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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>
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| [[File:Spectrum.png|thumbnail|Spectrum of Blunt Cardiac Injury]]
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| ===Complications<ref> Raja, A. "Thoracic Trauma." In Rosen’s Emergency Medicine., 9th ed. </ref>===
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| *Fatal [[arrhythmia]]s, conduction abnormalities
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| *[[CHF]]
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| *[[Cardiogenic shock]]
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| *Hemopericardium with [[tamponade]]
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| *[[Cardiac rupture]]
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| *[[valvular emergencies|Valvular rupture]]
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| *Intraventricular thrombi, thromboembolic phenomena
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| *Coronary artery occlusion
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| *[[Ventricular aneurysm]]s
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| *Constrictive [[pericarditis]]
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| ==Clinical Features==
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| ===Penetrating Trauma===
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| *Location
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| **Stab wounds
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| ***Usually affect heart if enter via the "cardiac box"
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| ****Chest area bounded by sternal notch, xiphoid, and nipple
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| **GSW can affect heart even if enters at distant site
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| *Ventricles are at greatest risk due to anterior location | | *Ventricles are at greatest risk due to anterior location |
| **RV (involved in 40% of injuries) | | **RV (involved in 40% of injuries) |
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| **RA (involved in 20% of injuries) | | **RA (involved in 20% of injuries) |
| **LA (involved in 5% of injuries) | | **LA (involved in 5% of injuries) |
| *[[Cardiac tamponade]]
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| **Most often results from stab wounds; up to 80% of myocardial stab wounds may develop cardiac tamponade
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| **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>
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| *Cardiac missiles
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| **Those that cause BP instability, free or partially exposed should be removed
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| **Most intramyocardial and intrapericadrial bullets can be left in place
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| ===Blunt Trauma=== | | ==Clinical Features== |
| *Up to 20% of all MVC deaths are due to blunt cardiac injury | | *Stab wounds |
| *Most often involves the right heart (due to ant location) | | **Usually affect heart if enter via the "cardiac box" |
| **Injury to valves occurs in 10% | | ***Chest area bounded by sternal notch, xiphoid, and nipple |
| *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> | | *Gun shot wound can affect heart even if enters at distant site |
| **Myocardial contusion with cardiac dysfunction | |
| **Myocardial contusion with dysrhythmias
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| ***[[Sinus tachycardia]]
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| ***PAC/[[Premature_ventricular_contraction|PVC]]
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| ***Atrial [[Atrial_fibrillation_(main)|fibrillation]]/[[Atrial_flutter|flutter]]
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| **[[Myocardial infarction]] (coronary artery dissection/laceration/thrombosis)
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| **[[Valvular emergencies|Valvular injury]] (acute [[heart failure]])
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| ***Leaflet injury
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| ***Rupture of papillary muscles or chordae tendineae
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| **Cardiac structural injury (septal injury, [[cardiac rupture|wall rupture]])
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| *[[Commotio Cordis]]
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| **Primary electrical event resulting in the induction of [[Vfib]]
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| **Often an innocent-appearing blow to chest wall
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| ==Differential Diagnosis== | | ==Differential Diagnosis== |
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| ==Evaluation== | | ==Evaluation== |
| ===Workup=== | | ===Workup=== |
| *[[CXR]]
| | [[File:PericardialeffusionUS.png|thumb|Pericardial fluid on ultrasound]] |
| **Mediastinum widening is only suggestive of an aortic injury
| | [[File:Pericardial effusion with tamponade (cropped).gif|thumb|Transthoracic echo of pericardial fluid showing "swinging heart"]] |
| ***Lack of widening does not rule out aortic injury
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| *CTA
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| **Imaging study of choice for penetrating and blunt trauma
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| *[[FAST exam]] | | *[[FAST exam]] |
| **First view of FAST in penetrating injury should be pericardial | | **First view of FAST in penetrating injury should be pericardial |
| **Pericardial fluid detection (Sn 100%, Sp 97%) | | **Pericardial fluid detection (Sn 100%, Sp 97%) |
| *[[ECG]] | | ***In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise |
| **NPV for a normal ECG is 80-90% | | ***Differentiate pericardial effusion from pleural effusion using the parasternal long axis view. Pericardial effusions will have an anechoic stripe between the left atrium and descending thoracic aorta. In a pleural effusion, the stripe will be seen behind the descending thoracic aorta.<ref>Randazzo MR et al. Acad Emerg Med, 2003. PMID: 12957982</ref> |
| **Not as sensitive for right-sided injuries
| | *CTA |
| *[[Troponin]] | | **Imaging study of choice for penetrating and blunt trauma |
| **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,
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| clinical significance, and prognostic value of circulating
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| cardiac troponin I and T elevation in hemodynamically
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| stable patients with suspected myocardial contusion after
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| blunt chest trauma. J Trauma. 2000;48(5):924-931.</ref>
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| **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>
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| **[[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. | |
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| ===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>=== | | ==Management== |
| *Level 1 evidence | | *[[Thoracotomy]] vs. [[pericardiocentesis]] |
| **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).
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| *Level 2 evidence
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| **If new ECG changes consider admission for 24 hours telemetry and serial ECG/troponin
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| **If normal (or stable) ECG and normal troponin I (at any time), BCI is ruled out
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| **If hemodynamically stable, emergent bedside echo to assess for pericardial fluid
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| **Presence of sternal fracture alone does not predict presence of BCI and should not prompt monitoring if normal ECG/Troponin
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| *Level 3 evidence
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| **Troponin I should be measured routinely for patients with suspected BCI; if elevated patients should be admitted to a monitored bed with serial levels
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| ==Management== | | ===[[Cardiac tamponade]]=== |
| ===Penetrating Trauma===
| | *Most often results from stab wounds; up to 80% of myocardial stab wounds may develop cardiac tamponade |
| *[[Thoracotomy]]
| | *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> |
| *[[Pericardiocentesis]]
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| ===Blunt Trauma===
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| *Observe all patients with cont cardiac monitoring and interval assessment of cardiac markers | |
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| ==Great Vessels Injury== | | ===Cardiac missiles=== |
| ===Aorta===
| | *Those that cause BP instability, free or partially exposed should be removed |
| *Proximal descending aorta is most commonly injured in blunt trauma | | *Most intramyocardial and intrapericadrial bullets can be left in place |
| **Due to fixation of vessels between left subclavian artery and ligamentum arteriosum
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| *Most patients die at the scene | |
| *Control of BP and HR is important if operative management will be delayed
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| ===Subclavian=== | | ==Disposition== |
| *Usually due to direct trauma or fracture of first rib or clavicle
| | *Admit |
| *Loose shoulder restraint
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| ===IVC/SVC===
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| *Suspect if major hepatic injury or patient has bleeding that cannot be identified | |
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| ==See Also== | | ==See Also== |
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