EMMERGENCYCASE REPORT
Cardiac Contusion and Right Bundle Branch Block Michael S. Miller, MD Frederick C. Scott, MD Phoenix, Arizona
In a c a s e o f t r a n s i e n t right b u n d l e b r a n c h b l o c k d u e to n o n p e n e t r a t i n g chest t r a u m a , this a b n o r m a l e l e c t r o c a r d i o g r a p h i c f'mding w a s the s o l e manifestation o f c a r d i a c c o n t u s i o n . T h e r e is a h i g h f r e q u e n c y o f o c c u l t cardiac c o n t u s i o n a n d r o u t i n e e l e c t r o c a r d i o g r a p h y is r e c o m m e n d e d in the e v a l u a t i o n o f n o n p e n e t r a t i n g c h e s t t r a u m a .
Miller MS, Scott FC: Cardiac contusion and right bundle branch block. JACEP 6-504-505, November, 1977. trauma, chest; injury, blunt; injury, chest.
INTRODUCTION Cardiac contusion is generally considered one of the u n u s u a l causes of right bundle branch block ( R B B B ) 2 4 A recent case at our c o m m u n i t y hospital suggests t h a t this association may be more frequent t h a n g e n e r a l l y appreciated.
CASE REPORT A 27-year-old man was in usual good health until suffering a blow to the anterior chest from the steering wheel in an automobile accident. On admission to the emergency department, the patient complained of substernal discomfort and an electrocardiogram (EKG) revealed RBBB (Figure i) with a ventricular rate of 84. The next morning, the EKG (Figure 2) showed normal conduction with a
From the Maryvale Samaritan Hospital, Phoenix, Arizona. Address for reprints: Michael S. Miller, 'IgD, 5502 West Indian School Road, Phoenix, Arizona 85031.
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6:11 (Nov) 1977
sinus rate of 88. Over the next t h r e e days t h e p a t i e n t ' s E K G r e m a i n e d n o r m a l and cardiac isoenzymes were w i t h i n n o r m a l limits on three serial determinations. On the second day the p a t i e n t was free of pain and after three days he was discharged. In the eight weeks since his injury, the p at i en t has rem a i n e d s y m p t o m - f r e e an d h as res u m e d f u l l a c t i v i t y . His E K G rem a i n s normal.
DISCUSSION Standard reference textbooks e i t h e r fail to m e n t i o n n o n p e n e t r a t i n g chest t r a u m a as a cause of RBBB 1,2 or describe cardiac t r a u m a as an unu s u a l etiology of this electrocardiographic finding. Previous reports of t r a u m a t i c RBBB 3 h a v e described res i d u a l e l e c t r o c a r d i o g r a p h i c abhormalities, '~mild to m o d e r a t e " elevat i o n s of c a r d i a c e n z y m e s an d l a t e sequelae including posttraumatic p e r i c a r d i t i s a n d #.eronary i n s u f f i ciency. O t h e r c a s e ~ r e p o r t s and reviews of cardiac contusion 4,5 describe associated injury r a n g i n g from chest
w a l l h e m a t o m a to l i f e - t h r e a t e n i n g d a m a g e of o t h e r viscera. By w a y of contrast we h a v e pres e n t e d a case of cardiac c o n t u s i o n whose sole m a n i f e s t a t i o n was RBBB. T h e m i n i m a l s y m p t o m a t o l o g y and t h e t r a n s i e n t n a t u r e of t h e e l e c t r o c a r d i o g r a p h i c a b n o r m a l i t i e s in t h i s c a s e s h o u l d s e r v e to r e m i n d e m e r g e n c y physicians of the prevalence of cardiac contusion in the sett i n g of n o n p e n e t r a t i n g chest wall inj u r y . C a r d i a c i n j u r y h a s b e e n described as t h e most common unsuspected visceral injury responsible for d eat h in fatally injured accident victims. s ( T u r n to next page for Figures I and2.)
REFERENCES 1. Bellet S: Essentials of Cardiac Arrhythmias, ed 1. Philadelphia, WB Saunders, 1972, pp 132-133. 2. Goldman MJ: Clinical Electrocardiography ed 8. Los Altos, California, Lange Publishing Co, 1973, pp 113-121. 3. Zinnser HF, Thind GS: RBBB after non-penetrating injury to the chest wall. J A M A 207:1913-1915, 1969. 4. Rankin TJ, Patterson JW: Transient intraventricular block in cardiac contusion. A m Heart J 43:103-107, 1952. 5. Jones JW, Hewitt LW, Drapanas T: Cardiac contusion. Ann Surg 181:567574, 1975. 6. Liedtke AJ, DeMuth WE: Nonpenetrating cardiac injuries: A collective review. A m Heart J 86:687, 1973.
504/45
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=v~
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I i I1! !I! I111I1~ !i! !H!ill!il
------
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-
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Fig, 1. Right bundle branch block on the night of admission. ,,f~ ,::: i
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,: !ii~ i! : if: li :I ill
: :~[ ~' :!~til il ?,~iri:,i'i i
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Fig. 2. The following morning the patient's EKG demonstrates normal conduction.
46/505
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.
