Penetrating cardiac injury - Revision history

Rossdonaldson1: /* Management */

2019-08-17T20:10:50Z

Management

← Older revision		Revision as of 20:10, 17 August 2019
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	==Management==		==Management==
	*[[Thoracotomy]]		*[[Thoracotomy]] vs. [[pericardiocentesis]]
	*[[~~Pericardiocentesis~~]]

	===[[Cardiac tamponade]]===		===[[Cardiac tamponade]]===

Rossdonaldson1: /* Evaluation */

2019-08-17T20:09:59Z

Evaluation

← Older revision		Revision as of 20:09, 17 August 2019
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	==Evaluation==		==Evaluation==
	===Workup===		===Workup===
			[[File:PericardialeffusionUS.png\|thumb\|Pericardial fluid on ultrasound]]
			[[File:Pericardial effusion with tamponade (cropped).gif\|thumb\|Transthoracic echo of pericardial fluid showing "swinging heart"]]
	*[[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%)
			***In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise
			***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>
	*CTA		*CTA
	**Imaging study of choice for penetrating and blunt trauma		**Imaging study of choice for penetrating and blunt trauma

Rossdonaldson1: /* Clinical Features */

2019-08-17T20:02:13Z

Clinical Features

← Older revision		Revision as of 20:02, 17 August 2019
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	==Clinical Features==		==Clinical Features==
	*Location		*Stab wounds
	**Stab wounds		**Usually affect heart if enter via the "cardiac box"
	***Usually affect heart if enter via the "cardiac box"		***Chest area bounded by sternal notch, xiphoid, and nipple
	****Chest area bounded by sternal notch, xiphoid, and nipple		*Gun shot wound can affect heart even if enters at distant site
	**GSW can affect heart even if enters at distant site

	==Differential Diagnosis==		==Differential Diagnosis==

Rossdonaldson1 at 20:01, 17 August 2019

2019-08-17T20:01:44Z

@@ Line 1: / Line 1: @@
 ==Background==
+*Ventricles are at greatest risk due to anterior location
 ==Clinical Features==
 *Location
 **Stab wounds
@@ Line 9: / Line 12: @@
 ****Chest area bounded by sternal notch, xiphoid, and nipple
 **GSW can affect heart even if enters at distant site
 ==Differential Diagnosis==
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 *[[Thoracotomy]]
 *[[Pericardiocentesis]]
 ==Disposition==

Rossdonaldson1 at 20:00, 17 August 2019

2019-08-17T20:00:32Z

@@ Line 1: / Line 1: @@
 ==Background==
 ==Clinical Features==
@@ Line 33: / Line 20: @@
 **Those that cause BP instability, free or partially exposed should be removed
 **Most intramyocardial and intrapericadrial bullets can be left in place
 ==Differential Diagnosis==
@@ Line 58: / Line 26: @@
 ==Evaluation==
 ===Workup===
 *[[FAST exam]]
 **First view of FAST in penetrating injury should be pericardial
 **Pericardial fluid detection (Sn 100%, Sp 97%)
-*[[ECG]]
+*CTA
-**NPV for a normal ECG is 80-90%
+**Imaging study of choice for penetrating and blunt trauma
 ==Management==
 *[[Thoracotomy]]
 *[[Pericardiocentesis]]
-===Subclavian===
+==Disposition==
-*Usually due to direct trauma or fracture of first rib or clavicle
+*Admit
 ==See Also==

Rossdonaldson1: Created page with "==Background== Spectrum of disease due to blunt trauma to the chest wall - ranges from concussion to contusion to infarction to cardiac rupture and death.
2019-08-17T19:53:06Z

Created page with "==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..."

New page
==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>
[[File:Spectrum.png|thumbnail|Spectrum of Blunt Cardiac Injury]]

===Complications<ref> Raja, A. "Thoracic Trauma." In Rosen’s Emergency Medicine., 9th ed. </ref>===
Fatal [[arrhythmia]]s, conduction abnormalities
[[CHF]]
[[Cardiogenic shock]]
Hemopericardium with [[tamponade]]
[[Cardiac rupture]]
[[valvular emergencies|Valvular rupture]]
Intraventricular thrombi, thromboembolic phenomena
Coronary artery occlusion
[[Ventricular aneurysm]]s
Constrictive [[pericarditis]]

==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) <ref>Tintinalli's</ref>
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:<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>
Myocardial contusion with cardiac dysfunction
Myocardial contusion with dysrhythmias
[[Sinus tachycardia]]
PAC/[[Premature_ventricular_contraction|PVC]]
Atrial [[Atrial_fibrillation_(main)|fibrillation]]/[[Atrial_flutter|flutter]]
[[Myocardial infarction]] (coronary artery dissection/laceration/thrombosis)
[[Valvular emergencies|Valvular injury]] (acute [[heart failure]])
Leaflet injury
Rupture of papillary muscles or chordae tendineae
Cardiac structural injury (septal injury, [[cardiac rupture|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 DDX}}

==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<ref>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.</ref>
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>
[[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)<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>===
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===
[[Thoracotomy]]
[[Pericardiocentesis]]
===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==
[[Thoracic Trauma]]
*[[Blunt cardiac injury]]

==References==
<references/>

[[Category:Trauma]]
[[Category:Cardiology]]