Blunt Force Thoracic Trauma- what to do?
A 36-year-old male helmeted patient was transferred from an outside hospital following a high speed motorcycle accident in which he collided with another vehicle. Prior to transfer, the patient had a reported GCS of 14, was hemodynamically stable, and had suffered multiple rib and lower extremity fractures. Upon arrival to our trauma center, he became unresponsive and tachycardic and had a blood pressure of 56/42. He was intubated and underwent bilateral chest tube placement and aggressive fluid resuscitation. Focused Assessment with Sonography in Trauma (FAST) scan showed no evidence of intra-abdominal injury, but chest X-ray was suggestive of a possible left pleural effusion. CT images ruled out intracranial injury and spinal injury but did indicate bilateral hemopneumothorax. Following improvement in hemodynamic status, the patient underwent orthopedic surgery to address trauma to the lower extremities; intervention included intramedullary rodding of an open femur fracture and repair of a quadriceps tendon laceration. He tolerated the procedures well.
@gul Traumatic pericardial rupture is an uncommon finding with literature review putting the incidence at 0.3% out of all trauma cases; 68% are attributed to motor vehicle accidents and occur on the left side 64% of the time. The reported survival rate for these injuries has been estimated to be as low as 24% and as high as 47%. Of the reported cases, 64% were fatal due to delayed diagnosis and the discovery of rupture and/or cardiac herniation was made at the time of autopsy. Diagnosis of a pericardial rupture and the subsequent cardiac deviation is difficult in the trauma setting and is generally discovered during either exploratory surgery or other interventions for a related disorder. Symptoms and characteristics that are helpful in the diagnosis of cardiac herniation include a characteristic splashing murmur called a “Bruit de Moulin,” a hypotension that is unresponsive to fluid or pharmacological treatment and tachycardia. The lethal aspect of cardiac herniation involves the torsion of the great vessels and subsequent loss of cardiac output.