Dissection of the left main coronary artery after blunt thoracic trauma: Case report and literature review

Blunt chest trauma is commonly encountered by trauma surgeons and has a variable clinical course. The spectrum of cardiac injuries ranges from mild cardiac contusion to cardiac failure or death. The diagnosis of blunt cardiac injury (BCI) can be challenging because chemical markers, nuclear studies and echocardiogram rarely correlate with the severity of injury. This article reviews a case of coronary artery dissection leading to acute ischemia, the diagnostic recommendations for evaluating patients at risk for BCI, and the therapeutic options for traumatic coronary artery dissection.A 37 year-old white male presented as a trauma patient after a head-on motor vehicle collision at highway speed. The patient was the restrained driver; the driver of the other car was fatally injured at the scene. Primary survey revealed an intact airway. The patient was talking without stridor; breath sounds were equal bilaterally. Pulses were palpable in all extremities and there was no evidence of jugular venous distention. He was neurologically intact with a Glasgow Coma Score of 15. The patient complained of chest pressure and shortness of breath.Initial vital signs were: systolic blood pressure 118 mmHg, pulse 99 beats per minute, respiratory rate 28 breaths per minute, and an oxygen saturation of 94% with supplemental oxygen at 2 liters per minute. He had a thoracic contusion consistent with a seatbelt sign and his sternum was tender to palpation. Physical findings also revealed a deformity of the left ankle. He had no history of medical problems or previous chest pain. Prior to the incident his only surgery was a knee arthroscopy. He had a 30 pack-year history of smoking and drank alcohol regularly.The trauma evaluation was completed, including cervical spine, chest and pelvis radiographs, and a trauma laboratory panel (chest radiograph, Figure 1). An electrocardiogram (Figure 2) demonstrated acute ST elevation in leads I, aVL, aVF, and V2-V5. Based on the EKG findings suggestin