Blunt cardiac injury: Difference between revisions

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==Background==
==Background==
*Spectrum of disease due to blunt trauma to the chest wall - ranges from concussion to contusion to infarction to cardiac rupture and death.<ref name="El-Menyar">El-Menyar A, Al Thani H, Zarour A, Latifi R. Understanding traumatic blunt cardiac injury. Ann Card Anaesth. 2012 Oct-Dec;15(4):287-95. doi: 10.4103/0971-9784.101875.</ref>
*Most often involves the right heart (due to anterior location)
[[File:Spectrum.png|thumbnail|Spectrum of Blunt Cardiac Injury]]
**Injury to valves occurs in 10%


===Complications<ref> Raja, A. "Thoracic Trauma." In Rosen’s Emergency Medicine., 9th ed. </ref>===
{{Background BCI}}
*Fatal [[arrhythmia]]s, conduction abnormalities
*[[CHF]]
*[[Cardiogenic shock]]
*Hemopericardium with [[tamponade]]
*[[Cardiac rupture]]
*[[valvular emergencies|Valvular rupture]]
*Intraventricular thrombi, thromboembolic phenomena
*Coronary artery occlusion
*[[Ventricular aneurysm]]s
*Constrictive [[pericarditis]]


==Clinical Features==
==Clinical Features==
===Penetrating Trauma===
*Location
**Stab wounds
***Usually affect heart if enter via the "cardiac box"
****Chest area bounded by sternal notch, xiphoid, and nipple
**GSW can affect heart even if enters at distant site
*Ventricles are at greatest risk due to anterior location
**RV (involved in 40% of injuries)
**LV (involved in 35% of injuries)
**RA (involved in 20% of injuries)
**LA (involved in 5% of injuries)
*[[Cardiac tamponade]]
**Most often results from stab wounds; up to 80% of myocardial stab wounds may develop cardiac tamponade
**GSW less likely to develop into tamponade because it is more difficult for the pericardium to seal the defect (larger, more irregular in shape) <ref>Tintinalli's</ref>
*Cardiac missiles
**Those that cause BP instability, free or partially exposed should be removed
**Most intramyocardial and intrapericadrial bullets can be left in place
===Blunt Trauma===
*Up to 20% of all MVC deaths are due to blunt cardiac injury
*Most often involves the right heart (due to ant location)
**Injury to valves occurs in 10%
*May present as:<ref>Yousef R, Carr JA. Blunt cardiac trauma: a review of the current knowledge and management. Ann Thorac Surg. 2014;98(3):1134-1140. doi:10.1016/j.athoracsur.2014.04.043.</ref><ref>Mattox KL, Flint LM, Carrico CJ, et al. Blunt cardiac injury. The Journal of Trauma: Injury, Infection, and Critical Care. 1992;33(5):649-650.</ref><ref>Sybrandy KC, Cramer MJM, Burgersdijk C. Diagnosing cardiac contusion: old wisdom and new insights. Heart. 2003;89(5):485-489.</ref><ref>Elie M-C. Blunt cardiac injury. Mt Sinai J Med. 2006;73(2):542-552.</ref><ref>Edouard AR, Felten M-L, Hebert J-L, Cosson C, Martin L, Benhamou D. Incidence and significance of cardiac troponin I release in severe trauma patients. Anesthesiology. 2004;101(6):1262-1268.</ref>
*May present as:<ref>Yousef R, Carr JA. Blunt cardiac trauma: a review of the current knowledge and management. Ann Thorac Surg. 2014;98(3):1134-1140. doi:10.1016/j.athoracsur.2014.04.043.</ref><ref>Mattox KL, Flint LM, Carrico CJ, et al. Blunt cardiac injury. The Journal of Trauma: Injury, Infection, and Critical Care. 1992;33(5):649-650.</ref><ref>Sybrandy KC, Cramer MJM, Burgersdijk C. Diagnosing cardiac contusion: old wisdom and new insights. Heart. 2003;89(5):485-489.</ref><ref>Elie M-C. Blunt cardiac injury. Mt Sinai J Med. 2006;73(2):542-552.</ref><ref>Edouard AR, Felten M-L, Hebert J-L, Cosson C, Martin L, Benhamou D. Incidence and significance of cardiac troponin I release in severe trauma patients. Anesthesiology. 2004;101(6):1262-1268.</ref>
**Myocardial contusion with cardiac dysfunction
**Myocardial contusion with cardiac dysfunction
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***Lack of widening does not rule out aortic injury
***Lack of widening does not rule out aortic injury
*CTA
*CTA
**Imaging study of choice for penetrating and blunt trauma
**Imaging study of choice
*[[FAST exam]]
*[[FAST exam]]
**First view of FAST in penetrating injury should be pericardial
**First view of FAST in penetrating injury should be pericardial
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==Management==
==Management==
===Penetrating Trauma===
*Observe all patients with continous cardiac monitoring and interval assessment of cardiac markers
*[[Thoracotomy]]
*[[Pericardiocentesis]]
===Blunt Trauma===
*Observe all patients with cont cardiac monitoring and interval assessment of cardiac markers


