Journal of Pediatric Surgery VOL 25, NO 3
MARCH 1990
Cardiac Contusion in Pediatric By Suzanne
T. Ildstad,
Patients
David J. Tollerud, Richard G. Weiss,
With Blunt Thoracic Trauma Joseph
A. Cox, and Lester W. Martin
Cincinnati, Ohio 0 To investigate the prevalence of myocardial contusion associated with blunt chest trauma in the pediatric age group, all patients admitted to our institution during a 6-month period with blunt thoracic trauma severe enough to produce a pulmonary contusion or rib fracture were prospectively evaluated. Cardiac evaluation was undertaken, including a multiple-gated acquisition (MUGA) cardiac scan, serial electrocardiograms (ECG), and serum creatine phosphokinase (CPK) and CPK isoenzymes. Seven patients, ranging in age from 2% to 16 years, with rib fractures or pulmonary contusion by chest roentgenogreph were identified. One patient was injured as a passenger in a motor vehicle accident, five were struck by automobiles as pedestrians, and one sustained traumatic asphyxia when a car, supported by a jack, fell on his chest. All had at least one other major organ system injured. All patients had pulmonary contusions as determined by chest radiograph, and two had associated rib fractures. In 43% (three of seven) of patients, a significant cardiac contusion was identified, defined by abnormal right or left ventricular wall motion and a decreased ejection fraction on MUGA scan, and confirmed by an increase in cardiac enzymes and isoenzymes. However, in contrast with adults, no patients had ECG abnormalities. This limited series suggests that cardiac contusion may occur frequently in pediatric patients who have suffered from blunt thoracic trauma significant enough to result in pulmonary contusion. An MUGA scan provides a rapid, noninvasive assessment of cardiac damage in this setting. Further studies will be required to determine the clinical significance and longterm consequences of traumatic myocardial damage in the pediatric population. 0 1990 by W.B. Saunders Company. INDEX WORDS: Pediatric trauma: cardiac contusion.
C racic trauma has only recently
ARDIAC CONTUSION secondary to blunt thois an important clinical entity that been characterized in the adult patient population.1-5 Increased physician awareness combined with the availability of radionuclide myocardial imaging 6-11 has demonstrated that this entity occurs more frequently than previously recognized in adults who have sustained blunt thoracic trauma. The frequency of cardiac contusion in pediatric patients who sustain significant blunt thoracic trauma has not been reported previously. Journal Of Pediatric Sur@e?ry,Vol 25, No 3 (March), 1990: pp 287-289
MATERIALS AND METHODS All patients admitted to the Children’s Hospital Medical Center who had sustained significant blunt thoracic trauma from June 1987 to February 1988, as assessed by a pulmonary contusion or rib fractures, were enrolled in the study. The diagnosis of pulmonary contusion was established radiographically. Serial cardiac enzymes and isoenzymes, and serial electrocardiograms (ECG) were performed in addition to multiple-gated acquisition (MUGA) cardiac scans using technetium 99 radioisotope.6,91’0The scan was performed within 36 hours of the initial traumatic injury in all patients. Both right and left ventricular ejection fractions were quantitated, and the lower limit of normal in our nuclear medicine department was determined at 40%. RESULTS
Patient Characteristics
During the 8-month study interval, seven patients were admitted to Children’s Hospital Medical Center for treatment of significant blunt thoracic trauma, resulting in one or more fractured ribs or a pulmonary contusion. These patients were prospectively enrolled for MUGA scan, cardiac enzymes and isoenzymes, and ECG to evaluate for the presence of a cardiac contusion. The patients ranged in age from 21/2to 18 years. Mechanism
of Injury and Associated
Injuries
One patient was injured in a motor vehicle accident as a passenger, five were struck by an automobile as pedestrians, and one patient sustained traumatic asphyxia when a car, supported by a jack, fell on his chest. All patients had sustained multiple trauma with at least one other major organ system injured. The most frequent associated injuries were fractures of the
From the Department of Pediatric Surgery, Children’s Hospital Medical Center, Cincinnati. OH. Date accepted: October 26.1988. Address reprint requests to Suzanne T. Ildstad, MD. Assistant Professor of Surgery, Children’s Hospital of Pittsburgh, Pittsburgh, PA 15213. 0 1990 by W.B. Saunders Company. 0022-3468/90/2503-0001$03.00/0
287
288
ILDSTAD ET AL
Table 1. Blunt Thoracic Patient No.
