Acute and long-term clinical significance of myocardial contusion following blunt thoracic trauma: results of a prospective study

Troponin I New Biomarker in Traumatic Brain Injury

Mortality in traumatic brain injury (TBI) is thought to be pathology in the heart-brain axis but its effect on the prognosis of traumatic brain injury remains unclear. Our study aimed to investigate the relationship between cardiac troponin I (cTnI) level and prognosis in TBI patients. Between January 2017 and May 2021, 480 patients diagnosed with TBI, who applied to the emergency department, were retrospectively included in this multicentric study. The databases of the hospitals were examined comprehensively and the demographic, clinical, laboratory, radiological, and therapeutic data and results of the patients were obtained. The severity of trauma and clinical status was evaluated with AIS, Injury Severity Score (ISS), ASA physical status, and Glasgow Coma Scale (GCS). The severity of the trauma was evaluated with the ISS. The modified Rankin Scale (mRS) and the Glasgow Outcome Scale (GOS) at discharge were used to evaluate in-hospital clinical outcomes. cTnI levels were classified into three categories: normal (< 0.05 ng/ml), mildly elevated (0.05–0.99 ng/ml), and severely elevated (≥ 1 ng/ml). The mean age of the patients was 41.7 and 75.4% of them were men. It was observed that mortality among patients over 65 years (13.9%) increased. High cTnI was detected in 284 (59.1%) patients. Although it was not statistically significant regarding the elevation of cTnI in patients under 65 years of age (P = 0.62), the difference was significant for cTnI in patients over 65 years of age (P < 0.001). The relationship between cTnI elevation was found to be statistically significant (P < 0.001) as the severity of the trauma increased and when severe additional traumas (thoracic, abdominal, or pelvic) occurred. A high cTnI level is associated with poor prognosis in TBI patients. cTnI measurement is a useful tool for early risk stratification and accelerated care; however, further prospective studies are needed.

Evaluation of Myocardial Injury using Standard Diagnostic Tools and Tissue Doppler Imaging in Blunt Trauma Chest

INTRODUCTION

Myocardial contusion is an entity in chest trauma which is difficult to diagnose. Current practice relies more on cardiac-specific biochemical markers and standard echocardiography, but no gold standard test exists. The application of Tissue Doppler imaging is yet unexplored.

AIM

The present study was designed to evaluate cardiac injury in patients with blunt trauma chest using conventional trans-thoracic echocardiography parameters and Tissue Doppler imaging.

MATERIALS AND METHODS

After ethical approval was taken from the Hospital and University and a written informed consent from all patients/attendants, this prospective study was conducted on a total of 30 patients in range of 15-60 years of age with blunt trauma chest. Patients with positive Trop-T and raised CPK (> 308 IU/L), raised CK-MB (> 24 IU/L) levels were suspected to have myocardial injury and were enrolled in the study. All patients fulfilling the inclusion criteria then underwent 2D-Echo and Tissue Doppler Imaging. Results of the observations were analysed using chi-square test.

RESULTS

Out of the total of 30 patients, 63.3% showed ECG changes suggestive of cardiac injury. A 76.7% patients suffered systolic dysfunction and 36.6% patients suffered diastolic dysfunction irrespective of ECG changes. On comparison of early filling velocity wave i.e., E wave (measured by transthoracic echocardiography) and tricuspid annular velocity Em wave (measured by tissue Doppler echocardiography) at tricuspid valve, we found statistically significant difference among two techniques. (p = 0.04).

CONCLUSION

Echocardiography is very sensitive parameter for evaluation of myocardial contusion. Tissue Doppler imaging provides additional and reliable information.

Blunt cardiac injury in trauma patients with thoracic aortic injury

Trauma patients with thoracic aortic injury (TAI) suffer blunt cardiac injury (BCI) at variable frequencies. This investigation aimed to determine the frequency of BCI in trauma patients with TAI and compare with those without TAI. All trauma patients with TAI who had admission electrocardiography (ECG) and serum creatine kinase-MB (CK-MB) from January 1999 to May 2009 were included as a study group at a level I trauma center. BCI was diagnosed if there was a positive ECG with either an elevated CK-MB or abnormal echocardiography. There were 26 patients (19 men, mean age 45.1 years, mean ISS 34.4) in the study group; 20 had evidence of BCI. Of 52 patients in the control group (38 men, mean age 46.9 years, mean ISS 38.7), eighteen had evidence of BCI. There was a significantly higher rate of BCI in trauma patients with TAI versus those without TAI (77% versus 35%, P < 0.001).

