Blunt cardiac injury

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[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]
  • Commotio Cordis
    • Primary electrical event resulting in the induction of Vfib
    • Often an innocent-appearing blow to chest wall

Differential Diagnosis

Thoracic Trauma

Evaluation

Workup

  • 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[9]
    • Combination of normal ECG and normal troponin has NPV of 100% for significant blunt cardiac injury[10][11]
    • 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.

EAST GUIDELINES (2012)[12]

  • 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

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. ↑ 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.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ Screening for blunt cardiac injury: An Eastern Association for the Surgery of Trauma practice management guideline.J Trauma. 73(5):S301-S306, November 2012
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