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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. 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

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  1. Case Presentation Presenter: intern 董又慈 Date: 2011.8.23 Supervisors: R2 洪紹恩/ VS 高維聖醫師

  2. Triage

  3. Chief Complaints Persistent chest pain after traffic accident on 2011-06-23 (for one day)

  4. Profile of the chest pain

  5. 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

  6. EKG@南門 I aVR II aVL III aVF v1 v4 v2 v5 v3 v6

  7. Head & Neck CT • No evidence of ICH • Hemosinus, no facial bone fracture

  8. LabData @南門

  9. Primary Survey • Airway • Breathing • Talk well, no respiratory distress • Circulation • HR: 97, BP: 139/57, SpO2: 99% • FAST: negative • Disability • Exposure

  10. 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

  11. Complete EKG @ ED

  12. Chest Plain Film Previous CXR @南門 Portable CXR@NCKUH ED

  13. 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

  14. 13:23 Laboratory Data @ ED

  15. 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

  16. 13:40 Sent patient to angio room

  17. 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

  18. Follow-up • 2011.6.25 CCU • Chest pain improved!! • Dyslipidemia • 2011.6.27 • Transferred to the general ward

  19. Discussion Blunt cardiac injury(Bci)

  20. 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

  21. 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.

  22. 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

  23. Clinical Features • Pericardial tamponade → • Hypotension, jugular vein engorgement, muffled heart sound • Hypotension, low cardiac output • Precordial pain • Heart murmur • Dysrythmias of different types

  24. EKG • Unexplained sinus tachycardia • Premature ventricular contractions • A new bundle branch block • ST depressions or elevations

  25. ECHO • FAST: R/O pericardial tamponade • Bedside echocardiogram: • Wall motion abnormalities • Valvular rupture or dysfunction • Thrombus • Transesophageal echocardiogram • Transthoracic echocardiogram

  26. 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

  27. 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

  28. 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

  29. Thank you for your attention.

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