Blunt traumatic pericardial rupture and cardiac herniation is a rare but often fatal injury from severe chest trauma. The authors present two cases of this condition where early diagnosis was missed. Case 1 involved a motorbike accident with subsequent deterioration and discovery of a large pericardial tear and cardiac herniation requiring emergency surgery. Case 2 from a car collision developed hemorrhage from a longitudinal pericardial tear and left ventricular laceration discovered at thoracotomy. Diagnosis is difficult but important signs include unexplained cardiovascular instability, prominent cardiac shadows, and large pneumopericardium on imaging. Prompt surgical repair of pericardial defects and relocation of the heart is the primary treatment when identified

1. Blunt Traumatic Pericardial Rupture and Cardiac
Herniation with a Penetrating Twist
Sherren P B1, Galloway R1, Healy M2
1
SpR Intensive care, 2Consultant Anaesthesia and Intensive care, The Royal London Hospital, London, UK.
INTRODUCTION
Blunt Traumatic Pericardial Rupture (BTPR) and
cardiac herniation following chest trauma is an
unusual and often fatal condition. Although there has
been a multitude of case reports of this condition in
past literature, the recurring theme is that of a missed
injury1,2. Its occurrence in severe blunt trauma is in
the order of 0.4%3,4. It is an injury that frequently
results in pre/early hospital death and diagnosis at
autopsy, probably owing to a combination of
diagnostic difficulties, lack of familiarity, associated
polytrauma and injuries3,5. Of the patients who survive
to hospital attendance, the mortality rate within
trauma centres is in the order of 57-64%6.
METHODOLOGY
We present two interesting cases of BTPR and
cardiac herniation and a literature review.
CASE REPORTS
Case 1. A 21-year-old male was admitted to the Royal
London hospital (RLH) via a district general hospital
following a motorbike accident. He was initially
hypoxic, cardiovascularly stable, unable to move his
legs and had a GCS of 15/15. Over the next 36 hours
his haemodynamic indices deteriorated despite
bilateral tube thoracostomies, fluids and inotropes;
spinal shock was implicated and transferred as such.
Peri-transfer, the patient’s condition deteriorated and
on arrival he was in cardiorespiratory extremis. In the
handover, little mention was made of his newly
developed dextracardia, high Alveolar-arterial gradient
and extreme inotropic support. The patient was retrauma called and the following chest radiograph
(Figure 1a) and coronal chest computed tomography
(Figure 1b) images were obtained.
1a.
1b.
Given the large pneumopericardium and displaced
heart on computed tomography (CT), a clamshell
thorocotomy was performed and a large right-sided
tear of the pericardium with cardiac herniation was
found. The heart was relocated and the pericardium
was repaired. There was an immediate reduction in
inotropic support. Post operative issues included a
ventilator acquired pneumonia, paraplegia secondary
to a spinal cord injury (SCI) and AF. That aside, he
made a good recovery during his 14-day ICU stay.
Case 2. A 45-year-old male who was the driver in a
road traffic collision and was brought into the RLH by
air ambulance. Pre-hospital, he was intubated with
drug assistance and had bilateral thoracostomies. He
was noted on arrival to have a multitude of rib
fractures, flail chest and surgical emphysema.
Bilateral tube thoracostomies were placed with
immediate improvement in ventilation/oxygenation.
Of note cardiac pulsations were felt with the finger
sweep of the left pleural space.
•Tachycardia and dysrrthymias may be seen,
such as the atrial tachyarrythmias.
• Displaced and heaving apex beat2,7
• A splashing murmur “bruit de Moulin” as a
result of the heart moving in a
haemopneumopericardium9.
Investigations - There are a multitude of
investigations available to assist in the diagnosis:
i.Electrocardiogram - dysrrthymias, axis deviation2,7,10
and bundle branch block8,9 may all be present.
Ischaemic changes may be noted as a result of extra
luminal coronary artery occlusion7,10. Rippey et al10
reported an elevated Troponin I of 9.20 μg/L.
ii.Chest radiograph – is a valuable tool and
abnormalities include a prominent cardiac silhouette
2b.
(“boot shaped”); distinct visible pericardial contour;
pneumopericardium; pneumomediastinum; bowel
loops within pericardial sac and cardiac herniation
into either hemithorax 2,7,9. Associated pulmonary and
skeletal pathology will usually be seen10.
•Echocardiography - Has been used but the
sensitivity for diagnosing even large pericardial
defects is thought to be low6. The importance of
transthoracic echo lies in its ability to rule out
differential diagnoses (cardiac contusion/
tamponade) quickly in the shocked patient.
