Bluat Traumatic Rupture of Pulmonary Vein, Left Atrium, and Bronchus Peter P. McKeown, FRACS, Alexander Rosernurgy, MD, and Patricia Conant, MS Divisions of Cardiovascular & Thoracic Surgery and General Surgery, University of South Florida, Tampa, Florida
A 22-year-old man fell 12.2 m (40 ft), injuring the right lower lobe bronchus, right inferior pulmonary vein, and left atrium. These injuries were not associated with fractures, cardiac tamponade, or pneumothorax. The severity of injury became apparent only upon right
thoracotomy for persistent hemorrhage. This case presented special diagnostic and surgical challenges and suggests a role for the increased use of bronchoscopy in major blunt chest trauma. (Ann Thorac Surg 1991;52:1171-2)
I
for 2 weeks. Within 2 months dramatic recovery of speech and motor activity enabled transfer to a rehabilitation center.
njury to the heart, great vessels, and tracheobronchial structures from blunt trauma may not be suspected clinically but may occur in 10% to 15%of fatal accidents [l, 21. Concomitant injuries and lack of clinical signs may obscure the diagnosis. We report this challenging case of a tear in the right inferior pulmonary vein and left atrium combined with transection of the right lower lobe bronchus. A 22-year-old man was found pulseless and unconscious after falling from an overpass. MAST trousers were placed and resuscitation commenced at the scene. On arrival in the emergency room he responded to deep pain on the left side only. Deep tendon reflexes were absent. Pupils were dilated but reactive. Breath sounds were decreased on the right, with no evidence of subcutaneous emphysema or cardiac tamponade. Chest roentgenography showed opacification of the right hemithorax without mediastinal widening, pneumothorax, or fractures. A chest tube was placed with no obvious air leak. Head computed tomographic scan showed no pathology. Emergency right thoracotomy was performed for persistent chest hemorrhage. A double-lumen endotracheal tube was placed and bronchoscopy was attempted to confirm correct positioning, but visualization was limited. When the chest was entered, a large amount of blood was present in the mediastinum. The pericardium had a large rent. A 7-cm tear extending from the inferior pulmonary vein into the left atrium was discovered after temporary manual control of hemorrhage was achieved (Fig 1).Large sutures were placed to repair the tear. This compromised the inferior pulmonary vein, necessitating a right lower lobectomy. The right lower lobe bronchus had an unexpected, almost complete traumatic transection. After the repairs repeat bronchoscopy did not demonstrate further bronchial injuries. Computed tomographic scan 1 week later disclosed a hemorrhagic occipital infarct. The patient remained comatose and ventilator dependent Accepted for publication April 24, 1991. Address reprint requests to Dr McKeown, Division of Cardiovascular & Thoracic Surgery, Suite 730, 4 Columbia Dr, Tampa, FL 33606.
0 1991 by The Society of Thoracic Surgeons
Comment Bright and Beck [3] launched early investigation into effects of blunt trauma to the heart. In 1958 Parmely and associates [4] found myocardial rupture in 64% of 546 postmortem cases of nonpenetrating trauma to the heart, but it was clinically suspected only once. Successful operative repair of a right atrial tear was reported by Desforges and co-workers in 1955 [5]. Subsequent reports describe isolated chamber rupture [I, 4, 681, multiple chamber rupture [4, 6-81, chamber rupture with or without pericardial tears [3, 4, 7, 81, myocardial rupture associated with large airway injuries [2, 81, and those with injuries to great vessels [2]. Death from cardiac rupture occurs from exsanguination or tamponade. The clinical presentation is profound hypotension, hypovolemia, and massive hemothorax. Tamponade physiology is not always a reliable clinical indicator of cardiac trauma as 30% of patients have associated pericardial tears [l].Blunt injuries to the airway are seen most often as tracheobronchial disruptions. In one study the postmortem incidence of tracheobronchial injuries was 2.8% after blunt trauma [2]. Bronchial disruption when in communication with the pleural space can produce symptoms of dyspnea, hemoptysis, cyanosis, subcutaneous and mediastinal emphysema [2]. Pneumothorax or mediastinal air may not be present if the tear is not in communication with the pleura. Motor vehicle accidents are the most frequent cause of blunt chest trauma. Severe injury to intrathoracic structures may occur in the absence of fractures and can be attributed to several mechanisms: (1)indirect or "hydraulic ram" force from the abdomen and lower extremities, which increases intrathoracic pressure and produces rupture without a direct blow to the chest; (2) bidirectional compression between the sternum and vertebral bodies; ( 3 ) acceleration/deceleration effect on the fixed structures in the chest; and (4) blast forces. Intrathoracic structures 0003-4975/91/$3.50
1172
CASE REPORT McKEOWN ET AL BLUNT THORACIC TRAUMA
Ann Thorac Surg 1991;52:1171-2
Fig 1 . Almost complete transection of right lower lobe bronchus (A) and a 7-cm tear extending from the inferior pulmonary vein into the left atrium (B) from blunt trauma.
