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• W2034269282 abstract "Motor vehicle collisions are a common cause of nonpenetrating chest trauma. Arrhythmias due to this mechanism are assumed based on electrocardiograms obtained after significant time delay. Implantable cardioverter-defibrillators are primarily designed to treat ventricular fibrillation or ventricular tachycardia, yet additional features can be of diagnostic and therapeutic benefit. A 49-year-old man sustained a motor vehicle collision while driving his motorcycle. Another driver ran a stop sign and struck him, catapulting him into a nearby ditch. After a period of unconsciousness lasting “a few seconds,” he had excruciating, substernal, “sharp,” nonradiating chest pain. Initial vitals signs included a blood pressure of 112/68 mm Hg and a heart rate of 40 beats per minute. He was noted to be in “third-degree heart block” by electrocardiographic monitoring. He had a history of diabetes, myocardial infarctions in 2000 and 2006, coronary artery bypass graft surgery in 2006, ischemic cardiomyopathy with a left ventricular ejection fraction of 25%, and a left ventricular thrombus. A single-chamber implantable cardioverter-defibrillator (Medtronic Maximo VR 7232; Medtronic, Inc., Mounds View, Minn) was inserted in 2007. His medications included carvedilol, lisinopril, atorvastatin, and warfarin. In the trauma unit, an electrocardiogram demonstrated sinus rhythm at 97 beats per minute, complete atrioventricular block, and a paced rhythm at 40 beats per minute (Figure). The QRS morphology was consistent with pacing from the right ventricular apex. Interrogation of his implantable cardioverter-defibrillator demonstrated adequate capture threshold and impedance. The test for underlying rhythm revealed complete absence of a ventricular escape rhythm despite continued sinus node activity. The backup pacing mode was VVI-40 beats per minute. He was ventricularly sensed 99.4% and ventricularly paced 0.6% in the past 37 days. The total paced time of approximately 5 hours corresponded to the estimated time from the accident until the interrogation. The tachycardia therapies consisted of a single ventricular fibrillation zone at 188 beats per minute and no monitor zone. There were no recorded episodes of ventricular tachycardia or ventricular fibrillation. Computed tomography and transesophageal echocardiography revealed an acute right ventricular pseudoaneurysm. The patient was managed with warfarin cessation and observation. Atrioventricular conduction resumed on the 8th day and he was eventually discharged. Mechanisms for atrioventricular block in nonpenetrating chest trauma have been proposed, yet the cause is uncertain.1Liedtke A.J. DeMuth Jr, W.E. Nonpenetrating cardiac injuries: a collective review.Am Heart J. 1973; 86: 687-697Abstract Full Text PDF PubMed Scopus (250) Google Scholar, 2Liedtke A.J. Allen R.P. Nellis S.H. Effects of blunt cardiac trauma on coronary vasomotion, perfusion, myocardial mechanics, and metabolism.J Trauma. 1980; 20: 777-785Crossref PubMed Scopus (48) Google Scholar, 3Khoury M.Y. Moukarbel G.V. Obeid M.Y. Alam S.E. Effect of aminophylline on complete atrioventricular block with ventricular asystole following blunt chest trauma.Injury. 2001; 32: 335-338Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar While transvenous pacing for asystolic arrests have failed to show benefit,4Cummins R.O. Graves J.R. Larsen M.P. et al.Out-of-hospital transcutaneous pacing by emergency medical technicians in patients with asystolic cardiac arrest.N Engl J Med. 1993; 328: 1377-1382Crossref PubMed Scopus (86) Google Scholar those presenting with this scenario may represent a subset that could benefit if instituted expeditiously. Given the paucity of data guiding recovery of atrioventricular conduction, the optimal time for observation before implantation of a permanent pacemaker in those without a device is somewhat arbitrary,5Benitez R.M. Gold M.R. Immediate and persistent complete heart block following a horse kick.Pacing Clin Electrophysiol. 1999; 22: 816-818Crossref PubMed Scopus (22) Google Scholar and not addressed in guidelines.6Epstein A.E. DiMarco J.P. Ellenbogen K.A. et al.ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities.J Am Coll Cardiol. 2008; 51: e1-e62Abstract Full Text Full Text PDF PubMed Scopus (1277) Google Scholar Return of conduction is particularly important in this patient, as a high percentage of right ventricular pacing may worsen heart failure status.7The DAVID Trial InvestigatorsDual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial.JAMA. 2002; 288: 3115-3123Crossref PubMed Scopus (1671) Google Scholar In summary, this case demonstrates the diagnostic uses of stored device data and the therapeutic efficacy of instantaneous pacing in complete atrioventricular block and ventricular asystole after nonpenetrating chest trauma." @default.
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• W2034269282 date "2010-01-01" @default.
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• W2034269282 title "Immediate Pacing for Traumatic Complete Atrioventricular Block and Ventricular Asystole" @default.
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• W2034269282 doi "https://doi.org/10.1016/j.amjmed.2009.06.024" @default.
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