•CT - is a more sensitive tool for identifying
BTPR and cardiac herniation than plain
After 16 hours on the ICU the blood output from the left
radiographs. Changes indicative of pericardial
basal thoracostomy tube suddenly rose to 600ml/hour,
rupture include6:
with associated lactic acidosis and transfusion
- Focal pericardial dimpling and discontinuity
requirement. He was taken to theatre for a left-sided
- Pneumopericardium
thoracotomy where the following injuries were found and
- Interposition of lung between mediastinal
repaired: left-sided longitudinal rupture of the
structures.
pericardium and cardiac herniation; left ventricular
Characteristic changes for a cardiac heniation6:
laceration secondary to overlying rib fractures; multiple
- “Empty pericardial sac” sign
lung lacerations; and multiple flail ribs.
- “Collar” sign, constriction of the cardiac
A 3-week ITU admission ensued, which was complicated
contour by the pericardial band/defect
by pulmonary ARDS and recurrent atrial flutter. He was
•Magnetic Resonance Imaging (MRI) – Cardiac
discharged home after 6 weeks fully independent.
MR has been used in diagnostic uncertainties6.
Management - Once BTPR and cardiac herniation
DISCUSSION
is recognised, the treatment is simple and effective
Pathophysiology - Pericardial tears may involve either and involves rapid surgical relocation of the heart
the superior, left or right pleuropericardium or the and closure of pericardial defect 3,9.
diaphragmatic pericardium. The defect can allow cardiac
luxation and, in the case of diaphragmatic pericardial
tear, herniation of abdominal contents. Clarke et al.
reviewed 142 cases and found the superior/left/right CONCLUSION
pleuropericardium were injured in 4%/50%/17% BTPR and cardiac herniation is a complex and often
respectively with 27% occurring in the diaphragmatic fatal injury that usually presents under the umbrella
pericardium3,6. The rate of cardiac herniation was 28%3; of polytrauma. Clinicians must maintain a high index
however, in a more recent literature search, a rate of 64% of suspicion for BTPR but, even then, the diagnosis
of BTPR developed cardiac herniation6.
is fraught with difficulty. In blunt chest trauma,
Defects of the pleuropericardium usually occur vertically patients should be considered high risk for BTPR
along the phrenic nerve7. If the tear is approaching 8- when presenting with:
12cm, the heart can sublux through the defect8. The
• Cardiovascular instability with no obvious cause
resulting torsion of the great vessels can lead to a form of
•Prominent or displaced cardiac silhouette and
obstructive cardiogenic shock7.
asymmetrical large volume pneumopericardium
Clinical Presentation – Road traffic collisions and In the majority of cases, it is still an injury diagnosed
sudden decelerations are the most common mechanisms at autopsy or thoracotomy. With increasing
for BTPR. The following pattern of associated injuries awareness of the injury and improved use and
availability of imaging modalities, the survival rates
should also arouse suspicion of BTPR3:
will improve and cardiac ‘H’erniation could even be
•Cardiac - contusions and dysrrthmias (28%) Penetrating
considered the 5th H of reversible causes of blunt
cardiac injury secondary to rib fractures seen in case 2, is
traumatic PEA arrest.
not something previously reported.
• Chest - rib fractures, haemopneumothoraces and
REFERENCES
pulmonary contusions are almost universally seen.
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Clark DE et al. Traumatic rupture of the pericardium. Surgery
• Abdominal injuries (27%)
1983: 93; 495-503.
• Pelvic and long bone fracture indicative of a high
4.
Fulda G et al. Blunt traumatic rupture of the heart and the
pericardium: A ten-year experience(1979--1989). J Trauma 1991:
velocity/energy impact (49%)
31; 167-173
Symptoms - The patient may report palpitations, 5. Farhataziz N et al. Pericardial rupture after blunt chest trauma. J
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shortness of breath, chest and angina-type pains2.
6.
Sohn JH et al. Pericardial rupture and cardiac herniation after
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Journal of Radiology 2005: 78; 447–449
• Signs similar to that of tamponade; hypotension,
7.
Thomas et al. Diagnosis by video assisted thoracoscopy of
2
pulsus paradoxus and raised JVP . This haemodynamic
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to the extent of sudden cardiac arrest (often as a result of 9. Janson JT et al.Pericardial rupture and cardiac herniation after
blunt chest trauma Ann Thorac Surg 2003: 75; 581-582
change in patient’s position) which should
evoke a
10. Rippey JCR et al. Blunt traumatic rupture of the pericardium with
very high index of suspicion of BTPR.
cardiac herniation. CJEM 2004: 6(2); 126-129
The initial chest radiograph (Figure 2a) and coronal chest
CT (Figure 2b) can be seen below.
2a.