Diaz-Miron Jose L, Dillon Patrick A, Saini Arun, Balzer David T, Singh Jasvindar, Kolovos Nikoleta S, Duncan Jennifer G, Keller Martin S
Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St Louis, Missouri.
Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St Louis, Missouri.
J Emerg Med. 2014 Aug;47(2):150-4. doi: 10.1016/j.jemermed.2014.04.034. Epub 2014 Jun 11.
Traumatic coronary artery dissection (CAD) after blunt chest trauma (BCT) is extremely rare, particularly in children. Among coronary dissections, left main coronary artery (LMCA) dissection is the least common, with only two pediatric cases reported previously. Manifestations of coronary dissections can range from ST segment changes to sudden death. However, these manifestations are not specific and can be present with other cardiac injuries. To our knowledge we present the first pediatric case of traumatic LMCA dissection after sport-related BCT that was treated successfully with coronary stenting.
A 14-year-old child sustained BCT during a baseball game. Early in the clinical course, he had episodes of ventricular dysrhythmias, diffuse ST changes, rising troponin I, and hemodynamic instability. Emergent cardiac catheterization revealed an LMCA dissection with extension into the proximal left anterior descending artery (LADA). A bare metal stent was placed from the LMCA to the LADA, which improved blood flow through the area of dissection. He has had almost full recovery of myocardial function and has been managed as an outpatient with oral heart failure and antiplatelet medications. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case highlights that CAD, although rare, can occur after pediatric BCT. Pediatric emergency responders must have a heightened awareness that evidence of ongoing myocardial ischemia, such as evolving and focal myocardial infarction on electrocardiogram, persistent elevation or rising troponin I, and worsening cardiogenic shock, can represent a coronary event and warrant further evaluation. Cardiac catheterization can be both a diagnostic and therapeutic modality in such cases. Early recognition and management is vital for myocardial recovery.
钝性胸部创伤（BCT）后发生创伤性冠状动脉夹层（CAD）极为罕见，尤其是在儿童中。在冠状动脉夹层中，左主干冠状动脉（LMCA）夹层最为少见，此前仅报道过两例儿科病例。冠状动脉夹层的表现范围从ST段改变到猝死。然而，这些表现并不具有特异性，也可能与其他心脏损伤同时出现。据我们所知，我们报告了首例与运动相关的BCT后发生创伤性LMCA夹层的儿科病例，并成功通过冠状动脉支架置入术进行了治疗。
一名14岁儿童在棒球比赛中遭受BCT。在临床病程早期，他出现室性心律失常、弥漫性ST段改变、肌钙蛋白I升高以及血流动力学不稳定。紧急心脏导管检查显示LMCA夹层并延伸至左前降支近端（LADA）。在LMCA至LADA置入了一枚裸金属支架，改善了夹层区域的血流。他的心肌功能几乎完全恢复，目前作为门诊患者接受口服心力衰竭药物和抗血小板药物治疗。为什么急诊医生应该了解这个病例？：我们的病例强调，CAD虽然罕见，但可发生于儿科BCT后。儿科急救人员必须提高认识，即持续心肌缺血的证据，如心电图上演变的局灶性心肌梗死、肌钙蛋白I持续升高或上升以及心源性休克恶化，可能代表冠状动脉事件，需要进一步评估。在这种情况下，心脏导管检查既是一种诊断手段，也是一种治疗方式。早期识别和处理对心肌恢复至关重要。
