Blunt cardiac injury
Background
- Most often involves the right heart (due to anterior location)
- Injury to valves occurs in 10%
Blunt cardiac injury
- A spectrum of disease due to blunt trauma to the chest wall
- Ranges from cardiac contusion to infarction to cardiac rupture and death.[1]
- Commotio cordis is sudden cardiac arrest resulting from blunt chest trauma, in absence of underlying cardiac disease[2]
- Up to 20% of all MVC deaths are due to blunt cardiac injury
Clinical Features
- 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
Workup
- 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
- 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[8]
- Combination of normal ECG and normal troponin has NPV of 100% for significant blunt cardiac injury[9][10]
- 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)[11]
- 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
- Observe all patients with continous 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
Disposition
Complications[12]
- 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
See Also
External Links
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.
- ↑ Yousef R, Carr JA. Blunt cardiac trauma: a review of the current knowledge and management. Ann Thorac Surg. 2014 Sep;98(3):1134-40. doi: 10.1016/j.athoracsur.2014.04.043.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Screening for blunt cardiac injury: An Eastern Association for the Surgery of Trauma practice management guideline.J Trauma. 73(5):S301-S306, November 2012
- ↑ Raja, A. "Thoracic Trauma." In Rosen’s Emergency Medicine., 9th ed.