Trauma: Patient Characteristics
sex
Ace (vrj
Mechanism
and Associated
Injuries
of Injury
Associated
Injuries
1
3
Male
Traumatic asphyxia
Closed head injury
2
9
Male
Pedestrian, MVA
Closed head injury, skull fracture, tib-
39
4
Male
Pedestrian, MVA
Left rib fractures, right femur frac-
4s
3
Male
Passenger in MVA
Closed head injury, traumatic pancre-
5’
13
Male
Pedestrian, MVA
Splenic fracture, liver contusion, right
ial/fibular fracture tures atitis, liver contusion 7th rib fracture with pneumothorax, open fracture of iliac crest 6
7
Female
Pedestrian, MVA
Closed head injury
7
2%
Female
Pedestrian
Traumatic avulsion of left upper extremity, clavicular fracture
Abbrevfation: MVA, motcr vehicle accident. *Denotes patient with cardiac contusion.
bony skeleton in four patients and closed head injury in four patients, followed by liver and splenic injury in two patients, and traumatic pancreatitis in one (Table 1). Both patients with rib fractures also had a pulmonary contusion on chest radiograph. Analysis of Patients With Cardiac Contusion Three patients admitted to our hospital with significant blunt thoracic trauma were identified with myocardial contusions by MUGA scan (Table 2). In all patients, cardiac enzymes and isoenzymes confirmed significant myocardial damage. However, despite abnormal ventricular wall motion by MUGA scan and substantially elevated cardiac enzymes and isoenzymes, no ECG abnormalities or ventricular ectopy were detected in those patients during cardiac monitoring. Two of the three patients with cardiac contusions underwent emergency operative procedures within 24 hours of the injury to stabilize and/or debride associated skeletal injuries. In both patients, the operative procedures and general anesthesia were well tolerated, with no complications attributable to the myocardial contusion. One of the three patients underwent a repeat MUGA scan 3 weeks following the initial injury. At that time, myocardial function had returned to normal. DISCUSSION
Cardiac contusion secondary to blunt thoracic trauma is an important clinical entity that has only Table 2. Analysis of Patients Petiem NO:
Rib FWT.tW9
recently been characterized in the adult patient population. Increased physician awareness, combined with the availability of radionuclide myocardial imaging, has shown that this entity occurs more frequently than previously recognized in adults who have sustained blunt thoracic trauma.lM5 The frequency of cardiac contusion in pediatric patients who sustain significant blunt thoracic trauma has not been reported previously. Cardiac contusion has been described as an elusive entity, the diagnosis of which is dependent on clinical awareness.iT5 Patients targeted for prospective evaluation included those with blunt chest trauma significant enough to result in a pulmonary contusion and/or rib fracture. In this subset of trauma patients, 43% (three of seven) of patients had associated cardiac contusions. The flexibility of the rib cage in the child is believed to make rib fractures much less likely than in adults, even after a significant blunt impact. In our series of seven cases, all three patients with cardiac contusions had associated pulmonary contusions. However, only two of those three patients had rib fractures as well. Therefore, we recommended that pulmonary contusion, in addition to rib fractures, be used as an indicator of suspicion for concomitant cardiac contusion in pediatric trauma patients. In our series, cardiac contusions detected by MUGA scan were corroborated with significantly elevated creatine phosphokinase-myocardial band (CPK-MB) cardiac enzymes and isoenzyme analyses. These results are similar to those observed in adult patients who Who Sustained
Cardiac Contusion Evaluation
Pulmonw Contusion
MUGA
CPK @vlB%)t
ECG Abnormalii
3
No
Yes
+
Not available
No
4
Yes
Yes
Yes
Yes
12,468 (23%) 1,815 (17%)
No
5
+ +
*Refer to Table 1 for patient profile. tNormal upper limit of CPK-MB fraction in our laboratory is 5%.
