Chest pain in a young basketball player

A 32-year-old man was elbowed in the chest while fighting for a rebound in a recreational basketball game. He fell to the ground and his chest ached from the blow. Four days later he developed more severe chest pressure with dyspnea and came to the hospital. His chest wall was tender and his pulse slow, but the remainder of his physical examination was normal. Electrocardiogram showed sinus bradycardia, first-degree atrioventricular (AV) block, and occasional isorhythmic AV dissociation, but no ischemic ST-T changes. Cardiac troponin I rose to 1.74 ng/mL (normal <0.50). The patient therefore underwent coronary angiography, showing spiral dissection of the right coronary artery with extensive thrombus filling the distal portion of the vessel. Stenting was unsuccessful in restoring flow. This case highlights the potential dangers of blunt chest trauma in recreational sports and shows how angiography can distinguish myocardial contusion from coronary artery dissection.     

Emergent stent graft isolation of a knife-related subclavian arterial venous fistula: lessons learned during long-term follow-up.

We present the unusual case of a 42-year-old gentleman who entered the trauma center with a hemothorax and intermittent bright red pulsatile blood from three stab wounds in the ipsilateral supraclavicular fossa. The patient was found on emergent angiography to have a large right subclavian artery to vein fistula that was treated successfully with a Dacron-covered stent. Angiography, 2 years following stent-graft isolation, confirmed a durable result with evidence of hemodynamically insignificant neointimal growth through the pores of the graft material. This case provides insight into the long-term effects of a Dacron-covered stent in patients with traumatic arterial injury. We discussed the advantages and disadvantages of different graft materials based on these angiographic findings.     

Peri‐mitral ventriculoatrial fistula after blunt thoracic trauma

Blunt trauma to the chest can damage any thoracic organ. Heart valve damage and particularly mitral apparatus occurs relatively rare, and the patients are expected to become acutely symptomatic. However, in patients with multiple traumas, other dominant severe damages tend to draw away the attention of the physicians resulting in neglect of less salient heart injuries. Here, we present a patient with history of blunt chest trauma and incidental finding of posttraumatic severe mitral regurgitation.     

Traumatic aortic transection

We report three cases of patients with blunt thoracic trauma, who underwent transesophageal echocardiography (TEE) because of high index of clinical suspicion for acute traumatic aortic syndrome. TEE revealed three different locations of aortic injury one of which was not diagnosed with aortography.     

Esophageal Perforation Accompanying Mediastinitis in Blunt Trauma in a Patient with Thoracic Osteophytes

We herein report a 61-year-old man who sustained injury after a 2-m fall and developed mediastinitis. He presented to another hospital two days after the fall and was transferred to our hospital four days after the fall with a fever and dysphagia. Computed tomography revealed osteophytes on the second and third thoracic vertebrae and free air in the mediastinum, indicating esophageal perforation. Emergent surgery was performed. Intraoperatively, a longitudinal esophageal tear was identified. We stress the importance of being aware of the possibility of osteophyte-related esophageal perforation in patients with a history of a fall. A delayed diagnosis affects the prognosis.     

Associated Venous Injury Significantly Complicates Presentation,Management, and Outcomes of Axillosubclavian Arterial Trauma

Axillosubclavian vessel injury (ASVI) is associated with high morbidity and mortality. Most studies are single-center experiences of small numbers of patients with penetrating injury. We assessed 21st-century presentation and management of ASVI and focused on outcomes of combined arterial/venous injury. We reviewed the National Trauma Data Bank for patients with isolated arterial ASVI (group 1) and combined arterial/venous ASVI (group 2). Demographics, injury severity parameters, interventions, complications, and outcomes were compared. We identified 581 patients with ASVI (mean age 35.1; 88.1% male), with 466 isolated arterial injuries and 115 combined arterial/venous injuries. Group 2 had lower presenting systolic blood pressure and Glasgow Coma Scale, and had higher rates of operative repair (55.7 vs. 43.1%, p = 0.016) and higher mortality (33.9 vs. 13.9%, p < 0.001). There were no differences in amputation (5.2 vs. 2.4%, p = 0.121), compartment syndrome (2.6 vs. 1.9%, p = 0.713), and deep vein thrombosis (0.9 vs. 0.2%, p = 0.357). When separated by mechanism of injury, combined injuries from blunt trauma did increase amputation rates (27.8 vs. 4.2%, p = 0.002). Multivariate analysis revealed that combined arterial/venous injury significantly increased risk of death (odds ratio [OR], 2.99; confidence interval [CI], 1.73 to 5.17; p = 0.0001). Penetrating injury had higher odds of death than blunt injury (OR, 1.96; CI, 1.03 to 3.73; p = 0.041). ASVI is rare but extremely lethal. Concomitant venous and arterial injury is not associated with worse limb-related outcomes, except in blunt injuries and resultant amputations, but is associated with a threefold increase in mortality rates compared with isolated arterial injury.     

