Isolated shoulder pain secondary to pacer lead perforation

1. PATIENT PRESENTATION

A 75‐year‐old male with a history of coronary artery disease status post remote coronary artery bypass graft placement presented to the emergency department with right‐sided shoulder pain with radiation up to his neck and back. About 15 minutes before his symptoms, the patient picked up a heavy flooring piece. He denied use of anticoagulation. On arrival, the patient was in moderate distress with a blood pressure of 217/125 mmHg. His musculoskeletal exam was unremarkable. He had a white blood count of 24,300/μL. Computed tomography (CT) chest with contrast was significant for moderate hemopericardium with active contrast extravasation (Figures 1 and 2). The patient was started on a nicardipine drip with a target systolic blood pressure of 120–140 mmHg. He was admitted to the intensive care unit (ICU) for monitoring and ultimately discharged after stable repeat imaging.

FIGURE 1.

Contrast‐enhanced computed tomographic scanning in the coronal plane showed a 6 × 8 × 4 cm moderate sized mediastinal hematoma at the right superolateral aspect adjacent to the ascending aorta and anterior to the superior vena cava (arrow). P = posterior

FIGURE 2.

Contrast‐enhanced computed tomographic scanning in the axial plane showed a mediastinal hematoma (arrow) with 2 foci of active extravasation (blue arrows) and a small right pleural effusion. H = head, F = foot

2. DIAGNOSIS: ATRAUMATIC MEDIASTINAL HEMATOMA

Mediastinal hematomas are life‐threatening pathologies often caused by thoracic trauma, ruptured aneurysms, and recent iatrogenic insult. ¹ , ² , ³ Because of compression of structures within the thoracic cavity, a mediastinal hematoma may initially present with non‐specific features, such as chest pain, shortness of breath, and dysphagia. ¹ Suspicion of mediastinal hematomas should direct simultaneous assessment for associated life‐threatening sequelae, such as acute effusion resulting in cardiac tamponade, aortic dissection, and airway compromise from local compression. ¹ , ² , ³ , ⁴

Our patient's presentation was complicated by referred pain and a lack of typical risk factors, such as recent cardiac intervention and anticoagulation use. ¹ , ² , ⁵ However, our patient had a significant Valsalva, likely resulting in vascular trauma by pacer leads. ¹ , ⁶ A hypertensive patient with radiating shoulder pain, significant reactive leukocytosis, recent Valsalva, and a history of cardiac instrumentation may warrant CT imaging that will also assess for other mediastinal emergencies, such as aortic dissection, esophageal hematoma, and Boerhaave syndrome. ¹ , ² , ⁴ , ⁵ Management of mediastinal hematomas involves blood pressure control to hamper hematoma enlargement and coordination with cardiothoracic surgery. ⁷

DISCLAIMER

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Huang D, Wilson J, Ganti L. Isolated shoulder pain secondary to pacer lead perforation. JACEP Open. 2022;3:e12615. 10.1002/emp2.12615