==Great Vessels Injury==
===Great Vessels Injury===
===Aorta===
====Aorta====
*Proximal descending aorta is most commonly injured in blunt trauma
*Proximal descending aorta is most commonly injured in blunt trauma
**Due to fixation of vessels between left subclavian artery and ligamentum arteriosum
**Due to fixation of vessels between left subclavian artery and ligamentum arteriosum
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*Control of BP and HR is important if operative management will be delayed
*Control of BP and HR is important if operative management will be delayed


===Subclavian===
====Subclavian====
*Usually due to direct trauma or fracture of first rib or clavicle
*Usually due to direct trauma or fracture of first rib or clavicle
*Loose shoulder restraint
*Loose shoulder restraint
===IVC/SVC===
 
====IVC/SVC====
*Suspect if major hepatic injury or patient has bleeding that cannot be identified
*Suspect if major hepatic injury or patient has bleeding that cannot be identified
==Disposition==
==Complications<ref> Raja, A. "Thoracic Trauma." In Rosen’s Emergency Medicine., 9th ed. </ref>==
*Fatal [[arrhythmia]]s, conduction abnormalities
*[[CHF]]
*[[Cardiogenic shock]]
*Hemopericardium with [[tamponade]]
*[[Cardiac rupture]]
*[[valvular emergencies|Valvular rupture]]
*Intraventricular thrombi, thromboembolic phenomena
*Coronary artery occlusion
*[[Ventricular aneurysm]]s
*Constrictive [[pericarditis]]


==See Also==
==See Also==
*[[Thoracic Trauma]]
*[[Thoracic Trauma]]
*[[Commotio Cordis]]
*[[Commotio Cordis]]
*[[Penetrating cardiac injury]]
==External Links==
*[https://rebelem.com/blunt-cardiac-injury-bci/ REBEL EM - Blunt Cardiac Injury (BCI)]
*[https://www.emra.org/emresident/article/blunt-cardiac-injury-RBBB/ EMRA - Blunt Cardiac Injury Manifesting as RBBB on EKG]


==References==
==References==

Latest revision as of 02:02, 1 July 2021

Background

  • Most often involves the right heart (due to anterior location)
    • Injury to valves occurs in 10%


Blunt cardiac injury

Spectrum of Blunt Cardiac Injury
  • A spectrum of disease due to blunt trauma to the chest wall
  • Ranges from cardiac contusion to infarction to cardiac rupture and death.[1]
    • Commotio cordis is sudden cardiac arrest resulting from blunt chest trauma, in absence of underlying cardiac disease[2]
    • Up to 20% of all MVC deaths are due to blunt cardiac injury

Clinical Features

Differential Diagnosis

Thoracic Trauma

Evaluation

Workup

  • CXR
    • Mediastinum widening is only suggestive of an aortic injury
      • Lack of widening does not rule out aortic injury
  • CTA
    • Imaging study of choice
  • FAST exam
    • First view of FAST in penetrating injury should be pericardial
    • Pericardial fluid detection (Sn 100%, Sp 97%)
  • ECG
    • NPV for a normal ECG is 80-90%
    • Not as sensitive for right-sided injuries
  • Troponin
    • Trend in all patients
    • Troponin elevation alone is only 23% sensitive for BCI[8]
    • Combination of normal ECG and normal troponin has NPV of 100% for significant blunt cardiac injury[9][10]
    • Troponin elevation can stem from catecholamine-induced stress, hypovolemic shock with reperfusion injury, oxidative injury, bacterial or viral toxins or microcirculatory dysfunction. Look at history and patient exam findings.

