Mashiko Kazuki, Matsumoto Hisashi, Yasumatsu Hiroshi, Ueda Taichiro, Yamamoto Mariko, Funaki Yutaka, Toshimitsu Yasuko
Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan.
Trauma Case Rep. 2021 Mar 17;32:100464. doi: 10.1016/j.tcr.2021.100464. eCollection 2021 Apr.
A 38-year-old man was pressed on his trunk by a heavy object weighing about 100 kg. The patient was in shock status on arrival to the hospital. Circular collapse progressed rapidly during contrast computed tomography (CT) scanning. CT images revealed exacerbation of the right lateral deviation of the heart that was earlier seen on X-ray imaging. Considering cardiac herniation based on CT findings, we immediately performed resuscitative thoracotomy and clamshell thoracotomy at the emergency department. Intraoperative findings showed a pericardial defect, and the heart had deviated to the right thoracic cavity. Immediate repositioning revealed a marked improvement in circulation. Full-thickness cardiac injury was observed in the anterior wall of the left ventricle; no active bleeding was observed. We performed temporary thoracic wall closure after cardiorraphy for damage control. After admission to the intensive care unit, he presented with respiratory failure associated with pulmonary contusion. Therefore, veno-venous extracorporeal membrane oxygenation (V-V ECMO) was used from the 2nd to the 5th hospital day. After confirming no intra-thoracic events on the 6th hospital day, chest wall closure was performed. The patient subsequently developed heart failure and mitral regurgitation associated with papillary muscle rupture. On the 62nd hospital day, he underwent mitral annuloplasty at the cardiovascular surgery division; After rehabilitation till 152nd hospital day, he was discharged without any neurological abnormality. This was an extremely rare case with concomitant full-thickness myocardial injury, intracardiac injury, and cardiac herniation. Rapid resuscitative thoracotomy and damage control including V-V ECMO yielded good results. Retrospectively, cardiac herniation should have been suspected earlier basis this observation. Our report highlights that cardiac herniation should be considered in case of cardiac shadow aberrations in cases of blunt chest trauma, familiarity with condition and its characteristic imaging findings are critical for the doctor overseeing initial trauma treatment.
一名38岁男性被一个约100公斤重的重物压在躯干上。患者入院时处于休克状态。在进行对比计算机断层扫描（CT）时，环形塌陷迅速进展。CT图像显示心脏向右外侧偏移加重，这在早期的X线成像中就已出现。基于CT表现考虑为心脏疝，我们立即在急诊科进行了复苏性开胸和蛤壳式开胸手术。术中发现心包缺损，心脏已向右胸腔偏移。立即重新定位后，循环明显改善。左心室前壁观察到全层心肌损伤；未观察到活动性出血。我们在心脏缝合术后进行了临时胸壁闭合以控制损伤。入住重症监护病房后，他出现了与肺挫伤相关的呼吸衰竭。因此，在住院第2天至第5天使用了静脉 - 静脉体外膜肺氧合（V-V ECMO）。在住院第6天确认无胸腔内异常后，进行了胸壁闭合。患者随后出现了与乳头肌破裂相关的心力衰竭和二尖瓣反流。在住院第62天，他在心血管外科进行了二尖瓣环成形术；经过康复直至住院第152天，他出院时无任何神经功能异常。这是一例极为罕见的同时伴有全层心肌损伤、心内损伤和心脏疝的病例。快速的复苏性开胸和包括V-V ECMO在内的损伤控制取得了良好效果。回顾来看，基于此观察结果，应更早怀疑心脏疝。我们的报告强调，在钝性胸部创伤病例中出现心脏阴影异常时应考虑心脏疝，熟悉该病症及其特征性影像学表现对于负责初始创伤治疗的医生至关重要。
