Sudden death due to cardiac contusion: Forensic implications in a rare pediatric case.

Blunt chest trauma (BCT) often results in blunt cardiac injuries of little clinical concern, but cases of severe heart damage with high mortality rates have also been described. In particular, BCT should never be underestimated, especially when it is located in the anterior thoracic region. Among traffic accidents, motorcyclists are the most vulnerable and at the greatest risk. We report the case of a 14-year-old boy who experienced BCT following a motorcycle accident. He was evaluated at the hospital and was found to be in good medical condition, without bruises or rib fractures. Electrocardiography revealed a left bundle branch block. The patient was kept overnight for observation and was discharged the following morning in a good health condition. However, five days later, the patient suddenly died. Autopsy revealed a cardiac contusion associated with a full-thickness myocardial rupture and massive hemopericardium. Histologically, hemorrhagic infiltration foci, fibrin deposits, neutrophilic granulocytes, and well-defined areas of necrosis were detected in the context of recent fibrosis. Coronary thrombosis was not observed. The cause of death was identified as cardiac contusion that caused myocardial necrosis and, ultimately, cardiac rupture. Because the boy suffered a recent BCT and was assessed at the hospital, issues of medical malpractice were raised. This case demonstrates the potential lethality of blunt chest trauma in pediatric patients and demonstrates the importance of not underestimating such events, even in the absence of clinically identified chest injuries.

A Fatal Case of Cardiac Contusion After Blunt Chest Injury.

ABSTRACT: In this article, we report the autopsy findings of a 48-year-old man who sustained blunt trauma to the thorax. A medical record review revealed no history of cardiac disease. He presented to the hospital with a computed tomography-verified fracture of the left fourth and fifth ribs, and pulmonary and cardiac contusion. He was released from the hospital in stable condition at his own request 7 days later. Because of sudden deterioration, he was readmitted to the hospital the next day. Electrocardiogram detected cardiac arrhythmia on the 15th day after chest trauma. Electrocardiography detected pericardial effusion and severe mitral insufficiency resulting in left ventricular failure. Death was attributed to diffuse alveolar damage-complicating pneumonia due to cardiac contusion with mitral insufficiency occurring 25 days after hospital admission. Internal examination revealed diffuse fibrinous pericarditis, left atrial tear right above the anterior mitral valve leaflet with intrapericardial granulation tissue, and no sign of myocardial damage. Immunohistochemistry showed significantly more CD68-positive macrophages within tissue taken from the heart, a finding indicative of previous atrial and ventricular myocardial contusion. This case report demonstrates that routine hematoxylin and eosin staining may not always reveal significant myocardial damage.

Management of Seat Belt-type Blunt Abdominal Aortic Trauma and Associated Injuries in Pediatric Patients.

BACKGROUND: "Seat belt-type" pediatric abdominal aortic trauma is uncommon but potentially lethal. During high speed motor vehicle collisions (MVCs), seat or lap belt restraints may concentrate forces in a band-like pattern across the abdomen, resulting in the triad of hollow viscus perforation, spine fracture, and aortoiliac injury. We report 4 cases of pediatric seat belt-type aortic trauma and review management strategies for the aortic disruption and the associated constellation of injuries. METHODS: -approved, retrospective review of all pediatric patients requiring surgical intervention for seat belt-type constellation of abdominal aortic/iliac and associated injuries over a 5-year period. Blunt thoracic aortic injuries were excluded. RESULTS: We identified 4 patients, ranging from 2 to 17 years of age, who required surgical correction of seat belt-type aortoiliac trauma and associated injuries: 3 abdominal aortas and 1 left common iliac artery. The majority (3/4 patients) were hemodynamically unstable at emergency room presentation, and all underwent computed tomography angiography of the chest/abdomen/pelvis during initial resuscitation. Injuries of the suprarenal and proximal infrarenal aorta were accompanied by unilateral renal artery avulsion requiring nephrectomy. Presumed or proven spinal instability mandated supine positioning and midline laparotomy, with medial visceral rotation utilized for proximal injuries. Aortoiliac injuries requiring repair were accompanied by significant distal intraluminal prolapse of dissected intima, with varying degrees of obstruction. Conduit selection was dictated by the presence of enteric contamination and the rapid availability of an autologous conduit. The sole neurologic deficit was irreparable at presentation. CONCLUSIONS: Seat belt aortoiliac injuries in pediatric patients require prompt multidisciplinary evaluation. Evidence of contained aortoiliac transection, major branch vessel avulsion, and bowel perforation mandates immediate exploration, which generally precedes spinal interventions. Lesser degrees of aortoiliac injuries have been managed with surveillance, but long-term follow-up is needed to fully validate this approach.