may be violated by a fractured rib or sternum [l-6, 81; however, bony fractures of the thorax do not necessarily herald severe injuries. A subset of patients have serious intrathoracic injuries without rib fractures [ 2 4 , 7, 81. Energy not dissipated by ribs may target soft tissue rather than bone [7]. This case had several unusual features. Despite the height of the fall, bony injuries were absent and the initial head computed tomographic scan results were normal. Evidence of widened mediastinum or signs of tamponade were absent. Initially the right lung was poorly ventilated from the massive hemothorax. Reexpansion after drainage was confirmed by roentgenography. The bronchial tear was contained by the surrounding lung parenchyma. Lack of pneumothorax or air leak is peculiar with almost complete transection of the right lower lobe bronchus. This suggests the need for a more liberal and aggressive use of bronchoscopy in major blunt chest injuries. When the left atrial tear was discovered, suctioning of the surgical field was done cautiously to avoid air embolus. Surgical control of the extensive, rapidly bleeding site posed a major challenge as application of standard vascular clamps was impractical. Insertion of a Foley catheter with a large enough balloon to control the bleeding would have impeded venous return and filling of the left ventricle. The initial attempt to repair the tear without jeopardizing the inferior pulmonary vein was unsuccessful. Control was achieved using number 2 polypropylene suture with a large needle, facilitating the repair with the field essentially obscured by blood. This technique decreased the risk of air embolism and provided quick control of the massive hemorrhage but compromised the
inferior pulmonary vein. Transection of the bronchus was not suspected clinically or by gross inspection of the lung. Only when lower lobe fissures were dissected was the extent of injury realized. In summary, in this patient cardiac rupture and tears of a pulmonary vein and bronchus were not clinically suspected as rib fractures, subcutaneous emphysema, pn,eumothorax, and physiologic signs of tamponade were absent. This case report stresses a heightened index of suspicion for critical intrathoracic injuries with blunt chest trauma and advocates the more liberal use of bronchoscopy in these patients.
References 1. Getz BS, Davies E, Steinberg SM, Beaver BL, Koenig FA. Blunt cardiac trauma resulting in right atrial rupture. JAMA 1986; 255:761-3. 2. Bertelsen S, Howitz P. Injuries of the trachea and bronchi. Thorax 1972;27:188-94. 3. Bright EF, Beck CS. Nonpenetrating wounds of the heart. Am Heart J 1935;10:293-321, 4. Parmley LF, Manion WC, Mattingly TW. Nonpenetrating traumatic injury of the heart. Circulation 1958;18:371-96. 5. Desforges G, Ridder WP, Lenoci RJ. Successful suture of ruptured myocardium after nonpenetrating injury. N Engl J Med 1955;252:567-9. 6. Patton AS, Guyton SW, Lawson DW, Shannon JM. Treatment of severe atrial injuries. Am J Surg 1981;141:46!%71. 7. Shorr RM, Crittenden M, Indeck M, Hartunian SL, Rodriguez A. Blunt thoracic trauma: analysis of 515 patients. Ann Surg 1987;206:20G5. 8. Calhoon JH, Hoffmann TH, Trinkle JK, Harman PK, Grover FL. Management of blunt rupture of the heart. J Trauma 1986;26:495502.