EAST GUIDELINES (2012)[11]

  • Level 1 evidence
    • ECG to be performed on all patients suspected of BCI (looking for various ECG changes including ischemic changes, nonspecific ST changes, arrhythmia, conduction blocks, though most common is sinus tachycardia).
  • Level 2 evidence
    • If new ECG changes consider admission for 24 hours telemetry and serial ECG/troponin
    • If normal (or stable) ECG and normal troponin I (at any time), BCI is ruled out
    • If hemodynamically stable, emergent bedside echo to assess for pericardial fluid
    • Presence of sternal fracture alone does not predict presence of BCI and should not prompt monitoring if normal ECG/Troponin
  • Level 3 evidence
    • Troponin I should be measured routinely for patients with suspected BCI; if elevated patients should be admitted to a monitored bed with serial levels

Management

  • Observe all patients with continous cardiac monitoring and interval assessment of cardiac markers

Great Vessels Injury

Aorta

  • Proximal descending aorta is most commonly injured in blunt trauma
    • Due to fixation of vessels between left subclavian artery and ligamentum arteriosum
  • Most patients die at the scene
  • Control of BP and HR is important if operative management will be delayed

Subclavian

  • Usually due to direct trauma or fracture of first rib or clavicle
  • Loose shoulder restraint

IVC/SVC

  • Suspect if major hepatic injury or patient has bleeding that cannot be identified

Disposition

Complications[12]

See Also

External Links

References

  1. ↑ El-Menyar A, Al Thani H, Zarour A, Latifi R. Understanding traumatic blunt cardiac injury. Ann Card Anaesth. 2012 Oct-Dec;15(4):287-95. doi: 10.4103/0971-9784.101875.
  2. ↑ Yousef R, Carr JA. Blunt cardiac trauma: a review of the current knowledge and management. Ann Thorac Surg. 2014 Sep;98(3):1134-40. doi: 10.1016/j.athoracsur.2014.04.043.
  3. ↑ Yousef R, Carr JA. Blunt cardiac trauma: a review of the current knowledge and management. Ann Thorac Surg. 2014;98(3):1134-1140. doi:10.1016/j.athoracsur.2014.04.043.
  4. ↑ Mattox KL, Flint LM, Carrico CJ, et al. Blunt cardiac injury. The Journal of Trauma: Injury, Infection, and Critical Care. 1992;33(5):649-650.
  5. ↑ Sybrandy KC, Cramer MJM, Burgersdijk C. Diagnosing cardiac contusion: old wisdom and new insights. Heart. 2003;89(5):485-489.
  6. ↑ Elie M-C. Blunt cardiac injury. Mt Sinai J Med. 2006;73(2):542-552.
  7. ↑ Edouard AR, Felten M-L, Hebert J-L, Cosson C, Martin L, Benhamou D. Incidence and significance of cardiac troponin I release in severe trauma patients. Anesthesiology. 2004;101(6):1262-1268.
  8. ↑ Bertinchant JP, Polge A, Mohty D, et al. Evaluation of incidence, clinical significance, and prognostic value of circulating cardiac troponin I and T elevation in hemodynamically stable patients with suspected myocardial contusion after blunt chest trauma. J Trauma. 2000;48(5):924-931.
  9. ↑ Salim A, Velmahos GC, Jindal A, et al. Clinically significant blunt cardiac trauma: role of serum troponin levels combined with electrocardiographic findings. The Journal of Trauma: Injury, Infection, and Critical Care. 2001;50(2):237-243.
  10. ↑ Velmahos GC, Karaiskakis M, Salim A, et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. The Journal of Trauma: Injury, Infection, and Critical Care. 2003;54(1):45–50–discussion50–1. doi:10.1097/01.TA.0000046315.73441.D8.
  11. ↑ Screening for blunt cardiac injury: An Eastern Association for the Surgery of Trauma practice management guideline.J Trauma. 73(5):S301-S306, November 2012
  12. ↑ Raja, A. "Thoracic Trauma." In Rosen’s Emergency Medicine., 9th ed.
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