This 24 year old driver of a car was transferred from another hospital. He had been in a high speed motor vehicle while affected by drugs, and had sustained head and chest injuries. He is drowsy but his vital signs are normal.
On arrival he has a chest Xray, an Xray of his pelvis and an ECG.
+ What are the important findings in the Xrays and in the ECG?
The chest x-ray is slightly rotated to the right shows:
- Widened mediastinum that raises the issue of an aortic tear. There is no apical capping, and the aorta was normal on CAT scan
- Scoliosis to the patient's left that begins at the T5-T6 vertebral level. CAT scan of the thoracic spine showed a compression fracture of the superior endplate of the T6 vertebra, but there was no instability of the vertebral column
- Fracture of the 7th rib
The x-ray of the pelvis shows:
- Normal bony anatomy of the pelvis
- Very large bladder filled with a mixture of contrast from CAT studies and urine. The contrast is pooled inferiorly and centrally to form a pear shaped density, and the urine passed since the contrast studies is less dense and floats above and lateral to the "pear".
The ECG shows:
- Sinus arrhythmia
- The second complex in Leads I, II and aVR has a unusual shape, which could be an artefact.
- Slight ST elevation in Lead II and Leads V2 to V6 that is (probably) due to early repolarization rather than cardiac injury. The computer report stated "consider anterior infarction" and "ST elevation suggests pericarditis". The bedside FAST study showed normal cardiac structure and contraction.
- The patient should be monitored for 12-24 hours given the presence of thoracic bony injuries, and have a formal echocardiogram study before discharge.
Take Home Lesson
The ECG of persons with significant injuries due to trauma can have pre-existing changes (such as bundle branch block), may have non specific changes or changes that might (possibly) be due to cardiac trauma. Apart from tachycardia and non-specific ST-T changes most ECG changes in the trauma setting are not the result of direct cardiac trauma.