Two-dimensional transthoracic echocardiographic finding of left atrial compression resulting from blunt trauma to the thoracic spine

We present an adult female in whom two-dimensional transthoracic echocardiography demonstrated encroachment of the thoracic spine on the left atrium (LA) resulting in a very small, compressed LA cavity by a prominent thoracic spine shadow. Computed tomography (CT) scan of the chest showed compression of the LA produced by localized anterior deformation of the thoracic spine which had resulted from blunt injury to her spine following a fall from a swing several years previously.     

Acute severe mitral regurgitation after blunt chest trauma

Myocardial contusion and aortic injury are well‐known cardiac complications of blunt chest trauma, but valvular injury is rare. Traumatic valve injuries most commonly involve the aortic valve, with isolated mitral valve injury being quite rare. We report a case of acute severe mitral regurgitation due to ruptured chordae tendineae requiring surgical repair following a motor vehicle accident.     

Blunt abdominal trauma causing jejunal rupture

Two cases of jejunal rupture from blunt abdominal trauma are described. One followed a motorcycle accident, and the other followed a punch to the abdomen. Both patients initially had unremarkable abdominal examinations. After surgical repair of the ruptures, the patients recovered uneventfully. Jejunal rupture secondary to blunt abdominal trauma is not common, but its subdued clinical presentation and the nonspecific laboratory findings make diagnosis difficult. High morbidity and mortality are associated with this type of injury when diagnosis and treatment are delayed. Small bowel rupture should be considered in any patient with a history of significant blunt abdominal trauma and persistent abdominal pain.     

Early recognition of diaphragmatic injuries from blunt trauma

Rupture of the diaphragm from blunt trauma was identified in 42 patients in four years. The contribution of peritoneal lavage in identifying these injuries was examined. More than 93% of the ruptured diaphragms were identified within 24 hours. Peritoneal lavage was positive in 89% of patients who had no other source of intraabdominal hemorrhage. Chest radiography alone identified 41% of the patients who had diaphragm injury. If the peritoneal lavage is negative and the best radiograph is not diagnostic but suspicion of diaphragm injury remains, the lavage catheter can still be used to instill contrast into the peritoneum. Peritoneal lavage, when used in combination with chest radiography, is a reliable, rapid, and simple aid in identifying ruptured diaphragms from blunt trauma.     

Traumatic disruption of the brachiocephalic artery

We report the case of a patient presenting with blunt chest and head injuries. Initial emergency department evaluation revealed a pulmonary contusion and suspected closed head injuries. Computed tomographic scan of the head was unremarkable. An angiogram performed to further investigate the nature of his head injuries revealed a disruption of the brachiocephalic artery. The lesion was surgically repaired in the operating room and the patient was moved to the intensive care unit, where he remained comatose and died from complications of his head and chest injuries on the seventh post-operative day. The pathophysiology and clinical manifestations of injuries to the brachiocephalic artery are discussed.     

Incidental finding of arteria lusoria during transradial coronary catheterization: Significance in interventional cardiology

Arteria lusoria is the most common anomaly of the aortic arch with an incidence of 0.5%–2.5%. It is mostly diagnosed incidentally while performing imaging for evaluation of other unrelated medical conditions. The aberrant right subclavian artery arises beyond the origin of the left subclavian artery from the aortic arch. This results in a complex right‐subclavian‐aortic anatomy which leads to difficulty in transradial coronary angiography. This can lead to prolonged procedure time and increased use of catheters by unaware interventionists. This is even more important if this is encountered in the setting of an acute myocardial infarction. Our review takes into account clinical significance of this uncommon anomaly in the field of interventional cardiology.     

Should the emergency IVP be used more selectively in blunt renal trauma?

A retrospective study was performed to determine if the emergency intravenous pyelogram (IVP) is being overused in the evaluation of blunt renal trauma. Medical records of 105 blunt renal trauma patients undergoing IVPs for suspected blunt renal trauma were analyzed. Eighty-eight patients (83.8%) had normal IVPs, and 17 patients (16.2%) had abnormal IVPs. Three of the 105 patients (2.9%) required urologic surgical intervention. The medical records of these patients were examined in detail because it was believed that this patient population needed to be identified by emergency IVP. All three patients requiring urologic surgery had gross hematuria. All three patients had one or more associated injuries. Two of the three patients had flank tenderness and/or flank mass. The third patient was obtunded. From this study and information from the literature an algorithm has been constructed as a guideline for a prospective study. Following this guideline no patients in the study requiring urologic surgical intervention would have been missed. Of patients requiring an emergency IVP, 7.3% would have required urologic surgery. This would have resulted in a savings of $10,432 at our institution.     

Myocardial contusion presented as acute myocardial infarction after chest trauma

A 46-year-old male patient developed an acute myocardial infarction and congestive heart failure following blunt chest trauma. Electrocardiogram (ECG) revealed acute anterior myocardial infarction. Echocardiography showed akinesis of interventricular septum, dyskinesis in apical anterior wall, and severe impairment of left ventricular overall systolic function. Coronary angiography revealed normal coronary arteries. The patient followed a low-intensity physical medicine rehabilitation program. Follow-up was without new complications or deterioration of congestive heart failure. Five months later the patient presented with fulminant acute pulmonary edema and cardiogenic shock. Cardiopulmonary resuscitation was unsuccessful.