NM-231
Peri-operative complex arrhythmia as a clinical manifestation of blunt chest trauma after MVA.
Cruz Beltran S, Rosenberg, md E, Austin, md T
Emory University - Children's Healthcare of Atlanta, Atlanta, Georgia, United states of america
Introduction: According to the Centers for Disease Control and Prevention, the leading cause of pediatric mortality is unintentional injury with motor vehicles being the overriding source. (1) Factors associated with mortality from motor vehicle accidents (MVA) in this age group include being unrestrained or improperly restrained and the crash occurring on a rural road. (2) Death normally occurs due to traumatic brain injury and/or blunt force chest and abdominal trauma. This case report details a rare perioperative event in a pediatric patient that underwent an emergent diaphragm repair due to an MVA.
Case Report: Our patient was a 13 year old female who presented after being an unrestrained passenger in a high speed, roll over MVA. Her initial GCS was 14 with the following injuries: left traumatic diaphragm rupture, left femoral neck fracture, right femur fracture, bilateral pelvic fractures, multiple tooth avulsions, an abdominal wall laceration and left chest wall abrasion. She was electively intubated in the emergency department and taken to the operating room for an exploratory laparotomy with repair of her diaphragm and pelvic/femoral fixation to follow. During her initial surgery, the patient began to exhibit short periods of narrow complex, stable tachyarrhythmias mixed with sinus rhythm. Her dysrhythmias became more frequent with marked lability in maintaining a perfusing rhythm. Concern for pericardial tamponade and structural damage prompted an intraoperative echocardiogram and cardiology consult. Her echocardiogram showed no evidence of tamponade and normal cardiac function. It was felt she had likely suffered direct myocardial injury to her His-Purkinje system and AV node with resultant dysrhythmias. Since the patient continued to have frequent tachyarrhythmias, her orthopedic procedure was canceled and she was transported to the PICU. Upon arrival to PICU, her narrow complex tachycardia changed to a pulseless, wide complex tachycardia requiring several rounds of CPR with defibrillation, initiation of B-blockade, lidocaine, amiodarone and code dose epinephrine. She stabilized to a sinus rhythm intermixed with a non-perfusing ventricular escape rhythm and ultimately became dysrhythmia free after 48 hours.
Discussion: Blunt cardiac injury (BCI) is unusual in children with a prevalence of 0.3% in blunt trauma cases. (3) Manifestations of this manner of injury include dysrhythmias, unexplained hypotension, and cardiac-specific enzyme elevation. Death in these patients may result quickly from acute pump failure due to septal or valvular defects. (4) If BCI is suspected perioperatively, echocardiography may be warranted to rule out both structural damage and cardiac tamponade while cardiac-specific enzymes should be drawn to confirm diagnosis. Management of BCI is largely supportive with inotropes for contusion-related hypotension and/or anti-arrhythmics for dysrhythmias. Patients with BCI should be continuously monitored for 24 – 48 hours for delayed development of dysrhythmias and hypotension.
References:
1. https://www.cdc.gov
2. J Pediatr 187 (2017): 295-302.
3. Crit Care Med 30.11 (2002): S409-S415.
4. J Trauma 40.1 (1996): 61-67.
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