A 22-year-old man fell 12.2 m (40 ft), injuring the right lower lobe bronchus, right inferior pulmonary vein, and left atrium. These injuries were not associated with fractures, cardiac tamponade, or pneumothorax. The severity of injury became apparent only upon right
thoracotomy for persistent hemorrhage. This case presented special diagnostic and surgical challenges and suggests a role for the increased use of bronchoscopy in major blunt chest trauma. (Ann Thorac Surg 1991;52:1171-2)
I
for 2 weeks. Within 2 months dramatic recovery of speech and motor activity enabled transfer to a rehabilitation center.
njury to the heart, great vessels, and tracheobronchial structures from blunt trauma may not be suspected clinically but may occur in 10% to 15%of fatal accidents [l, 21. Concomitant injuries and lack of clinical signs may obscure the diagnosis. We report this challenging case of a tear in the right inferior pulmonary vein and left atrium combined with transection of the right lower lobe bronchus. A 22-year-old man was found pulseless and unconscious after falling from an overpass. MAST trousers were placed and resuscitation commenced at the scene. On arrival in the emergency room he responded to deep pain on the left side only. Deep tendon reflexes were absent. Pupils were dilated but reactive. Breath sounds were decreased on the right, with no evidence of subcutaneous emphysema or cardiac tamponade. Chest roentgenography showed opacification of the right hemithorax without mediastinal widening, pneumothorax, or fractures. A chest tube was placed with no obvious air leak. Head computed tomographic scan showed no pathology. Emergency right thoracotomy was performed for persistent chest hemorrhage. A double-lumen endotracheal tube was placed and bronchoscopy was attempted to confirm correct positioning, but visualization was limited. When the chest was entered, a large amount of blood was present in the mediastinum. The pericardium had a large rent. A 7-cm tear extending from the inferior pulmonary vein into the left atrium was discovered after temporary manual control of hemorrhage was achieved (Fig 1).Large sutures were placed to repair the tear. This compromised the inferior pulmonary vein, necessitating a right lower lobectomy. The right lower lobe bronchus had an unexpected, almost complete traumatic transection. After the repairs repeat bronchoscopy did not demonstrate further bronchial injuries. Computed tomographic scan 1 week later disclosed a hemorrhagic occipital infarct. The patient remained comatose and ventilator dependent Accepted for publication April 24, 1991. Address reprint requests to Dr McKeown, Division of Cardiovascular & Thoracic Surgery, Suite 730, 4 Columbia Dr, Tampa, FL 33606.
0 1991 by The Society of Thoracic Surgeons
Comment Bright and Beck [3] launched early investigation into effects of blunt trauma to the heart. In 1958 Parmely and associates [4] found myocardial rupture in 64% of 546 postmortem cases of nonpenetrating trauma to the heart, but it was clinically suspected only once. Successful operative repair of a right atrial tear was reported by Desforges and co-workers in 1955 [5]. Subsequent reports describe isolated chamber rupture [I, 4, 681, multiple chamber rupture [4, 6-81, chamber rupture with or without pericardial tears [3, 4, 7, 81, myocardial rupture associated with large airway injuries [2, 81, and those with injuries to great vessels [2]. Death from cardiac rupture occurs from exsanguination or tamponade. The clinical presentation is profound hypotension, hypovolemia, and massive hemothorax. Tamponade physiology is not always a reliable clinical indicator of cardiac trauma as 30% of patients have associated pericardial tears [l].Blunt injuries to the airway are seen most often as tracheobronchial disruptions. In one study the postmortem incidence of tracheobronchial injuries was 2.8% after blunt trauma [2]. Bronchial disruption when in communication with the pleural space can produce symptoms of dyspnea, hemoptysis, cyanosis, subcutaneous and mediastinal emphysema [2]. Pneumothorax or mediastinal air may not be present if the tear is not in communication with the pleura. Motor vehicle accidents are the most frequent cause of blunt chest trauma. Severe injury to intrathoracic structures may occur in the absence of fractures and can be attributed to several mechanisms: (1)indirect or "hydraulic ram" force from the abdomen and lower extremities, which increases intrathoracic pressure and produces rupture without a direct blow to the chest; (2) bidirectional compression between the sternum and vertebral bodies; ( 3 ) acceleration/deceleration effect on the fixed structures in the chest; and (4) blast forces. Intrathoracic structures 0003-4975/91/$3.50
1172
CASE REPORT McKEOWN ET AL BLUNT THORACIC TRAUMA
Ann Thorac Surg 1991;52:1171-2
Fig 1 . Almost complete transection of right lower lobe bronchus (A) and a 7-cm tear extending from the inferior pulmonary vein into the left atrium (B) from blunt trauma.
