation by rib fragmentsoccur in general immediately after the injury, are fatal inmost cases, and are hence not documented. Secondary heartperforation should not be misdiagnosed with secondarycardiac rupture (right atrium 41%, right ventricle 31%,left atrium 25% and left ventricle 9%) after heart contusion,which is also a relatively uncommon complication (0.3%),with a consecutive mortality rate as high as 80% [2]. In theliterature, heart perforation due to a fractured rib after bluntchest trauma has been reported in only four patients [3–5].All of these were caused by motor vehicle accidents. Onlyone patient was haemodynamically stable prior to surgery.These four heart injuries happened with a delay of 3 h to 15days after the accident. It seems, however, that secondaryperforation with haemodynamically unstable patientsoccurs within the first 24 h (3, 4 and in our case, 6 h). Inthree cases the left ventricle, and in one case the right ventri-cle, was injured.A CT scan of the chest is usually performed in the case offlail chest to demonstrate the chest deformity and the poten-tial underlying visceral lesions [3], but secondary perfora-T. Roth et al. / European Journal of Cardio-thoracic Surgery 21 (2002) 121–123122Fig. 1. Chest X-ray on admission (a) and after operative internal fixationwith removal of the chest tubes (b).Fig. 2. CT of the thorax on admission with the rib fractures and the chest-wall deformity.tion cannot be definitively precluded by this examination.Only two of the four patients reported in the literaturesurvived after secondary heart lesion [4,5]. This mechanismof heart perforation after blunt trauma should be known,because emergency surgery is life-saving in this condition.This case demonstrates the potentially fatal complica-tions which may occur in patients after major chest trauma,particularly with flail chest, even if they have been initiallyhaemodynamically stable. This should be considered inpost-traumatic care of patients after blunt chest trauma.Therefore we suggest an observation on ICU-setting for24 h in a centre with cardiothoracic surgery abilities.Early internal rib stabilization of left flail chest mightprevent the occurrence of secondary heart perforation.References[1] Calhoon JH, Grover FL, Trinkle JK. Chest trauma, approach andmanagement. Clin Chest Med 1992;13:55–67.[2] Brathwaite CE, Rodriguez A, Turney SZ, Dunham CM, Cowley R.Blunt traumatic cardiac rupture: a 5-year experience. Ann Surg1990;212:701–704.[3] Galvin IF, Costa R, Murton M. Fractured rib with penetrating cardio-pulmonary injury. Ann Thorac Surg 1993;56(3):558–559.[4] Glock Y, Roux D, Dalous P, Puel P. Left ventricular perforation by ribfracture after closed chest injury. A propos of 2 cases. Ann Chir1986;40(2):98–101.[5] Bourguignon N, Godier S, Genevois A, Kaeffer N, Dureuil B. Heartinjury following closed thoracic injury. Ann Fr Anesth Reanim1996;15(7):1088–1089.T. Roth et al. / European Journal of Cardio-thoracic Surgery 21 (2002) 121–123 123

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