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Cardiac trauma
From WikEM
Contents
Background
- Spectrum of disease due to blunt trauma to the chest wall - ranges from mild contusion to cardiac rupture and death.[1]
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
- Usually affect heart if enter via the "cardiac box"
- GSW can affect heart even if enters at distant site
- Stab wounds
- 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) [2]
- 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:[3][4][5][6][7]
- Myocardial contusion with cardiac dysfunction
- Myocardial contusion with dysrhythmias
- Sinus tachycardia
- PAC/PVC
- Atrial fibrillation/flutter
- 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
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Evaluation
- CXR
- Mediastinum widening is only suggestive of an aortic injury
- Lack of widening does not rule out aortic injury
- Mediastinum widening is only suggestive of an 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
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
- ↑ 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.
- ↑ Tintinalli's
- ↑ 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.
- ↑ 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.
- ↑ Sybrandy KC, Cramer MJM, Burgersdijk C. Diagnosing cardiac contusion: old wisdom and new insights. Heart. 2003;89(5):485-489.
- ↑ Elie M-C. Blunt cardiac injury. Mt Sinai J Med. 2006;73(2):542-552.
- ↑ 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.
- ↑ 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.
- ↑ 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.