No
CARDIAC CONTUSION
299
IN BLUNT TRAUMA
have sustained a myocardial contusion. l-5 However, in distinct contrast with most reported series in adults, where up to 80% of patients exhibited ECG abnormalities and cardiac arrhythmias,‘-5 no ECG changes were observed in our pediatric patients who had sustained myocardial contusions. The advantage of the MUGA scan is an immediate assessment of possible cardiac damage, which is especially helpful for patients who require elective surgical procedures that could be postponed to allow healing of the myocardial damage. While cardiac enzymes and isoenzymes require hours to days for availability, the MUGA scans can be performed at the bedside immediately following the injury, yielding immediate results. Only recently have the long-term sequelae of traumatic myocardial contusions in adults been reported.12 A recent report from the trauma unit of the University of Western Ontario reported a 7% early in-hospital mortality due to complications associated with a traumatic myocardial contusion but no long-term sequelae. l2 Patients who could be located for follow-up evaluation 1 year or more following the injury were indistinguishable from controls who had not sustained
a cardiac contusion.12 The acute and long-term sequelae of cardiac contusions in the pediatric patient have not been described. In our study, two patients who underwent emergent operative procedures had no anesthetic or postoperative complications attributable to the myocardial contusion itself. In one patient who underwent a follow-up MUGA scan 3 weeks following the injury, myocardial function had returned to normal. Studies are currently in progress at our institution to quantify the long-term effects of traumatic myocardial injury in pediatric trauma patients. In summary, cardiac contusion seems to be a relatively common occurrence in pediatric patients who sustain severe thoracic trauma. Pulmonary contusion, especially when accompanied by rib fractures, should raise the clinica suspicion for occult myocardial damage. The long-term sequelae and short-term clinical significance of traumatic myocardial contusion in this setting are currently under investigation. ACKNOWLEDGMENT The authors wish to thank Julie Ludwig and Corrine Case for excellent manuscript preparation.
REFERENCES 1. Saunders CR, Doty DB: Myocardial contusion. Surg Gynecol Obstet 144595603, 1977 2. Spelman JR. Cited by: Liedtke AF, Demuth WE Jr: Nonpenetratiug cardiac injuries: A collective review. Am Heart J 86:687-97, 1973 3. Sutherland GR, Calvin JE, Driedger AA, et al: Anatomic and cardiopulmonary responses to trauma with associated blunt cheat injury. JTrauma 21:1-12,198l 4. Doty DB, Anderson AE, Rose EF, et al: Cardiac trauma: Clinical and experimental correlations of myocardial contusion. Ann Surg 180:452-460,1974 5. Jones JW, Hewitt RL, Drapanas T: Cardiac contusion: A capricious syndrome. Ann Surg 181:567-574,1975 6. Go RT, Chiu CL, Doty DB, et al: Radionuclide imaging of experimental myocardial contusion. J Nucl Med 15: 1174-l 175, 1974
7. Gonzalez AC, Waldo W, Gravanis M, et al: Imaging of experimental myocardial contusion: Observations and pathologic correlations. AJR 128:1039-1040, 1977 8. Chiu CL, Roelof JD, Go RT, et al: Coronary angiographic and scintigraphic findings in experimental cardiac contusion. Radiology 116:679-683,1975 9. Coleman J, Gonzales A, Harlaftis N, et al: Myocardial contusion: Diagnostic value of cardiac scanning and echocardiography. Surg Forum 27:293-294,1976 10. Datz FL, Lewis SE, Parkey RW, et al: Radionuclide evaluation of cardiac trauma. Semin Nucl Med 101187-192, 1980 11. Brantigan CO, Burdik D, Hopeman AR, et al: Evaluation of technetium scanning for myocardial contusion. J Trauma 18:460463,1978 12. Sturaitis M, McCollum D, Sutherland G, et al: Lack of significant long-term sequelae following traumatic myocardiil contusion. Arch Intern Med 146:1765-1769, 1986
MARCH 1990
Cardiac Contusion in Pediatric By Suzanne
T. Ildstad,
Patients
David J. Tollerud, Richard G. Weiss,
With Blunt Thoracic Trauma Joseph
A. Cox, and Lester W. Martin
