Cardiac Trauma


Article Author:
Steven Warrington


Article Editor:
Kunal Mahajan


Editors In Chief:
Jonathan dela Cruz
Therese Mead


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
7/30/2019 4:27:27 PM

Introduction

Cardiac trauma can be grouped by method of injury as either blunt or penetrating with outcomes ranging from lethal injuries to spontaneously resolving arrhythmias. Those with lethal injuries often succumb quickly with some documenting over 90% of individuals expiring before arriving at a hospital, and only a 20-75% survival rate of those that make it to the hospital.[1]

Etiology

Blunt cardiac trauma is generally caused by a direct impact to the anterior chest, high-speed sudden deceleration, compression of the chest, or a mixture of those.  Motor vehicle accidents are the most common cause and can include involve all three of the mechanisms above.  Individuals struck by motor vehicles, falls, crush injuries, and seemingly innocuous trauma such as sports-related (baseball hitting a chest) or animal-related (animal kick) may also cause blunt cardiac injury (BCI).[2]

Penetrating cardiac trauma has been primarily due to stab wounds, with gunshot wounds being the second leading cause. Non-firearm related blast injuries and impalements are also causes of penetrating cardiac trauma.[3]

Epidemiology

Blunt cardiac injury: BCI may affect anyone, but most often affects males with an average age in the 30s.  Pediatric patients with blunt cardiac injury are also often male, with an average age of 7 and most commonly from motor vehicle accidents. Patient’s with blunt thoracic trauma have been noted to have as high as a 30% incidence of electrical abnormalities.

Penetrating cardiac injury: Any gender or aged individual may be the victim of a penetrating cardiac injury, but males and those in the 3rd or 4th decade of life are most common.  The right ventricle is most frequently injured, followed by the left ventricle, and then atria or multiple-chamber injuries.[4]

History and Physical

The history of events for patients with a cardiac injury is often straightforward detailing some mechanism injuring the chest or back. However, some individuals may give alternative stories due to potential legal ramifications or altered mentation.  A subset of patients may also be unconscious or without a pulse with only information available from first responders.

The physical examination of a patient with potential cardiac trauma should typically follow the primary and secondary survey of Advanced Trauma Life Support (ATLS).  Along with obtaining initial vital signs, and after ensuring the airway and breathing or intact and not compromised, a brief evaluation of circulation and the cardiac system should take place.  Inspection for obvious anterior/lateral chest wounds, auscultation for the presence of muffled heart tones, murmurs, and arrhythmias, and palpation for strength and presence of pulses should be done.  Following completion of a primary survey, the secondary survey should include further examination for a potential cardiac injury such as evaluating for distended neck veins and evaluating for signs of trauma to the posterior and lateral torso. While a patient may have stable vital signs and few features to suspect cardiac injury, findings concerning for cardiac trauma include hypotension, tachycardia, arrhythmias, visible trauma, distended neck veins, muffled heart sounds, and other signs of shock.[5]

Evaluation

Evaluating patients with concern for cardiac trauma following physical examination is multi-faceted and varies depending on the nature of the mechanism of injury.  A general trauma evaluation is typical and usually, includes plain films of the chest and point-of-care ultrasound (POCUS).

Plain films of the chest have limited utility for the diagnosis of BCI but may have some utility in penetrating cardiac trauma. They may demonstrate the presence and approximate location of a foreign body, the presence of a hemothorax, displaced heart, and other non-cardiac thoracic injuries.  Acute cardiac tamponade is unlikely to show significant findings on an initial plain film. 

POCUS is common in emergency departments with a focused assessment with sonography for trauma (FAST) exam done routinely that includes a cardiac view, which can aid in rapidly diagnosing pericardial effusions.  While physical examination such as distended neck veins and abnormal vital signs can be used with POCUS for demonstrating tamponade, the findings of inferior vena cava distension and septal bounce can also be identified on POCUS.  For individuals more proficient with POCUS, or through ordering a formal echocardiography study, other findings such as wall motion and valvular abnormalities may be identified.  If the views are suboptimal and the patient as stable then transesophageal echocardiography may be beneficial and may provide additional information about the great vessels.

Computed Tomography (CT) is also part of the trauma evaluation if the patient is stable enough.  It has a high sensitivity for pericardial or myocardial lacerations, cardiac luxation, other thoracic injuries, and can help identify the path of a projectile and location of a foreign body.[6]

Evaluation specific to blunt cardiac trauma is difficult as there are no validated screening criteria for BCI.  An electrocardiogram (ECG), while not standard in the evaluation of the acutely injured patient, is useful in demonstrating the presence of new dysrhythmias, which should make a clinician suspicious of BCI (excluding sinus tachycardia).  A normal ECG alone has a high negative predictive value for BCI.  In addition to an ECG, cardiac enzymes such as cardiac-specific troponins should be considered to add on to the routine trauma evaluation.  Troponins can help evaluate for the presence of a myocardial contusion or ischemia secondary to a vessel injury, and also have a high negative predictive value of blunt cardiac injury.  A normal ECG and troponin within the normal range have been shown to have near 100% negative predictive value for blunt cardiac injury, though there is a debate at when to perform the troponin, and if serial troponins should be done.[7]

Further evaluation based on the suspected underlying injury may be beneficial such as angiography for those with infarction patterns on ECG, or cardiac magnetic resonance (MR) imaging to help identify the extent of a myocardial contusion.