Finite Element Analysis of the Mechanism of Traumatic Aortic Rupture (TAR).

As many as 80% of patients with TAR die on the spot while out of those reaching a hospital, 30% would die within 24 hours. Thus, it is essential to better understand and prevent this injury. The exact mechanics of TAR are unknown. Although most researchers approve it as a common-sense deceleration injury, the exact detailed mechanism of TRA still remains unidentified. In this work, a deceleration mechanism of TAR was carried out using finite element analysis (FEA). The FE analysis aimed to predict internal kinematics of the aorta and assist to comprehend the mechanism of aorta injury. The model contains the heart, lungs, thoracic aorta vessel, and rib cage. High-resolution computerized tomography (HR CT scan) was used to provide pictures that were reconstructed by MIMICS software. ANSYS FE simulation was carried out to investigate the behavior of the aorta in the thoracic interior after deceleration occurred during a car crash. The finite element analysis indicated that maximum stress and strain applied to the aorta were from 5.4819e5 to 2.614e6 Pa and 0.21048 to 0.62676, respectively, in the Y-direction when the initial velocity increased from 10 to 25 m/s. Furthermore, in the X-direction when the velocity changed from 15 to 25 m/s, the stress and strain values increased from 5.17771e5 to 2.3128e6 and from 0.22445 to 0.618, respectively.

Thermodynamic interference with bile acid demicelleization reduces systemic entry and injury during cholestasis.

Bile acids (BA), with their large hydrophobic steroid nucleus and polar groups are amphipathic molecules. In bile, these exist as micelles above their critical micellar concentration (CMC). In blood at low concentrations, these exist as monomers, initiating cellular signals. This micellar to monomer transition may involve complex thermodynamic interactions between bile salts alone or with phospholipids, i.e. mixed micelles and the aqueous environment. We therefore went on to test if therapeutically relevant changes in temperature could influence micellar behavior of bile salts, and in turn whether this affected the biological responses in cells, and in vivo. Sodium taurocholate (STC) belongs to a major class of bile salts. STC has a CMC in the 5-8 mM range and its infusion into the pancreatic duct is commonly used to study pancreatitis. We thus studied micellar breakdown of STC using isothermal titration calorimetry (ITC), dynamic light scattering and cryogenic transmission electron microscopy. Under conditions relevant to the in vivo environment (pH 7.4, Na 0.15 M), ITC showed STC to have a U shaped reduction in micellar breakdown between 37 °C and 15 °C with a nadir at 25 °C approaching ≈90% inhibition. This temperature dependence paralleled pancreatic acinar injury induced by monomeric STC. Mixed micelles of STC and 1-palmitoyl, 2-oleyl phosphatidylcholine, a phospholipid present in high proportions in bile, behaved similarly, with ≈75% reduction in micellar breakdown at 25 °C compared to 37 °C. In vivo pancreatic cooling to 25 °C reduced the increase in circulating BAs after infusion of 120 mM (5%) STC into the pancreatic duct, and duct ligation. Lower BA levels were associated with improved cardiac function, reduced myocardial damage, shock, lung injury and improved survival independent of pancreatic injury. Thus micellar breakdown of bile salts is essential for their entry into the systemic circulation, and thermodynamic interference with this may reduce their systemic entry and consequent injury during cholestasis, such as from biliary pancreatitis.

Cardiothoracic injuries after CardioPump CPR: a report of two cases and review of the literature.

