Cardiac and Great Vessel Injuries in Children following Blunt Trauma: An Institutional ReviewCardiac and Great Vessel Injuries in Children following Blunt Trauma: An Institutional ReviewTiao GM, Griffith PM, Szmuszkovicz JR*, Mahour GH. The Division of Pediatric Surgery and Cardiology*, Tiao GM, Griffith PM, Szmuszkovicz JR*, Mahour GH. The Division of Pediatric Surgery and Cardiology*,

Childrens Hospital of Los Angeles and the University of Southern California – Keck School of Medicine, Los Angeles, CaliforniaChildrens Hospital of Los Angeles and the University of Southern California – Keck School of Medicine, Los Angeles, California

The purpose of this study was to review the incidence of cardiac and great vessel injury following blunt trauma in children at a single institution. Method: A retrospective review from the trauma registry encompassing 2744 patients with injuries from blunt mechanisms was performed.

Results: Eleven patients sustained cardiac injury. Four patients had clinically evident cardiac contusions. All recovered uneventfully. Another four patients who died from CNS injury were found to have cardiac contusions on autopsy but none had clinical evidence of contusion. One patient had a traumatic ventricular septal defect (VSD) that required operative repair. Autopsy demonstrated an unsuspected VSD in another patient. A third patient was diagnosed with a ventricular septal aneurysm that was treated medically. Two patients had great vessel injuries. One patient had a contained disruption of the superior vena cava that was managed non-operatively and another patient had a mid-thoracic periaortic hematoma without intimal disruption found at autopsy. One patient had both cardiac and great vessel injuries. Discrete aneurysms of two coronary artery septal branches and a pulmonary outflow tract aneurysm were identified by cardiac catheterization. The patient was treated non-operatively without complications.

Conclusions: Cardiac and great vessel injury following blunt trauma is uncommon in children. Cardiac contusion is the most common injury encountered but had minimal clinical significance. Non-contusion cardiac injury is rare but may require surgical intervention. No patient with aortic transection was identified in our review.

PatientClinical

ManifestationECHO Clinical Course

1 Arrhythmia Normal Unremarkable

2 Arrhythmia Normal Unremarkable

3 ArrhythmiaDilated left ventricle

Transient use of antiarrhythmic

medication

4Unexplained hypotension

Wall motion abnormalities

Transient use of inotropic medication

CARDIAC CONTUSIONS

4 cardiac contusions found at autopsy – no clinical manifestations of arrhythmia or hypotension

PatientClinical

ManifestationECHO Clinical Course

1 Arrhythmia Normal Unremarkable

2 Arrhythmia Normal Unremarkable

3 ArrhythmiaDilated left ventricle

Transient use of antiarrhythmic

medication

4Unexplained hypotension

Wall motion abnormalities

Transient use of inotropic medication

CARDIAC CONTUSIONS

4 cardiac contusions found at autopsy – no clinical manifestations of arrhythmia or hypotension

Cardiac and great vessel injury following blunt trauma can have significant morbidity and potential mortality. The spectrum of blunt cardiac injury ranges from myocardial contusion to anatomic disruption such as valve dysfunction or myocardial rupture. In the adult population, blunt cardiac injury was once considered the most under-diagnosed traumatic injury. A recent review suggests the incidence of cardiac trauma to be as high as 20% following blunt chest trauma.

The incidence of great vessel injury following blunt trauma in the adult population has been estimated to be as high as 15%. Aortic transection is the most common great vessel injury. Injuries to other great vessels including the pulmonary and innominate arteries have been reported in the literature. Most individuals who sustain aortic injury expire at the incident scene; however, with improved emergency medical services it is possible that more patients with this injury may reach medical attention. As a result, there has been heightened awareness of great vessel injury.

In the pediatric age group, the incidence of cardiac and great vessel injury following blunt trauma has not been clearly established. Several recent series report a low incidence. In contrast, a study that reviewed the post-mortem examination results of children who expired because of traumatic causes found a 15% incidence of cardiac injury. The purpose of the present study was to determine the incidence of blunt cardiac and great vessel injury at a single institution and to review the method of diagnosis and the subsequent clinical course of these patients.