Penetrating cardiac injury evaluation should be considered for any individual with an open wound to the thorax.  Wounds within the imaginary box defined by the inferior clavicles, inferior costal margins, and mid-clavicular lines are especially concerning.  Echocardiography has been shown to have high sensitivity and specificity for cardiac wounds.  No further workup is needed aside from physical examination and echocardiography, though as mentioned above plain films may help provide approximate location and presence of foreign bodies.

Treatment / Management

Trauma patients should undergo routine ATLS care such as airway, breathing, and cervical spine protection.  Identification of a blunt or penetrating cardiac injury should prompt further specific care.

BCI has many possible patterns including dysrhythmias, contusions, rupture, valvular injury, and coronary artery injury. Dysrhythmias range from commotio cordis with non-perfusing ventricular fibrillation to stable first-degree atrioventricular blocks. Advanced cardiovascular life support (ACLS) management should be initiated for dysrhythmias, along with ruling out the presence of other traumatic injuries and alternative etiologies of the dysrhythmia.  The presence of any dysrhythmia outside of sinus tachycardia that is presumed new should prompt consideration of further cardiac telemetry monitoring and echocardiography if not already done.  Patients with atrial dysrhythmias have been shown to benefit from treatment, and a beta or calcium channel blocker should be considered for the stable patient.  In the unstable patient, electrical cardioversion may be an option if their instability is suspected secondary to the dysrhythmia.[4][8] 

Myocardial contusions can present with electrical disturbances or may be found only with an elevated troponin.  Treatment is supportive and determined by the severity other findings such as hypotension or high-grade dysrhythmias.  Evaluation of these patients parallels that of patients with myocardial infarctions, with a similar range of outcomes and complications.

Cardiac rupture may be lethal depending on the location and extent of damage to cardiac tissue.  Operative repair is indicated with a sternotomy or thoracotomy, and potentially cardiopulmonary bypass. Valvular injuries may be able to be repaired depending on the nature of the injury. Certain cases, such as papillary muscle rupture, may require valve replacement.[9]

Coronary artery lacerations or bleeding should be managed operatively with control of the involved artery and coronary bypass.  In cases that non-bleeding coronary artery injuries are suspected angiography with management based on findings is generally indicated such as with stenting or medical management.

Penetrating cardiac trauma is more straightforward in management with operative management ultimately required.  If the patient is unstable, a pericardiocentesis can be performed with a catheter placed for intermittent drainage to help temporarily stabilize the patient. A median sternotomy or thoracotomy is used to obtain access to the heart with a pericardiotomy done avoiding the phrenic nerve.  Lacerations can be controlled initially with digital pressure, vascular clamp (atrial wounds*) or the insertion of a Foley followed by inflation of the balloon and light traction.  Blood products may be able to be transfused through the Foley, in addition to helping temporize a cardiac wound.

Cardiac laceration repair can be done using 3-0 polypropylene (Prolene) sutures, typically in running, horizontal mattress, or purse stitch.  Pledgets or pieces of the pericardium are often used to distribute tension when repairing ventricular wounds.  Key points to remember while repairing the wound are to ensure taking adequate bites of the myocardium to help avoid tissue tearing, placing ventricular sutures during ventricular contraction to help minimize tearing of myocardium and to avoid ligating coronary arteries when repairing cardiac wounds.  Posterior heart lacerations may need to be done with patience as elevating the heart for a continued period of time to visualize, place sutures, and tie sutures, as lifting the heart can cause hypotension and potentially cardiac arrest. Finally, staples have also been used in place of suture to help close the wound, though are controversial.[9]

Pearls and Other Issues

Foreign bodies that visible externally on patient arrival, and suspected to be related to a penetrating cardiac injury, should be left in place temporarily to allow for set-up for operative evaluation and care.  Otherwise, retained foreign bodies should be removed operatively if there is contamination or electrical abnormalities.

Emergency department thoracotomy is controversial due to survival rates ranging from around 1-30% depending on the patient population.  Despite low survival rates, as the alternative is guaranteed death, it is still performed in select situations.  Individuals with blunt trauma and loss of vital signs are less likely to survive.  An emergency thoracotomy should be considered for blunt trauma victims with the loss of pulses less than 5-10 minutes (depending on the literature followed), though there have been reports of survivors with up to 15 minutes of loss of pulses.  An emergent thoracotomy should be considered for penetrating trauma victims with the loss of pulses less than 15 minutes, though survivors have again been documented with up to 32 minutes of CPR.

