Blunt traumatic pericardial rupture and cardiac herniation with a penetrating twist: two case reports

Abstract

Background: Blunt Traumatic Pericardial Rupture (BTPR) with resulting cardiac herniation following chest trauma is an unusual and often fatal condition. Although there has been a multitude of case reports of this condition in past literature, the recurring theme is that of a missed injury. Its occurrence in severe blunt trauma is in the order of 0.4%. It is an injury that frequently results in pre/early hospital death and diagnosis at autopsy, probably owing to a combination of diagnostic difficulties, lack of familiarity and associated polytrauma. Of the patients who survive to hospital attendance, the mortality rate is in the order of 57-64%.

Methods: We present two survivors of BTPR and cardiac herniation, one with a delayed penetrating cardiac injury secondary to rib fractures. With these two cases and literature review, we hope to provide a greater awareness of this injury

Conclusion: BTPR and cardiac herniation is a complex and often fatal injury that usually presents under the umbrella of polytrauma. Clinicians must maintain a high index of suspicion for BTPR but, even then, the diagnosis is fraught with difficulty. In blunt chest trauma, patients should be considered high risk for BTPR when presenting with:Cardiovascular instability with no obvious cause. Prominent or displaced cardiac silhouette and asymmetrical large volume pneumopericardium. Potentially, with increasing awareness of the injury and improved use and availability of imaging modalities, the survival rates will improve and cardiac Herniation could even be considered the 5th H of reversible causes of blunt traumatic PEA arrest.

Figure 1

Plain supine AP chest radiograph showing a prominent, right-sided cardiac silhouette ('boot shaped'); bilateral pulmonary contusions; rib fractures; endotracheal and tube thoracostomies. With the benefit of hindsight there is the suggestion of a left-sided pneumopericardium surrounded by a faint pericardial contour.

Figure 2

Axial chest CT demonstrating multiple parenchymal lung contusions; collapsed bilateral haemopneumothoraces; tube thoracostomies; surgical emphysema; large left-sided pneumopericardium; and displacement of the heart into the right hemithorax.

Figure 3

Coronal chest CT demonstrating most of the axial findings including the prominent pneumopericardium and displacement of the heart into the right hemithorax.

Figure 4

Plain supine AP chest radiograph showing extensive surgical emphysema; multitude of rib fractures and flail on the left side; bilateral pulmonary contusions and suggestion of a haemothorax on the left side; a rotated 'boot shaped' cardiac silhouette, with clear demarcation of cardiac silhouette from the diaphragm; pneumomediastinum; the pericardial contour is also distinctly visible; endotracheal tube.

Figure 5

Axial chest CT showing most of the pathology found on the plain radiograph but also bilateral anterior pneumothoraces; large volume anterior pneumopericardium; tube thoracostomies.