Difference between revisions of "Cardiac injury"

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*[[Blunt cardiac injury]]
*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>
*[[Penetrating cardiac injury]]
[[File:Spectrum.png|thumbnail|Spectrum of Blunt Cardiac Injury]]
*Complications:<ref> Raja, A. "Thoracic Trauma." In Rosen’s Emergency Medicine., 9th ed. </ref>
**Fatal [[arrhythmia]]s, conduction abnormalities
**[[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==
===Penetrating Trauma===
**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>
**Myocardial contusion with cardiac dysfunction
**Myocardial contusion with dysrhythmias
***[[Sinus tachycardia]]
***Atrial [[Atrial_fibrillation_(main)|fibrillation]]/[[Atrial_flutter|flutter]]
**[[Myocardial infarction]] (coronary artery dissection/laceration/thrombosis)
**[[Valvular emergencies|Valvular injury]] (acute [[heart failure]])
***Leaflet injury
***Rupture of papillary muscles or chordae tendineae
**Cardiac structural injury (septal injury, [[cardiac rupture|wall rupture]])
*[[Commotio Cordis]]
**Primary electrical event resulting in the induction of [[Vfib]]
**Often an innocent-appearing blow to chest wall
==Differential Diagnosis==
{{Thoracic trauma DDX}}
*'''''EAST GUIDELINES''''' 2012<ref>Screening for blunt cardiac injury: An Eastern Association for the
Surgery of Trauma practice management guideline.J Trauma. 73(5):S301-S306, November 2012</ref>
*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
**Mediastinum widening is only suggestive of an aortic injury
***Lack of widening does not rule out aortic injury
**Imaging study of choice for penetrating and blunt trauma
*[[FAST exam]]
**First view of FAST in penetrating injury should be pericardial
**Pericardial fluid detection (Sn 100%, Sp 97%)
**NPV for a normal ECG is 80-90%
**Not as sensitive for right-sided injuries
**Trend in all patients
**Troponin elevation alone is only 23% sensitive for BCI<ref>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.</ref>
**Combination of normal ECG and normal [[troponin]] has NPV of 100% for significant blunt cardiac injury<ref>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.</ref><ref>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.</ref>
**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.
===Penetrating Trauma===
===Blunt Trauma===
*Observe all patients with cont cardiac monitoring and interval assessment of cardiac markers
==Great Vessels Injury==
*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
*Usually due to direct trauma or fracture of first rib or clavicle
*Loose shoulder restraint
*Suspect if major hepatic injury or patient has bleeding that cannot be identified
==See Also==
*[[Thoracic Trauma]]
*[[Commotio Cordis]]

Latest revision as of 19:56, 17 August 2019