Difference between revisions of "Cardiac injury"

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==Background==
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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>
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*[[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
 
**[[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==
 
===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>
 
**Myocardial contusion with cardiac dysfunction
 
**Myocardial contusion with dysrhythmias
 
***[[Sinus tachycardia]]
 
***PAC/[[Premature_ventricular_contraction|PVC]]
 
***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}}
 
 
 
==Evaluation==
 
 
 
*'''''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
 
 
 
 
 
 
 
*[[CXR]]
 
**Mediastinum widening is only suggestive of an aortic injury
 
***Lack of widening does not rule out aortic injury
 
*CTA
 
**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%)
 
*[[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<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.
 
 
 
==Management==
 
===Penetrating Trauma===
 
*[[Thoracotomy]]
 
*[[Pericardiocentesis]]
 
===Blunt Trauma===
 
*Observe all patients with cont 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
 
 
 
==See Also==
 
*[[Thoracic Trauma]]
 
*[[Commotio Cordis]]
 
 
 
==References==
 
<references/>
 
  
 
[[Category:Trauma]]
 
[[Category:Trauma]]
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[[Category:Cardiology]]

Latest revision as of 19:56, 17 August 2019