A retrospective review of the trauma registry at Childrens Hospital of Los Angeles from 1992-1998 was performed

There were 2744 blunt trauma victims enrolled in the registry:

• 1409 admissions - 486 to the intensive care unit• 87 patients expired, 66 post-mortem exams

were available for review

14 patients with cardiac or great vessel injury:• 9 patient’s cardiac or great vessel injury were

identified clinically• 5 patient’s injuries were identified at autopsy

The 14 patient’s charts were analyzed for the mechanism of injury, the type of injury, the clinical course and the subsequent outcome.

Fourteen patients with injuriesEleven patients sustained cardiac injury

Eight cardiac contusions (Table)1 ventricular septal defect and ventricular aneurysm (case 1)1 ventricular septal aneurysm (case 2)1 ventricular septal defect (case 3)

Two patients had great vessel injury (Table)1 superior vena cava intimal disruption1 periaortic hematoma with intact intima

One patient had a combined great vessel & cardiac injury

Coronary artery and pulmonary outflow tract aneurysm (case )

Incidence among admissionsCardiac injury 0.4%Great vessel injury 0.2%

Incidence of concomitant organ injury - 93%CNS injuries (10 out of 14) Intra-abdominal solid organ injury (4 out of 14)Pulmonary contusion (3 out of 14) Extremity fracture (1 out of 14)

Mortality - 42% (6 deaths)CNS injury was the cause of death in five of the six patients 83.3% One patient expired due to an anatomic cardiac injury

• Cardiac and great vessel injury following blunt trauma is uncommon in children

• Cardiac contusion is the most common injury encountered but had minimal clinical significance

• Non-contusion cardiac injury is rare but may require surgical intervention

• No patient with aortic transection was identified in our review

1. Moront ML, Williams JA, Eichelberger MR. The injured child: an approach to care. Ped Clin North Am. 1994, 41:1201.2. Spellman JR. cited by Leidtke AJ, Demuth WF. Nonpenetrating cardiac injury: A collective review. Am Heart J 1973, 86:687-697.3. Pretre R, Chilcott M. Current concepts: Blunt trauma to the heart and great vessels. NEJM, 1997, 336(9): 626-632.4. Hawkins ML, Carraway RP, Ross SE et al. Pulmonary artery disruption from blunt thoracic trauma. Am Surg, 1988, 54:148-53.5. Bliss DW, Newth CJL, Stein JE. Blunt traumatic injury to the coronary arteries and pulmonary artery in a child. J Trauma, in press.6. Doan E, Gorton ME. Traumatic disruption of the innominate and right pulmonary arteries: case report. J Trauma, 1997, 43:701-2.7. Dowd M, Krug S. Pediatric Blunt Cardiac Injury: Epidemiology, clinical features and Diagnosis. J Trauma: Injury, Infection and Critical Care. 1996, 40:61-67.8. Bromberg B, Mazziotti M, Canter C et al. Recognition and management of nonpenetrating cardiac trauma in children. J Pediatr 1996, 128:536-41.9. Scorpio R, Wesson D, Smith C et al. Blunt cardiac injuries in children: a postmortem study. J Trauma: Injury, Infection and Critical Care. 1996, 41:306309.10. Mozzetti M, Devin J, Susselman M et al. A pediatric survivor of left ventricular rupture after blunt chest trauma. Ann of Emerg Med, 1990, 19:386-389.11. Moront M, Lefrak E and Bechara A. Traumatic rupture of the interventricular septum and tricuspid valve: a case report. J Trauma, 1991, 31:143-136.12. Dougherty J, Gabram S, Glickstein M et al. Traumatic intramyocardial dissection secondary to significant blunt chest trauma: a case report. J Trauma, 1993, 34:300-302.13. Bintz M, Gall W, Boyd W. Blunt cardiac valve trauma: report of an unusual case and review of the literature. Contemporary Surg, 1988, 32:93-96.14. Ildstad S, Tollerud D, Weiss R et al. Cardiac contusion in pediatric patients with blunt thoracic trauma. J Ped Surg, 1990, 25:287-289.15. Kato K, Kushimoto S, Mashiko K et al. Blunt traumatic rupture of the heart: an experience in Tokyo. J Trauma, 1994, 36:859-64.16. Tellez D, Hardin W, Masato T et al. Blunt cardiac injury in children. J Ped Surg, 1987, 22:1123-1128.17. Gunnar W, Martin M, Smith R et al. The utility of cardiac evaluation in the hemodynamically stable patient with suspected myocardial contusion. American Surgeon, 1991, 373-377.18. Pearson G, Karr S, Trachiotis G et al. A retrospective review of the role of transesophageal echocardiography in aortic and cardiac trauma in a level I pediatric trauma center. J Am Soc Echocardiogr, 1997, 10:949-955.19. Eddy C, Rusch VW, Flingner CL et al. The epidemiology of traumatic rupture of the thoracic aorta in children: a 13-year review. J Trauma, 1990, 30:989-992.

