Wednesday, April 23, 2014

Male in 30's, 2 days after Motor Vehicle Collsion, complains of Chest Pain and Dyspnea

This male in his 30s with h/o Hypertension ran broadside into another car at 40 miles per hour (65 km per hour) 2 days prior.  There was significant damage to the car and air bags deployed and hit him in the chest.  After this, he had chest pain, mid sternal pressure, with significant shortness of breath, and was unable to lay flat or sleep at night due to the shortness of breath. 

BP was 167/114, RR 24, pulse 117 and SpO2 90% on room air.  Heart sounds and breath sounds were unremarkable.

He had an ECG recorded:
There is sinus tachycardia.  There is high voltage suggestive of LVH, along with a large negative component of the P-wave in V1 which is diagnostic of left atrial hypertrophy and supports LVH.  There is the T-wave inversion in V5 and V6 which one might think is typical of the repoloarization abnormalities due to LVH, but they are out of proportion.  The T-waves in V2 and V3 could be Wellens' T-waves or LVH.

A bedside echo was done to look for effusion and function:

MVC with chest pain from Stephen Smith on Vimeo.

This is a parasternal short axis.  Now you can see that the wall closest to the transducer is not moving.

Anterior WMA after MVC, parasternal short axis from Stephen Smith on Vimeo.

This shows severely decreased LV function with a definite anterior wall motion abnormality.

A troponin was drawn and was minimally elevated. A NT proBNP was 5000 (normal up to 900).


Differential Diagnosis:

1. This must be myocardial contusion, right?  Anterior chest trauma in a 30-something, with chest pain, and anterior wall motion abnormality.
2. Or it is just cardiomyopathy due to LVH and Hypertension, right?
3. Or it is Stress (takotsubo) cardiomyopathy, from the stress of a motor vehicle collision.
4. Or could it be ACS/MI?



Outcome:
Angiography was done immediately:
LAD: Type III LAD. 99% proximal to mid LAD stenosis. D1 with 30% proximal
stenosis.
LCx: Proximal 90% circ stenosis prior to the first significant OM. 90% mid
circ stenosis prior to a large L-PLA.
RCA: Diffuse 30% lesions. The mid PDA has an 80% stenosis.
Ramus: 80% proximal lesion in the ramus (small to medium vessel)

Echo
Regional wall motion abnormality-anterior, septum and apex, akinetic to dyskinetic.
Regional wall motion abnormality-inferoposterior .
Left ventricular hypertrophy concentric .
Left ventricular enlargement .
Decreased left ventricular systolic performance severe.The estimated left ventricular ejection fraction is 23%

The patient went for CABG

Lesson:

If you investigate, you'll frequently be surprised by what you find.  An ECG and Echo are important tests in a patient with chest pain.  And this is also true after trauma.

See this ECG in tragic case of a 6 yo after motor vehicle trauma.

See also these cases of myocardial contusion: One and Two


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