Case study of a 22 y.o. male driver of car, head on collision on an interstate highway, blunt chest trauma, rupture of pericardium with herniation of heart into left pleural cavity
The accident occurred not far from The Dalles, an Oregon town on the Columbia River about a 1 ½ hour drive from Portland. EMTs extricated him from the vehicle, “needled his left chest” to release a tension pneumothorax, and transported him to the nearest hospital, Mid Columbia Medical Center (MDMC), in The Dalles about 10 minutes away.
On patient arrival at the hospital, the surgeon on call inserted a left chest tube and re-expanded the patient’s left lung. The surgeon noticed the patient’s neck veins were distended, his facial skin was slightly cyanotic, and blood pressure was falling as the heart rate as rising: signs that the patient might have pericardial tamponade.
The surgeon did a left anterior thoracotomy to examine the pericardium for blood. Upon opening the left chest, he saw that the patient’s left and right ventricle had herniated through a 7 cm. long tear in the pericardium just anterior to the left phrenic nerve. The torn pericardial edges wrapped around the patient’s atrioventricular groove, essentially compressing the venous return to the patient’s right and left atrium, causing the symptoms mimicking a pericardial tamponade. The surgeon had never seen a pericardial rupture with biventricular herniation in his entire medical and surgical career. Multiple attempts to push the heart back into the pericardial sac only caused ventricular tachycardia. He realized that the patient was too unstable to transport to Emanuel and called for help from Emanuel.
We mobilized the MSTT and asked the trauma OR nurse to bring cardiac sutures and 12 inch long Allis tissue forceps. We arrived in the operating room at MCMC and scrubbed in. We used long Allis tissue forceps to grasp the edges of the pericardial tear anteriorly and posteriorly and pulled on the pericardial edges to create a “yawning” gap, allowing the beating heart to fall back into the pericardial sac; the patient’s blood pressure and heart rate stabilized. We sutured the tear in the pericardium and closed the patient’s left anterior thoracotomy. We asked the surgeon if he wanted to continue taking care of this patient, as the patient was now stable, but he declined.
We transported the patient to Emanuel, admitted him to our combined trauma and heart surgery ICU, and extubated him the following day. We discharged him from hospital a week later. We followed him in our trauma clinic for two visits, then referred him back to the surgeon in The Dalles.
Medical Clarification:
Blunt trauma pericardial rupture with herniation is extremely rare (estimated 0.4%). Most patients with this pathology die before arriving in the hospital.
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