Cardiac trauma

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Background

  • Spectrum of disease due to blunt trauma to the chest wall - ranges from concussion to contusion to infarction to cardiac rupture and death.[1]
Spectrum of Blunt Cardiac Injury
  • Complications
    • Fatal arrhythmias
    • Conduction abnormalities
    • CHF
    • Cardiogenic shock
    • Hemopericardium with tamponade
    • Cardiac rupture
    • Valvular rupture
    • Intraventricular thrombi
    • Thromboembolic phenomena
    • Coronary artery occlusion
    • Ventricular aneurysms
    • Constrictive pericarditis

[2]

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) [3]
  • 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:[4][5][6][7][8]
    • Myocardial contusion with cardiac dysfunction
    • Myocardial contusion with dysrhythmias
    • Myocardial infarction (coronary artery dissection/laceration/thrombosis)
    • Valvular injury (acute heart failure)
      • Leaflet injury
      • Rupture of papillary muscles or chordae tendineae
    • Cardiac structural injury (septal injury, 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

Evaluation

  • 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
    • Combination of normal ECG and normal troponin has NPV of 100% for significant blunt cardiac injury[9][10]

Management

Penetrating Trauma

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

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. Raja, A. "Thoracic Trauma." In Rosen’s Emergency Medicine., 9th ed.
  3. Tintinalli's
  4. 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.
  5. 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.
  6. Sybrandy KC, Cramer MJM, Burgersdijk C. Diagnosing cardiac contusion: old wisdom and new insights. Heart. 2003;89(5):485-489.
  7. Elie M-C. Blunt cardiac injury. Mt Sinai J Med. 2006;73(2):542-552.
  8. 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.
  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.