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l 6:11 (Nov) 1977 J ~ P
Cardiac Contusion and Right Bundle Branch Block Michael S. Miller, MD Frederick C. Scott, MD Phoenix, Arizona
In a c a s e o f t r a n s i e n t right b u n d l e b r a n c h b l o c k d u e to n o n p e n e t r a t i n g chest t r a u m a , this a b n o r m a l e l e c t r o c a r d i o g r a p h i c f'mding w a s the s o l e manifestation o f c a r d i a c c o n t u s i o n . T h e r e is a h i g h f r e q u e n c y o f o c c u l t cardiac c o n t u s i o n a n d r o u t i n e e l e c t r o c a r d i o g r a p h y is r e c o m m e n d e d in the e v a l u a t i o n o f n o n p e n e t r a t i n g c h e s t t r a u m a .
Miller MS, Scott FC: Cardiac contusion and right bundle branch block. JACEP 6-504-505, November, 1977. trauma, chest; injury, blunt; injury, chest.
INTRODUCTION Cardiac contusion is generally considered one of the u n u s u a l causes of right bundle branch block ( R B B B ) 2 4 A recent case at our c o m m u n i t y hospital suggests t h a t this association may be more frequent t h a n g e n e r a l l y appreciated.
CASE REPORT A 27-year-old man was in usual good health until suffering a blow to the anterior chest from the steering wheel in an automobile accident. On admission to the emergency department, the patient complained of substernal discomfort and an electrocardiogram (EKG) revealed RBBB (Figure i) with a ventricular rate of 84. The next morning, the EKG (Figure 2) showed normal conduction with a
From the Maryvale Samaritan Hospital, Phoenix, Arizona. Address for reprints: Michael S. Miller, 'IgD, 5502 West Indian School Road, Phoenix, Arizona 85031.
J~)
6:11 (Nov) 1977
sinus rate of 88. Over the next t h r e e days t h e p a t i e n t ' s E K G r e m a i n e d n o r m a l and cardiac isoenzymes were w i t h i n n o r m a l limits on three serial determinations. On the second day the p a t i e n t was free of pain and after three days he was discharged. In the eight weeks since his injury, the p at i en t has rem a i n e d s y m p t o m - f r e e an d h as res u m e d f u l l a c t i v i t y . His E K G rem a i n s normal.
DISCUSSION Standard reference textbooks e i t h e r fail to m e n t i o n n o n p e n e t r a t i n g chest t r a u m a as a cause of RBBB 1,2 or describe cardiac t r a u m a as an unu s u a l etiology of this electrocardiographic finding. Previous reports of t r a u m a t i c RBBB 3 h a v e described res i d u a l e l e c t r o c a r d i o g r a p h i c abhormalities, '~mild to m o d e r a t e " elevat i o n s of c a r d i a c e n z y m e s an d l a t e sequelae including posttraumatic p e r i c a r d i t i s a n d #.eronary i n s u f f i ciency. O t h e r c a s e ~ r e p o r t s and reviews of cardiac contusion 4,5 describe associated injury r a n g i n g from chest
w a l l h e m a t o m a to l i f e - t h r e a t e n i n g d a m a g e of o t h e r viscera. By w a y of contrast we h a v e pres e n t e d a case of cardiac c o n t u s i o n whose sole m a n i f e s t a t i o n was RBBB. T h e m i n i m a l s y m p t o m a t o l o g y and t h e t r a n s i e n t n a t u r e of t h e e l e c t r o c a r d i o g r a p h i c a b n o r m a l i t i e s in t h i s c a s e s h o u l d s e r v e to r e m i n d e m e r g e n c y physicians of the prevalence of cardiac contusion in the sett i n g of n o n p e n e t r a t i n g chest wall inj u r y . C a r d i a c i n j u r y h a s b e e n described as t h e most common unsuspected visceral injury responsible for d eat h in fatally injured accident victims. s ( T u r n to next page for Figures I and2.)
REFERENCES 1. Bellet S: Essentials of Cardiac Arrhythmias, ed 1. Philadelphia, WB Saunders, 1972, pp 132-133. 2. Goldman MJ: Clinical Electrocardiography ed 8. Los Altos, California, Lange Publishing Co, 1973, pp 113-121. 3. Zinnser HF, Thind GS: RBBB after non-penetrating injury to the chest wall. J A M A 207:1913-1915, 1969. 4. Rankin TJ, Patterson JW: Transient intraventricular block in cardiac contusion. A m Heart J 43:103-107, 1952. 5. Jones JW, Hewitt LW, Drapanas T: Cardiac contusion. Ann Surg 181:567574, 1975. 6. Liedtke AJ, DeMuth WE: Nonpenetrating cardiac injuries: A collective review. A m Heart J 86:687, 1973.
504/45
~!!ll!l,l~,,~li,~t~li~!!t,~!,!,iil
-
-~-
.... ~ ....
"
,, i~I i~, I~ ',~i, ! ,, ~!~ ~,i ii!'!, ,
¢,v~
. . . .
=v~
,
I i I1! !I! I111I1~ !i! !H!ill!il
------
°re
-
""
"
w ~.,..~
I ~ ' ~ r +~+* .
Fig, 1. Right bundle branch block on the night of admission. ,,f~ ,::: i
If! d
,: !ii~ i! : if: li :I ill
: :~[ ~' :!~til il ?,~iri:,i'i i
~r
;2 i
~
Fig. 2. The following morning the patient's EKG demonstrates normal conduction.
46/505
I
,
.
I
l 6:11 (Nov) 1977 J ~ P