Cincinnati, Ohio 0 To investigate the prevalence of myocardial contusion associated with blunt chest trauma in the pediatric age group, all patients admitted to our institution during a 6-month period with blunt thoracic trauma severe enough to produce a pulmonary contusion or rib fracture were prospectively evaluated. Cardiac evaluation was undertaken, including a multiple-gated acquisition (MUGA) cardiac scan, serial electrocardiograms (ECG), and serum creatine phosphokinase (CPK) and CPK isoenzymes. Seven patients, ranging in age from 2% to 16 years, with rib fractures or pulmonary contusion by chest roentgenogreph were identified. One patient was injured as a passenger in a motor vehicle accident, five were struck by automobiles as pedestrians, and one sustained traumatic asphyxia when a car, supported by a jack, fell on his chest. All had at least one other major organ system injured. All patients had pulmonary contusions as determined by chest radiograph, and two had associated rib fractures. In 43% (three of seven) of patients, a significant cardiac contusion was identified, defined by abnormal right or left ventricular wall motion and a decreased ejection fraction on MUGA scan, and confirmed by an increase in cardiac enzymes and isoenzymes. However, in contrast with adults, no patients had ECG abnormalities. This limited series suggests that cardiac contusion may occur frequently in pediatric patients who have suffered from blunt thoracic trauma significant enough to result in pulmonary contusion. An MUGA scan provides a rapid, noninvasive assessment of cardiac damage in this setting. Further studies will be required to determine the clinical significance and longterm consequences of traumatic myocardial damage in the pediatric population. 0 1990 by W.B. Saunders Company. INDEX WORDS: Pediatric trauma: cardiac contusion.
C racic trauma has only recently
ARDIAC CONTUSION secondary to blunt thois an important clinical entity that been characterized in the adult patient population.1-5 Increased physician awareness combined with the availability of radionuclide myocardial imaging 6-11 has demonstrated that this entity occurs more frequently than previously recognized in adults who have sustained blunt thoracic trauma. The frequency of cardiac contusion in pediatric patients who sustain significant blunt thoracic trauma has not been reported previously. Journal Of Pediatric Sur@e?ry,Vol 25, No 3 (March), 1990: pp 287-289
MATERIALS AND METHODS All patients admitted to the Children’s Hospital Medical Center who had sustained significant blunt thoracic trauma from June 1987 to February 1988, as assessed by a pulmonary contusion or rib fractures, were enrolled in the study. The diagnosis of pulmonary contusion was established radiographically. Serial cardiac enzymes and isoenzymes, and serial electrocardiograms (ECG) were performed in addition to multiple-gated acquisition (MUGA) cardiac scans using technetium 99 radioisotope.6,91’0The scan was performed within 36 hours of the initial traumatic injury in all patients. Both right and left ventricular ejection fractions were quantitated, and the lower limit of normal in our nuclear medicine department was determined at 40%. RESULTS
Patient Characteristics
During the 8-month study interval, seven patients were admitted to Children’s Hospital Medical Center for treatment of significant blunt thoracic trauma, resulting in one or more fractured ribs or a pulmonary contusion. These patients were prospectively enrolled for MUGA scan, cardiac enzymes and isoenzymes, and ECG to evaluate for the presence of a cardiac contusion. The patients ranged in age from 21/2to 18 years. Mechanism
of Injury and Associated
Injuries
One patient was injured in a motor vehicle accident as a passenger, five were struck by an automobile as pedestrians, and one patient sustained traumatic asphyxia when a car, supported by a jack, fell on his chest. All patients had sustained multiple trauma with at least one other major organ system injured. The most frequent associated injuries were fractures of the
From the Department of Pediatric Surgery, Children’s Hospital Medical Center, Cincinnati. OH. Date accepted: October 26.1988. Address reprint requests to Suzanne T. Ildstad, MD. Assistant Professor of Surgery, Children’s Hospital of Pittsburgh, Pittsburgh, PA 15213. 0 1990 by W.B. Saunders Company. 0022-3468/90/2503-0001$03.00/0
287
288
ILDSTAD ET AL
Table 1. Blunt Thoracic Patient No.