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Case 3 -- A 4-year old male was found trapped beneath a 70lb barbell. The patient had arrested. Vital signs were restored at the scene with endotracheal intubation and resuscitation with intravenous fluid. En route to the hospital, the patient’s vital signs were lost. Despite maximal intervention in the emergency room including bilateral tube thoracostomy and pericardiocentesis, the patient expired. Post-mortem examination revealed a 4.5cm laceration of the intra-ventricular septum.

Case 1 – A 3-year old male was struck by an automobile. He sustained a pulmonary contusion and a grade II liver laceration. He was noted to have a Grade IV/VI systolic murmur on physical exam. An ECHO demonstrated a ventricular septal defect (VSD). Initially, it was unclear if this was a traumatic or a congenital abnormality. He was admitted to the ICU where he developed adult respiratory distress syndrome (ARDS) and congestive heart failure. Repeat ECHO showed the VSD and a ventricular aneurysm (figure 1).

Case 2 – An 11-year old female was involved in an auto versus pedestrian accident where she was struck and thrown 15 feet. A head CT scan demonstrated a cerebral contusion resulting in an admission to the pediatric intensive care. An abdominal CT scan was normal. Unexplained persistent hypotension in the ICU despite stable hemoglobin levels prompted an ECHO that demonstrated a dyskinetic intraventricular septum, a ventricular septal aneurysm and a shortening fraction of 14% (figure 3). The patient required inotropic support for 72 hours when her hypotension resolved. Follow-up ECHO post-discharge demonstrated complete resolution of her cardiac abnormalities

The patient underwent surgical intervention where a traumatic VSD was repaired and the aneurysm was resected. The patient recovered post-operatively and was discharged home. Subsequent follow-up identified a recurrence of the aneurysm by ECHO, which was confirmed by cardiac catheterization (figure 2). One-year post-initial injury, the recurrent aneurysm was resected. He recovered post-operatively and at follow-up has demonstrated no new abnormalities.

Case - A 5-year old female was a restrained passenger in a high-speed motor vehicle accident (5). She sustained a cerebral contusion, bilateral first rib fractures, a pulmonary contusion, a grade IV liver laceration and a pubic rami fracture. She developed ARDS requiring maximal ventilatory support. A CXR showed a widened mediastinum prompting a chest CT scan. The CT scan showed blood in the mediastinum. ECHO was non-diagnostic therefore she underwent cardiac catheterization, which showed a pulmonary outflow tract aneurysm and multiple discrete aneurysms of septal perforators off the left anterior descending coronary artery (figure 4 and 5).

The child was managed non-operatively and recovered. The patient underwent cardiac catheterization at 8 months post-discharge that demonstrated resolution of her injury.

Patient M echanism Injury Treatment Outcome

1 MVCMid-Thoracic periaortic hematoma (No Intimal Injury)

Non-OperativeDied from Neurologic

Injury

2Auto-Ped (Moderate

Speed)

Bilat Pulmonary ContusionsSup. Vena Cava Tear

Non-OperativeAlive at 6

year Follow-up

GREAT VESSEL INJURIES

Patient M echanism Injury Treatment Outcome

1 MVCMid-Thoracic periaortic hematoma (No Intimal Injury)

Non-OperativeDied from Neurologic

Injury

2Auto-Ped (Moderate

Speed)

Bilat Pulmonary ContusionsSup. Vena Cava Tear

Non-OperativeAlive at 6

year Follow-up

GREAT VESSEL INJURIES