|Year : 2016 | Volume
| Issue : 1 | Page : 13-15
Cardiac Tamponade from Isolated Right Atrial Rupture: A Rare Presentation of Blunt Chest Trauma Without Rib Fracture
Ganesh Kumar K Ammannaya, Chaitanya Raut, Chandan Kumar Ray Mohapatra, Harsh Seth
Department of CVTS, Lokmanya Tilak Municipal Medical College and General Hospital, Sion West, Mumbai, Maharashtra, India
|Date of Web Publication||15-Nov-2016|
Ganesh Kumar K Ammannaya
Department of CVTS, Lokmanya Tilak Municipal Medical College and General Hospital, Sion West, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Cardiac tamponade resulting from blunt chest trauma is an emergent and life-threatening condition. Cardiac rupture from blunt chest trauma is not a common presentation, and more so in the absence of rib or sternal fracture. We present a case of blunt chest trauma, who presented with features of cardiac tamponade. Emergency sternotomy revealed a right atrial rupture near the appendage which was surgically repaired. The patient also underwent simultaneous splenectomy for Grade 4 splenic injury. The patient recovered uneventfully. Prompt recognition of the injury based on a high index of suspicion must lead to immediate surgical intervention in order for these patients to survive, even in the absence of specialized imaging investigations.
Keywords: Blunt cardiac injuries, cardiac tamponade, right atrial rupture
|How to cite this article:|
Ammannaya GK, Raut C, Ray Mohapatra CK, Seth H. Cardiac Tamponade from Isolated Right Atrial Rupture: A Rare Presentation of Blunt Chest Trauma Without Rib Fracture. J Cardiothorac Trauma 2016;1:13-5
|How to cite this URL:|
Ammannaya GK, Raut C, Ray Mohapatra CK, Seth H. Cardiac Tamponade from Isolated Right Atrial Rupture: A Rare Presentation of Blunt Chest Trauma Without Rib Fracture. J Cardiothorac Trauma [serial online] 2016 [cited 2020 May 31];1:13-5. Available from: http://www.jctt.org/text.asp?2016/1/1/13/194054
| Introduction|| |
Cardiac injuries were present in 16% of the patients in Glinz and Turina series, suffering from blunt chest trauma. Twenty-five percent of these cases had no concomitant rib fractures.  Blunt cardiac injury (BCI) can vary from completely asymptomatic cardiac contusions to cardiac wall lacerations with pericardial tamponade and high mortality. The most common pattern of blunt cardiac trauma is cardiac contusion. The majority of BCIs associated with laceration is caused by penetrating trauma while cardiac wall laceration from blunt trauma is a highly uncommon presentation. ,, As compared to penetrating cardiac injuries, few BCIs make it to the hospital alive. According to Kulshrestha et al., 2.2% of BCIs reached the hospital alive as compared to 33.7% of penetrating cardiac injuries. 
| Case Report|| |
We present the case of a 22-year-old unidentified male who brought to the emergency room (ER) with a history of road traffic accident without any external sign of chest injury. He was irritable and presented with hypotension (blood pressure - 80/56 mm Hg) and tachycardia (heart rate - 128/min). Central venous pressure (CVP) was found to be 20 cm of H 2 O. There was bilaterally equal air entry and heart sounds were muffled on auscultation. Chest radiograph was suggestive of widening of mediastinum [Figure 1]. Despite fluid resuscitation and noradrenaline administration, the patient continued to be hypotensive and CVP persisted to be high. Due to unavailability of ultrasonography (USG) and transthoracic echocardiography (TTE) in ER, the patient was immediately shifted to operation theater for emergency median sternotomy on the basis of clinical suspicion of cardiac tamponade.