Trauma: Patient Characteristics
sex
Ace (vrj
Mechanism
and Associated
Injuries
of Injury
Associated
Injuries
1
3
Male
Traumatic asphyxia
Closed head injury
2
9
Male
Pedestrian, MVA
Closed head injury, skull fracture, tib-
39
4
Male
Pedestrian, MVA
Left rib fractures, right femur frac-
4s
3
Male
Passenger in MVA
Closed head injury, traumatic pancre-
5’
13
Male
Pedestrian, MVA
Splenic fracture, liver contusion, right
ial/fibular fracture tures atitis, liver contusion 7th rib fracture with pneumothorax, open fracture of iliac crest 6
7
Female
Pedestrian, MVA
Closed head injury
7
2%
Female
Pedestrian
Traumatic avulsion of left upper extremity, clavicular fracture
Abbrevfation: MVA, motcr vehicle accident. *Denotes patient with cardiac contusion.
bony skeleton in four patients and closed head injury in four patients, followed by liver and splenic injury in two patients, and traumatic pancreatitis in one (Table 1). Both patients with rib fractures also had a pulmonary contusion on chest radiograph. Analysis of Patients With Cardiac Contusion Three patients admitted to our hospital with significant blunt thoracic trauma were identified with myocardial contusions by MUGA scan (Table 2). In all patients, cardiac enzymes and isoenzymes confirmed significant myocardial damage. However, despite abnormal ventricular wall motion by MUGA scan and substantially elevated cardiac enzymes and isoenzymes, no ECG abnormalities or ventricular ectopy were detected in those patients during cardiac monitoring. Two of the three patients with cardiac contusions underwent emergency operative procedures within 24 hours of the injury to stabilize and/or debride associated skeletal injuries. In both patients, the operative procedures and general anesthesia were well tolerated, with no complications attributable to the myocardial contusion. One of the three patients underwent a repeat MUGA scan 3 weeks following the initial injury. At that time, myocardial function had returned to normal. DISCUSSION
Cardiac contusion secondary to blunt thoracic trauma is an important clinical entity that has only Table 2. Analysis of Patients Petiem NO:
Rib FWT.tW9
recently been characterized in the adult patient population. Increased physician awareness, combined with the availability of radionuclide myocardial imaging, has shown that this entity occurs more frequently than previously recognized in adults who have sustained blunt thoracic trauma.lM5 The frequency of cardiac contusion in pediatric patients who sustain significant blunt thoracic trauma has not been reported previously. Cardiac contusion has been described as an elusive entity, the diagnosis of which is dependent on clinical awareness.iT5 Patients targeted for prospective evaluation included those with blunt chest trauma significant enough to result in a pulmonary contusion and/or rib fracture. In this subset of trauma patients, 43% (three of seven) of patients had associated cardiac contusions. The flexibility of the rib cage in the child is believed to make rib fractures much less likely than in adults, even after a significant blunt impact. In our series of seven cases, all three patients with cardiac contusions had associated pulmonary contusions. However, only two of those three patients had rib fractures as well. Therefore, we recommended that pulmonary contusion, in addition to rib fractures, be used as an indicator of suspicion for concomitant cardiac contusion in pediatric trauma patients. In our series, cardiac contusions detected by MUGA scan were corroborated with significantly elevated creatine phosphokinase-myocardial band (CPK-MB) cardiac enzymes and isoenzyme analyses. These results are similar to those observed in adult patients who Who Sustained
Cardiac Contusion Evaluation
Pulmonw Contusion
MUGA
CPK @vlB%)t
ECG Abnormalii
3
No
Yes
+
Not available
No
4
Yes
Yes
Yes
Yes
12,468 (23%) 1,815 (17%)
No
5
+ +
*Refer to Table 1 for patient profile. tNormal upper limit of CPK-MB fraction in our laboratory is 5%.