Enhancing Healthcare Team Outcomes

Cardiac trauma is best managed by a mutlidisciplinary team that includes the emergency department physician, trauma surgeon, cardiologist, cardiac surgeon, radiologist, the perfusioniost, cardiac nurses and the intensivist. Cardiac trauma is initially managed according to ATLS protocol. Depending on the type of trauma, one may either observe the patient or the patient may need open heart surgery to repair a defect. The prognosis of these patients depends on age, associated trauma, shock at the time of presentation, availability of a cardiac surgeon and mental status on arrival.[10]


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Cardiac Trauma - Questions

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A 17-year old patient is stabbed in the left chest. He is taken to the operating room and explored. The diagonal coronary artery is found to be lacerated and bleeding. What is the best treatment for this patient?



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A patient presents after a driving into a brick wall at 40 miles per hour with bruising to the anterior chest and a seatbelt sign to the abdomen. The initial vital signs are stable, the airway is patent, and there is good breath sounds bilaterally. What should be done next?



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A 20-year-old patient is brought in following a motor vehicle accident and is intubated for airway protection due to severe intoxication and altered mental status. The patient’s vital signs are stable. There is bruising to the anterior chest and an electrocardiogram is done showing atrial fibrillation. Which of the following should be done for further evaluation?



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A patient is dropped off at the front of the emergency department yelling about a stab wound to the left chest and becomes unconscious with no palpable pulse as they are wheeled into the trauma bay. An emergency thoracotomy is performed with a significant amount of blood out of the left chest, a pericardial defect noted, and an approximately 1 cm laceration to the left ventricle. Which of the following methods of wound temporizing would be best in this situation?



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Which of the following is recommended when suturing a cardiac laceration closed?



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A patient presents with findings suspicious for a blunt cardiac injury. Which of the following combinations of tests have the best negative predictive value for blunt cardiac injury if they are normal?



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Cardiac Trauma - References

References

Dokoupil M,Marecová K,Uvíra M,Joukal M,Mrázková E,Chmelová J,Handlos P, Fatal delayed hemopericardium and hemothorax following blunt chest trauma. Forensic science, medicine, and pathology. 2019 Jan 16;     [PubMed]
Chen X,Miao Q,Yu Y,Zhang F,Sun L,Meng Y,Wang H,Li D, Blunt trauma-induced pericardial tamponade after video-assisted thoracoscopic surgery. The Annals of thoracic surgery. 2018 Nov 24;     [PubMed]
Šimek M,Konečný J,Hájek R,Čižmář I,Kutěj V,Lonský V, [Penetrating Injuries of the Heart and Great Vessels - Fifteen Years of Experience of the Cardiac Surgery Service as a Part of the Major Trauma Centre]. Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca. 2018;     [PubMed]
Panicker AT,Nugent K,Mink J,Glaser J,Bradley K,Siric F,Nomura JT, Bedside Ultrasonography in the Management of Penetrating Cardiac Injury Caused by a Nail Gun. The Journal of emergency medicine. 2018 Oct 30;     [PubMed]
Hegde R,Lafayette N,Sywak M,Ricketts G,Otero J,Kurtzman S,Zhang Z, Isolated right atrial appendage rupture following blunt chest trauma. Trauma case reports. 2018 Feb;     [PubMed]
Raptis DA,Bhalla S,Raptis CA, Computed Tomographic Imaging of Cardiac Trauma. Radiologic clinics of North America. 2019 Jan;     [PubMed]
Frustaci A,Placanica G,Galea N,Chimenti C, Auto-Reactive Myocarditis and Necrotizing Coronary Vasculitis After Blunt Chest Trauma. Circulation. Cardiovascular imaging. 2018 Sep;     [PubMed]
Vlček M,Jaganjac E,Niedoba M,Landor I,Neumann J, Current treatment procedures for civilian gunshot wounds. Rozhledy v chirurgii : mesicnik Ceskoslovenske chirurgicke spolecnosti. 2018 Winter;     [PubMed]
Wang D,Zhang F,Meng Y,Yu Y,Zhou K,Sun L,Miao Q,Li D, [Morphological analysis of cardiac rupture due to blunt injury, cardiopulmonary resuscitation and myocardial infarction in forensic pathology]. Nan fang yi ke da xue xue bao = Journal of Southern Medical University. 2018 Dec 30;     [PubMed]
Soni KD,Kaushik G,Gupta A,Singh V,Kumar S,Sagar S, From Emergency Department to Intensive Care Unit, Does The Delay Matter to Trauma Patients? Journal of emergencies, trauma, and shock. 2018 Jul-Sep;     [PubMed]

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