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Background: Two ATV accident cases that presented to Children's Hospital Colorado
All-terrain vehicle (ATV) accidents commonly lead to severe morbidity and mortality in children. Within four weeks in 2013, two children presented to Children’s Hospital Colorado requiring cardiac valve surgery following ATV accidents.
Both children originally presented to other hospitals, but were transferred to Children’s Colorado after delayed diagnoses of severe cardiac injury. Investigators from the Heart Institute at Children’s Colorado reviewed both patients.
Pinned by ATV in rollover accident
The patient arrived at a referring hospital with soft tissue injuries and a chest abrasion, and required surgery to close a knee laceration. After surgery, more injuries were discovered during a CT scan, including a cardiac injury. The patient was transferred to the Children’s Colorado Heart Institute for treatment.
An echocardiogram revealed severe tricuspid regurgitation and an avulsed anterior tricuspid valve leaflet. These injuries required cardiac surgical intervention and the patient was discharged home on post-operative day five.
Thrown over handlebars during ATV accident
The patient arrived at the referring hospital with several heart injuries, including severely damaged tricuspid and mitral valves and a traumatic ventricular septal defect (VSD) from the ATV accident. The patient was transferred to the Children’s Colorado Heart Institute for cardiac surgery.
The patient required replacement of the tricuspid and mitral valves, closure of VSDs and implantation of a permanent epicardial pacemaker. The patient was discharged home on post-operative day six.
Discussion: Cardiac injuries that can be caused by ATV accidents
There are several reasons why morbidity and mortality associated with ATV use have increased, including widespread popularity and greater vehicle speed. The pattern of injury is widely varied, and poor rider ATV fit could be a contributor to increased risk of accidents and injuries in children. Most ATV injuries are related to rollover accidents that lead to ejection or pinning.
>25% Of all ATV-related injuries occur among children under 16
23,000+ ATV-related injuries in 2014 for children under 16 (most recent data reported)
900+ Estimated ATV-related deaths among children (≤ 15 years old) since 2006
It’s rare for heart valves to become injured from blunt thoracic trauma, but rapid and severe compression of ventricles that occurs at the same time that the atrioventricular valves close can lead to an exponential increase in ventricular pressure, which is then transferred to valvular structures. The tricuspid valve is most commonly affected because of its anterior location. Early operative repair or replacement is recommended and associated with good long-term outcomes in children.
Traumatic tricuspid valve injury can also lead to second and third degree AV block. Additionally, traumatic VSDs can be created if there is an acute mechanical rupture or a delayed infarction or inflammatory rupture.
For children presenting with blunt chest trauma, it can be very useful to measure cardiac enzymes looking for myocardial injury. Both patients had elevated troponin cardiac enzymes on presentation to the referring hospital, consistent with the presence of a cardiac injury.
Conclusion: Cardiac screening recommendations after ATV accidents involving children
ATVs are viewed as recreational vehicles, but their use is associated with significant morbidity and mortality in children. These cases illustrate the potentially serious cardiac consequences of ATV accidents. Intracardiac injury may be rare, but possible myocardial injury should be considered when there is any significant blunt thoracic trauma.
The team recommends electrocardiograms, cardiac enzymes and potentially an echocardiogram for all patients presenting with high-impact blunt thoracic trauma from an ATV accident. A chest x-ray and CT scan can also be used to screen for cardiac injury. Patients who present with pulmonary contusions, cardiac contusions, pneumothorax and chest wall fractures should also be investigated for cardiac trauma.