Subxiphoid pericardial window confirmed the diagnosis of cardiac tamponade, following which a full median sternotomy was done immediately. Pericardiotomy revealed 250 ml of collected blood upon the evacuation, of which blood pressure showed an upward trend. A 10 mm × 5 mm laceration was noted in the right atrium close to the right atrial appendage [Figure 2]. The rent was successfully repaired by double layer of 5-0 polypropylene suture without cardiopulmonary bypass (CPB). Diagnostic peritoneal lavage was also done which showed hemoperitoneum and subsequent laparotomy revealed Grade 4 splenic injury. Splenectomy was performed for the same. The patient received 4 units of blood transfusion. Following surgery, the patient made an uneventful recovery and was discharged on day 14.
|Figure 2: Intraoperative image showing 10 mm × 5 mm cardiac rupture in the right atrium just below the right atrial appendage|
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| Discussion|| |
Unlike penetrating cardiac injuries in which the wound of entry is suggestive, BCIs often go missed.  The most common mode of BCI is attributed to motor vehicle accidents ,, and is associated with mortality rates ranging from 50% to 100%. ,, The first report of successful direct repair of right atrial rupture was published in 1955,  but to this day, successful surgical repair and survival of these patients remain uncommon. , A number of mechanisms have been hypothesized for BCI which include deceleration injury, compression of heart between the sternum and vertebral column, rib fractures, or transmission of venous pressure due to compression of abdomen or lower extremities. , The site of laceration depends on the phase of cardiac cycle when the blunt trauma occurred. As there was no external sign of blunt chest trauma, in this case, the likely mechanisms are transmitted venous pressure from blunt abdominal compression injury, compression of heart between the sternum and vertebral column and deceleration injury.
Cardiac rupture commonly presents with signs of cardiac tamponade,  i.e., clinical triad of hypotension, muffled heart sounds, and distended neck veins (the Beck triad) except when there is concomitant pericardial rent in which case presentation is of massive hemothorax. Associated exsanguinating injuries are known to mask the signs of tamponade. Electrocardiogram and cardiac enzymes are believed to have a role in ruling out cardiac injuries rather than confirming them in the acute setting. Although many reports describe radiographic findings of widened mediastinum and enlarged cardiac silhouette, radiography was found to be normal in many of the documented cases of tamponade in a National Trauma Data Bank study.  Almost all latest reviewed case reports and articles have reiterated the importance of focused assessment with sonography in trauma (FAST), TTE, and computed tomography in setting of suspected BCI which were not possible in this case. Ultrasound-guided pericardiocentesis shows its utility in being both diagnostic and a temporary therapeutic measure. According to Hirai et al., the color of blood aspirated on paracentesis gives a clue regarding the site of BCI.  Figueiredo et al. were able to diagnose tamponade in the absence of USG, on clinical suspicion, radiography and subxiphoid pericardial window as was done in this case. 
According to Brathwaite et al., the most common site of cardiac rupture is right atrium (40.6%), followed by right ventricle (31%), left atrium (25%), and finally left ventricle (12%).  Few autopsy studies have proved that right atrial appendage is thinner than right atrial wall, and hence, theoretically is more susceptible to rupture which is opposite to the observations in previous studies showing right atrial wall rupture to be more common than right atrial appendage rupture.
Subxiphoid pericardial window followed by median sternotomy is the preferred incision. Median sternotomy offers a good exposure to all chambers of the heart as well as to the great vessels, provides easy access for CPB, and can be easily extended into a laparotomy if the need arose. Pledgeted or nonpledgeted polypropylene suture repair has been preferred ,, in comparison to silk suture-repair. Postoperatively, evaluation for occult septal defects or valvular injuries has been recommended.
Timely diagnosis of BCI requires a very high index of clinical suspicion. Any patient presenting with chest trauma, signs of increased CVP, concomitant hypotension disproportionate to estimated blood loss or with an inadequate response to fluid administration and without a clear heart sound should be suspected of having cardiac wall laceration and pericardial tamponade. Prompt diagnosis and emergent surgical intervention is the only bet for survival in this subset of patients, with otherwise grave prognosis.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]