Although many clinical trials have demonstrated its efficacy during active compression-decompression cardiopulmonary resuscitation (ACD-CPR), the Ambu® CardioPump seems likely to cause severe and sometimes lethal injuries. In this paper, we report two cases observed at the Institute of Legal Medicine of Nancy, France. A 67-year-old man collapsed in the street, in the presence of witnesses, and without any sign of trauma. The autopsy revealed a flail chest, a wound of the left ventricle, a rupture of the right ventricle, and a wrenching of the inferior vena cava. A 71-year-old woman was found in her apartment during an accidental fire. The autopsy revealed a sternal fracture, many rib fractures, and a perforation of the superior vena cava, the pericardium, and the heart. Despite articles focusing on complications of the use of the CardioPump in the late 1990s, this technique is still used in practice. These two cases emphasize that iatrogenic injuries must be taken into account in the CardioPump benefit/risk balance and the relevance of its daily use.

ST-segment elevation after blunt chest trauma: myocardial contusion with normal coronary arteries or myocardial infarction following coronary lesions.

Cardiac lesions secondary to blunt chest trauma vary from insignificant arrhythmias to fatal cardiac rupture. Of these, a distinction remains difficult; face to ST-segment elevation on ECG with positive cardiac biomarkers, is it a myocardial contusion or a genuine myocardial infarction (MI) secondary to coronary lesions? We report the case of a patient admitted for multiple trauma. Initial assessment showed an ST segment elevation on ECG, along with multiple fractures and abdominal injuries. We would like to discuss, through this case, the similarities and the differences between myocardial infarction due to coronary lesions and myocardial contusion in a traumatic context, but also emphasize the difficulty of striking the right balance between thrombotic and bleeding risks in this situation, and insist on the importance of a multidisciplinary and collegial reflexion so we can offer these patients the best care there is.

Paediatric chest wall trauma causing delayed presentation of ventricular arrhythmia.

This report describes a paediatric patient presenting with haemodynamically stable non-sustained ventricular tachycardia 1 day after minor blunt chest trauma. Initial laboratory studies, chest X-ray and echocardiography were normal; however, cardiac MRI revealed precordial haematoma, myocardial contusion and small pericardial effusion. Throughout her hospital course, she remained asymptomatic aside from frequent couplets and triplets of premature ventricular contractions. Ectopy was controlled with oral verapamil. This case highlights how significant cardiac injury may be missed with standard diagnostic algorithms.

Cardiac Trauma.

Cardiac trauma is a leading cause of death in the United States and occurs mostly due to motor vehicle accidents. Blunt cardiac trauma and penetrating chest injuries are most common, and both can lead to aortic injuries. Timely diagnosis and early management are the key to improve mortality. Cardiac computed tomography and cardiac ultrasound are the 2 most important diagnostic modalities. Mortality related to cardiac trauma remains high despite improvement in diagnosis and management.

Imaging in blunt cardiac injury: Computed tomographic findings in cardiac contusion and associated injuries.

BACKGROUND: Blunt cardiac injury (BCI) may manifest as cardiac contusion or, more rarely, as pericardial or myocardial rupture. Computed tomography (CT) is performed in the vast majority of blunt trauma patients, but the imaging features of cardiac contusion are not well described. PURPOSE: To evaluate CT findings and associated injuries in patients with clinically diagnosed BCI. MATERIALS AND METHODS: We identified 42 patients with blunt cardiac injury from our institution's electronic medical record. Clinical parameters, echocardiography results, and laboratory tests were recorded. Two blinded reviewers analyzed chest CTs performed in these patients for myocardial hypoenhancement and associated injuries. RESULTS: CT findings of severe thoracic trauma are commonly present in patients with severe BCI; 82% of patients with ECG, cardiac enzyme, and echocardiographic evidence of BCI had abnormalities of the heart or pericardium on CT; 73% had anterior rib fractures, and 64% had pulmonary contusions. Sternal fractures were only seen in 36% of such patients. However, myocardial hypoenhancement on CT is poorly sensitive for those patients with cardiac contusion: 0% of right ventricular contusions and 22% of left ventricular contusions seen on echocardiography were identified on CT. CONCLUSION: CT signs of severe thoracic trauma are frequently present in patients with severe BCI and should be regarded as indirect evidence of potential BCI. Direct CT findings of myocardial contusion, i.e. myocardial hypoenhancement, are poorly sensitive and should not be used as a screening tool. However, some left ventricular contusions can be seen on CT, and these patients could undergo echocardiography or cardiac MRI to evaluate for wall motion abnormalities.