Ann Thorac Surg 1997;64:258-260
© 1997 The Society of Thoracic Surgeons
Case Report
Blunt Intrapericardial Rupture of the Pulmonary Artery in a Surviving Patient
Ronald H. Clements, MD,
Lee S. Wagmeister, MD,
Robert P. Carraway, MD
Departments of Surgery, Carraway Methodist Medical Center and The Norwood Clinic, Inc, Birmingham, Alabama
Accepted for publication March 10, 1997.
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Abstract
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Blunt chest trauma can produce a number of potentially lethal injuries, including pulmonary artery rupture. Survivors of pulmonary artery injuries are rare. Most previously reported surviving patients presented with hemothorax from a hilar injury. We report a patient who survived a blunt rupture of the intrapericardial portion of the pulmonary artery and thus presented with pericardial tamponade. The interventions that led to her survival are discussed.
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Introduction
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Blunt chest trauma can produce life-threatening injuries to the heart and great vessels as well as the aerodigestive tract. It is, however, particularly rare for a patient to sustain blunt injury to the pulmonary artery. Most patients who survive injuries to the pulmonary artery have the injury located in the hilum, thus presenting as hemothorax.
We report a patient who sustained an intrapericardial blunt rupture of the pulmonary artery in an automobile accident and the diagnostic and therapeutic interventions that led to her survival.
A 42-year-old woman was transported to Carraway Methodist Medical Center, a level one regional trauma center, after she and a passenger were involved in a high-speed motor vehicle collision. The passenger was dead at the scene. The patient presented to the trauma resuscitation room without hypotension, but she was unresponsive requiring intubation upon arrival.
Initial examination was remarkable for a flail segment of the right chest and a distended abdomen. Chest roentgenography revealed multiple right rib fractures, a fractured left clavicle, and a left pneumothorax, for which a chest tube was inserted. The heart silhouette was not enlarged, and the mediastinum was not widened. Other roentgenograms revealed a comminuted fracture of the right calcaneus and a fractured right patella. Initial hematocrit was 36.5%, and arterial blood gas analysis revealed a pH of 7.18, carbon dioxide tension of 50 mm Hg, oxygen tension of 64 mm Hg, and base deficit of 13.6.
Two large-bore, peripheral intravenous lines were inserted, and volume resuscitation was initiated. Foley catheter and nasogastric tube were inserted. A diagnostic peritoneal lavage was performed and was grossly positive, with 10 mL of blood aspirated from the peritoneal cavity. She was immediately taken to the operating room, where exploratory laparotomy revealed approximately 300 mL of blood from a grade two liver injury that was easily controlled with one suture ligature. No other source of blood loss was identified; however, the patient became profoundly hypotensive. Subxiphoid pericardial window released a large amount of blood under pressure. Median sternotomy was immediately performed, and the pericardium was opened widely. The superior vena cava was retracted to the right, and the aorta was retracted to the left to expose the laceration of the right pulmonary artery that extended onto the main pulmonary artery (Fig 1
). The surgeon's finger was inserted into the laceration of the pulmonary artery to control the hemorrhage until Allis clamps could be placed on the vessel. 4-0 Prolene (Ethicon, Somerville, NJ) was used to close the laceration in a running fashion. The heart and proximal great vessels were then carefully inspected, and no other injury was identified.
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Fig 1. . Aorta resected to show laceration of right pulmonary artery extending onto main pulmonary artery.
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Postoperatively, an aortogram revealed no aortic injury, and computed tomograms of the head showed no intracranial injury. She later underwent open reduction and internal fixation of the patella and calcaneus fractures. The patient recovered uneventfully from her injuries and was discharged on the eighth postoperative day without any symptoms referable to the pulmonary artery. At follow-up, she remains asymptomatic.
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Comment
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Injury to the pulmonary artery from blunt trauma is uncommon. Kemmerer and associates [1], in an autopsy series, found only 4 cases of blunt pulmonary artery injuries in 585 deaths. Even so, this injury should be in the differential diagnosis of any patient with chest pain, hypoxemia, and persistent bleeding from a hemothorax in the posttraumatic period. It must also be considered in the setting of pericardial tamponade.