No
CARDIAC CONTUSION
299
IN BLUNT TRAUMA
have sustained a myocardial contusion. l-5 However, in distinct contrast with most reported series in adults, where up to 80% of patients exhibited ECG abnormalities and cardiac arrhythmias,‘-5 no ECG changes were observed in our pediatric patients who had sustained myocardial contusions. The advantage of the MUGA scan is an immediate assessment of possible cardiac damage, which is especially helpful for patients who require elective surgical procedures that could be postponed to allow healing of the myocardial damage. While cardiac enzymes and isoenzymes require hours to days for availability, the MUGA scans can be performed at the bedside immediately following the injury, yielding immediate results. Only recently have the long-term sequelae of traumatic myocardial contusions in adults been reported.12 A recent report from the trauma unit of the University of Western Ontario reported a 7% early in-hospital mortality due to complications associated with a traumatic myocardial contusion but no long-term sequelae. l2 Patients who could be located for follow-up evaluation 1 year or more following the injury were indistinguishable from controls who had not sustained
a cardiac contusion.12 The acute and long-term sequelae of cardiac contusions in the pediatric patient have not been described. In our study, two patients who underwent emergent operative procedures had no anesthetic or postoperative complications attributable to the myocardial contusion itself. In one patient who underwent a follow-up MUGA scan 3 weeks following the injury, myocardial function had returned to normal. Studies are currently in progress at our institution to quantify the long-term effects of traumatic myocardial injury in pediatric trauma patients. In summary, cardiac contusion seems to be a relatively common occurrence in pediatric patients who sustain severe thoracic trauma. Pulmonary contusion, especially when accompanied by rib fractures, should raise the clinica suspicion for occult myocardial damage. The long-term sequelae and short-term clinical significance of traumatic myocardial contusion in this setting are currently under investigation. ACKNOWLEDGMENT The authors wish to thank Julie Ludwig and Corrine Case for excellent manuscript preparation.
REFERENCES 1. Saunders CR, Doty DB: Myocardial contusion. Surg Gynecol Obstet 144595603, 1977 2. Spelman JR. Cited by: Liedtke AF, Demuth WE Jr: Nonpenetratiug cardiac injuries: A collective review. Am Heart J 86:687-97, 1973 3. Sutherland GR, Calvin JE, Driedger AA, et al: Anatomic and cardiopulmonary responses to trauma with associated blunt cheat injury. JTrauma 21:1-12,198l 4. Doty DB, Anderson AE, Rose EF, et al: Cardiac trauma: Clinical and experimental correlations of myocardial contusion. Ann Surg 180:452-460,1974 5. Jones JW, Hewitt RL, Drapanas T: Cardiac contusion: A capricious syndrome. Ann Surg 181:567-574,1975 6. Go RT, Chiu CL, Doty DB, et al: Radionuclide imaging of experimental myocardial contusion. J Nucl Med 15: 1174-l 175, 1974
7. Gonzalez AC, Waldo W, Gravanis M, et al: Imaging of experimental myocardial contusion: Observations and pathologic correlations. AJR 128:1039-1040, 1977 8. Chiu CL, Roelof JD, Go RT, et al: Coronary angiographic and scintigraphic findings in experimental cardiac contusion. Radiology 116:679-683,1975 9. Coleman J, Gonzales A, Harlaftis N, et al: Myocardial contusion: Diagnostic value of cardiac scanning and echocardiography. Surg Forum 27:293-294,1976 10. Datz FL, Lewis SE, Parkey RW, et al: Radionuclide evaluation of cardiac trauma. Semin Nucl Med 101187-192, 1980 11. Brantigan CO, Burdik D, Hopeman AR, et al: Evaluation of technetium scanning for myocardial contusion. J Trauma 18:460463,1978 12. Sturaitis M, McCollum D, Sutherland G, et al: Lack of significant long-term sequelae following traumatic myocardiil contusion. Arch Intern Med 146:1765-1769, 1986