Diagnostic Dilemmas and Current Controversies in Blunt Chest Trauma

Blunt chest injuries are common encounters in the emergency department. Instead of a comprehensive review of the management of all chest injuries, this review focuses on injuries that can be difficult to diagnose and manage, including blunt aortic injury, cardiac contusion, and blunt diaphragmatic injury. This review also discusses some recent controversies in the literature regarding the use of prophylactic antibiotics for tube thoracostomy and the optimal management of occult pneumothorax. The article concludes with a discussion of the management of rib fractures in the elderly.

Diverse morphological lesions and serious arrhythmias with hemodynamic insults occur in the early myocardial contusion due to blunt impact in dogs

To investigate the morphology and hemodynamics of the early myocardial contusion, an animal model of cardiac contusion was established by impact to the precordial region at sternum at velocity of 10.0m/s with a mechanical elastic-cord propelled impactor in 19 dogs. The electrocardiogram and both the left and right intra-ventricular pressures were recorded continuously throughout the experiment. Histological and immunohistochemical examinations of myoglobin, creatine kinase-MB and fibrinogen were conducted. At the moment of impact, abrupt over-pressures within the left and right ventricles occurred with concomitant serious arrhythmias followed by variety of cardiac conduction disorders and depressed left and right ventricular systolic pressures during the observation times. Histologically, lesions of myocardial contusions were identified at subepicardial, myocardial or subendocardial layer as interstitial hemorrhage, disruption or coagulative necrosis as well as contraction band necrosis of the muscle fibers, which might be categorized into the hemorrhagic, necrotized and mixed forms. The three forms of lesions were found to exist independently, or co-existed in a heart. However, severity of the lesions varied greatly with different parts even within a heart. Intravascular thromboses were occasionally discovered post-impact. Immunohistochemically, loss of myoglobin and creatine kinase-MB from cardiac cells, and accumulation of fibrinogen at the cell membranes were detected 5min post-impact. The intracellular accumulation of fibrinogen increased with extension of post-impact intervals. Our results indicate that diverse morphological lesions concomitant with hemodynamic compromise and serious, even fatal arrhythmias occur in the early myocardial contusion, and intravascular thromboses are occasionally produced, suggesting that traumatic myocardial ischemic lesion may be induced due to blunt impact to the precordial region.

Electrocardiographic ST-segment elevation in the trauma patient: acute myocardial infarction vs myocardial contusion

The diagnosis of myocardial contusion in the setting of blunt trauma engenders much discussion and controversy-partly because of the lack of a gold standard for its identification other than histologic findings at autopsy. Furthermore, blunt cardiac trauma represents a spectrum of disorders ranging from transient electrocardiographic change to sudden death from myocardial rupture; hence, no single terminology exists to define such a wide range of scenarios. Here, we present 2 cases of electrocardiographic ST-segment elevation after high-speed motor vehicle crashes resulting in numerous injuries, including blunt chest trauma. Both patients demonstrated electrocardiographic ST-segment elevation, resulting from myocardial contusion and acute myocardial infarction.

Bedside echocardiography in chest trauma

Bedside US has an established role in the evaluation of chest trauma patients. Transthoracic echocardiography and TEE can be used to obtain critical information at the bedside for many emergent conditions, including the immediate detection of hemopericardium and acute aortic injury. More recent work has demonstrated that US also can be used to detect hemothoraces and pneumothoraces with accuracy. These diagnostic techniques can improve patient outcome and are within the scope of practice of emergency physicians and trauma surgeons. Physicians caring for trauma patients should be familiar with these techniques.

Blunt cardiac injury

In summary, the incidence of BCI following blunt thoracic trauma patients has been reported between 20% and 76%, and no gold standard exists to diagnose BCI. Diagnostic tests should be limited to identify those patients who are at risk of developing cardiac complications as a result of BCI. Therapeutic interventions should be directed to treat the complications of BCI. Finally, the prognosis and outcome of BCI patients is encouraging