may be violated by a fractured rib or sternum [l-6, 81; however, bony fractures of the thorax do not necessarily herald severe injuries. A subset of patients have serious intrathoracic injuries without rib fractures [ 2 4 , 7, 81. Energy not dissipated by ribs may target soft tissue rather than bone [7]. This case had several unusual features. Despite the height of the fall, bony injuries were absent and the initial head computed tomographic scan results were normal. Evidence of widened mediastinum or signs of tamponade were absent. Initially the right lung was poorly ventilated from the massive hemothorax. Reexpansion after drainage was confirmed by roentgenography. The bronchial tear was contained by the surrounding lung parenchyma. Lack of pneumothorax or air leak is peculiar with almost complete transection of the right lower lobe bronchus. This suggests the need for a more liberal and aggressive use of bronchoscopy in major blunt chest injuries. When the left atrial tear was discovered, suctioning of the surgical field was done cautiously to avoid air embolus. Surgical control of the extensive, rapidly bleeding site posed a major challenge as application of standard vascular clamps was impractical. Insertion of a Foley catheter with a large enough balloon to control the bleeding would have impeded venous return and filling of the left ventricle. The initial attempt to repair the tear without jeopardizing the inferior pulmonary vein was unsuccessful. Control was achieved using number 2 polypropylene suture with a large needle, facilitating the repair with the field essentially obscured by blood. This technique decreased the risk of air embolism and provided quick control of the massive hemorrhage but compromised the
inferior pulmonary vein. Transection of the bronchus was not suspected clinically or by gross inspection of the lung. Only when lower lobe fissures were dissected was the extent of injury realized. In summary, in this patient cardiac rupture and tears of a pulmonary vein and bronchus were not clinically suspected as rib fractures, subcutaneous emphysema, pn,eumothorax, and physiologic signs of tamponade were absent. This case report stresses a heightened index of suspicion for critical intrathoracic injuries with blunt chest trauma and advocates the more liberal use of bronchoscopy in these patients.
References 1. Getz BS, Davies E, Steinberg SM, Beaver BL, Koenig FA. Blunt cardiac trauma resulting in right atrial rupture. JAMA 1986; 255:761-3. 2. Bertelsen S, Howitz P. Injuries of the trachea and bronchi. Thorax 1972;27:188-94. 3. Bright EF, Beck CS. Nonpenetrating wounds of the heart. Am Heart J 1935;10:293-321, 4. Parmley LF, Manion WC, Mattingly TW. Nonpenetrating traumatic injury of the heart. Circulation 1958;18:371-96. 5. Desforges G, Ridder WP, Lenoci RJ. Successful suture of ruptured myocardium after nonpenetrating injury. N Engl J Med 1955;252:567-9. 6. Patton AS, Guyton SW, Lawson DW, Shannon JM. Treatment of severe atrial injuries. Am J Surg 1981;141:46!%71. 7. Shorr RM, Crittenden M, Indeck M, Hartunian SL, Rodriguez A. Blunt thoracic trauma: analysis of 515 patients. Ann Surg 1987;206:20G5. 8. Calhoon JH, Hoffmann TH, Trinkle JK, Harman PK, Grover FL. Management of blunt rupture of the heart. J Trauma 1986;26:495502.
