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Case Presentation. Presenter: intern 董又慈 Date: 2011.8.23 Supervisors: R2 洪紹恩 / VS 高維聖醫師. Triage. Chief Complaints. Persistent chest pain after traffic accident on 2011-06-23 (for one day). Profile of the chest pain. Present Illness. Traffic accident with a confronted truck

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case presentation

Case Presentation

Presenter: intern 董又慈

Date: 2011.8.23

Supervisors: R2 洪紹恩/ VS 高維聖醫師

chief complaints
Chief Complaints

Persistent chest pain after traffic accident

on 2011-06-23 (for one day)

present illness
Present Illness
  • Traffic accident with a confronted truck
  • Head injury and chest contusion
  • Taken to 恆春南門醫院 where…
    • laceration wound was sutured
    • persistent retrosternal chest dull pain
    • admitted for observation
  • AAD, came to our ED on 2011-06-24
ekg @
EKG@南門

I

aVR

II

aVL

III

aVF

v1

v4

v2

v5

v3

v6

head neck ct
Head & Neck CT
  • No evidence of ICH
  • Hemosinus, no facial bone fracture
primary survey
Primary Survey
  • Airway
  • Breathing
    • Talk well, no respiratory distress
    • Circulation
      • HR: 97, BP: 139/57, SpO2: 99%
      • FAST: negative
    • Disability
    • Exposure
physical examination
Physical Examination
  • HEENT:
    • L/W, hematoma at left frontal region.
    • Ecchymosis at left eyelid
    • E.O.M.: normal, pupils size(2.5/2.5), light reflex: R(+)L(+),
  • Chest:
    • No jugular vein engorgement
    • Regular heart beats, no murmur
  • Abdomen:
    • No visible lesions
    • Soft and flat, normoactive bowel sound
  • Extremities:
    • Warm. No edema. ROM fine
chest plain film
Chest Plain Film

Previous CXR @南門

Portable CXR@NCKUH ED

12 40 cv man visited
12:40 CV Man Visited
  • Bedside echocardiogram
    • Dilated LV
    • Borderline LV systolic performance with anteroseptal, anterior hypokinesis, apical akinesis
    • Trivial TR
    • No pericardial effusion
    • Not dilated IVC
  • Impression:
    • Anterioir ST elevation susp. traumatic STEMI, R/O Takotsubo syndrome
impressions and plans
Impressions And Plans
  • 1. STEMI, cause?
    • Trauma related? Coincidence?
    • Other risk factor? Only smoking
  • 2. Head injurywith scalp hematoma, facial laceration, and left hemosinus
  • 4. Multiple contusion
13 40
13:40

Sent patient to angio room

cath note
CATH Note
  • Coronary angiography
    • LAD: Atheosclerosis with total occlusion
    • LCX: Atherosclerosis without significant stenosis
    • RCA: Atherosclerosis with a 50% stenosis
    • Collateral from RCA to mLAD showed haziness and coronary dissection was suspected
  • Cath diagnosis:

1.Recent MI/Ant. wall/Killip I with persistent angina

2.CAD/2-V-D(LAD+RCA) susp traumatic related coronary injury--> PCI

follow up
Follow-up
  • 2011.6.25 CCU
    • Chest pain improved!!
    • Dyslipidemia
  • 2011.6.27
    • Transferred to the general ward
definition
Definition
  • It is hard to definite.
  • Blunt cardiac injury (BCI) encompasses a spectrum of pathology.
  • To describe BCIs in terms of specific injuries was preferred:
    • Myoardiac rupture
    • Septal rupture
    • Valvular injury
    • Cardiac contusion
      • Myocardial infarction or cardiac dysfunction
  • Commotiocodis
risk factor and epidemiology
Risk Factor And Epidemiology
  • High-speed motor vehicular crashes:
    • Greater than 20 miles per hour
    • Bending of the steering wheel
  • Falls and crush injuries
  • Violence
  • The true incidence of blunt cardiac injuries remains difficult to estimate.
mechanism and pathophysiology
Mechanism And Pathophysiology

Rapid deceleration

Kinetic energy transferred to the chest

Structural rupture

Compression between spine and sternum

Abrupt pressure increase in the chest and abdomen

Suddenly increased intraventricular pressure

Shearing force due to relative velocity

Myocardium contusion

Fragments from fracture

Coronary dissection or thrombosis

clinical features
Clinical Features
  • Pericardial tamponade →
    • Hypotension, jugular vein engorgement, muffled heart sound
  • Hypotension, low cardiac output
  • Precordial pain
  • Heart murmur
  • Dysrythmias of different types
slide24
EKG
  • Unexplained sinus tachycardia
  • Premature ventricular contractions
  • A new bundle branch block
  • ST depressions or elevations
slide25
ECHO
  • FAST: R/O pericardial tamponade
  • Bedside echocardiogram:
    • Wall motion abnormalities
    • Valvular rupture or dysfunction
    • Thrombus
  • Transesophageal echocardiogram
  • Transthoracic echocardiogram
cardiac enzyme
Cardiac Enzyme
  • CK, CK-MB
    • Does NOT establish NOR correlate with BCI
  • TnT, TnI
    • More specific to cardiac muscle
    • A diagnostic tool for myocardial injury
heart injury protocol
創傷外科 HeartInjuryProtocol

Chestblunttrauma

CXR, ECG, cardiac enzyme

Symptoms,

CK-MB↑

Arrhythmia

Conditionstable

shock

Trauma mechanism suggest impact to heart

Conditionunstable

  • Cardiac tamponade
  • Ventricular akinesia
  • Other structural injury

Yes

No

Intensivecare,andthenadmittedtoregularward

No need for intensive care or testing despite of minimal ECG change or mild elevated C-MB

Angina-like chest pain

CK-MB↑

Minor arrhythmia

Progressive dyspnea, ischemic ECG, complex arrhythmia

Intensive care

Specific therapy

echocardiography

Monitored in an intermediate care unit

Echocardiography if symptoms > 12 hrs

reference
Reference
  • Trauma, Court-Brown, Charles M./McQueen, Margaret M./Tornetta, Paul./Lippincott Williams & Willkins, 2006
  • Cardiac surgery in the adult, Cohn, Lawrence H., 1937-/Edmunds, L. Henry./McGraw-Hill Medical, 2008
  • ATLS, 8thedision
  • 成大醫院急診部急診外科臨床指引手冊
  • 成大醫院創傷病人處理流程
  • ST-Segment Elevation in Conditions OtherThan Acute Myocardial Infarction, NEJM 2003; 349:2128