An extensive search of the surgical literature revealed sporadic reports of patients who sustained blunt injury of the pulmonary artery [2–4]. These cases generally present in one of three ways. First, the patient may have massive hemothorax requiring thoracotomy. The injury of the pulmonary artery at the hilum is thus diagnosed and treated, often requiring pneumonectomy. Second, a partial tear of the pulmonary artery may be contained within the connective tissue surrounding the vessel, which leads to the formation of a pseudoaneurysm that may be asymptomatic for a variable period of time or cause respiratory distress that resembles pulmonary embolism. The third presentation is that of a delayed onset of a large pleural effusion. An angiogram may be necessary if a large quantity of hemorrhagic fluid is aspirated from the chest.
We report a case that demonstrates a fourth clinical presentation of a pulmonary artery injury, namely, pericardial tamponade. Expeditious and accurate diagnosis of pericardial tamponade in the unstable patient is of paramount importance if the patient is to be salvaged. This can be accomplished in a number of ways. Pericardiocentesis can be both diagnostic and therapeutic. Ultrasound has been used by Rozycki and associates [5] to diagnose pericardial fluid accurately and noninvasively. A third option is subxiphoid pericardial window, as was the case in the current patient. Localization of the injury can then be made by direct inspection through a median sternotomy, which should not be delayed once the diagnosis is made.
We believe most intrapericardial injuries of the pulmonary artery can be repaired without the use of cardiopulmonary bypass. The bleeding can usually be controlled by direct pressure until proximal control is gained or until the repair is completed. Access to the right pulmonary artery can be obtained by retracting the superior vena cava to the right and the aorta to the left. If necessary, the aorta and main pulmonary artery can be separated and retracted as described by Hawkins and colleagues [2]. This affords exposure of the main trunk and both branches of the pulmonary arteries at their origins to allow proximal control if needed. Exposure of the left pulmonary artery within the pericardium is usually straightforward, requiring minimal dissection. Another option for control of the hemorrhage is to gently apply Allis clamps directly over the laceration if it is in an exposed location. Closure can then be accomplished safely and efficiently without unnecessary dissection in this region.
In conclusion, blunt injury of the pulmonary artery is an uncommon injury that carries substantial mortality. Most of these wounds present with massive hemothorax requiring thoracotomy. We report a patient who survived an unusual presentation of a blunt injury to the pulmonary artery, ie, pericardial tamponade. Salvage of either type of pulmonary artery injury depends on clinical suspicion, rapid diagnosis, immediate operation, and vigorous resuscitation. The trauma surgeon must be prepared to approach pulmonary artery injuries in either situation.
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Footnotes
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Address reprint requests to Dr Carraway, Surgical Education, Carraway Methodist Medical Center, 1600 Carraway Blvd, Birmingham, AL 35234.
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References
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- Kemmerer WT, Eckert WG, Gathright JB, Reemtsma K, Creech O Jr. Patterns of thoracic injuries in fatal traffic accidents. J Trauma 1961;1:595–9.[Medline]
- Hawkins ML, Carraway RP, Ross SE, Johnson RC, Tyndal EC, Laws HL. Pulmonary artery disruption from blunt thoracic trauma. Am Surg 1988;54:148–52.[Medline]
- Dillon WP, Taylor AT, Mineau DE, Datz FL. Traumatic pulmonary artery pseudoaneurysm simulating pulmonary embolism. AJR 1982;139:818–9.[Free Full Text]
- Collins MP, Robinson GC. Traumatic rupture of the pulmonary artery. Ann Thorac Surg 1989;47:612–3.[Abstract]
- Rozycki GS, Feliciano DV, Schmidt JA, et al. The role of surgeon-performed ultrasound in patients with possible cardiac wounds. Ann Surg 1996;223:737–46.[Medline]
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