Understanding traumatic blunt cardiac injury

Blunt cardiac injury in the hemodynamically stable patient

ABSTRACT

Blunt cardiac injury (BCI) describes a spectrum of problems including severe, potentially life-threatening injuries from trauma. Pericardial effusion is an example of a BCI that has generally been assumed to imply serious underlying injury to the heart and should be considered hemopericardium until proven otherwise. A standard of care has been established to screen for BCI and treat hemodynamically unstable patients with an acute pericardial effusion presumably related to BCI. Less agreement exists on definitive treatment for hemodynamically stable patients with pericardial effusion after blunt cardiac trauma. This case study explores a new treatment for small to moderate hemopericardium in a stable patient after BCI.

Comprehensive Management of the Patient With Traumatic Cardiac Injury

Cardiac injuries are rare but potentially life-threatening, with a significant proportion of victims dying before arrival at the hospital. The in-hospital mortality among patients who arrive in-hospital alive also remains significantly high, despite major advancements in trauma care including the continuous updating of the Advanced Trauma Life Support (ATLS) program. Stab and gunshot wounds due to assault or self-inflicted injuries are the common causes of penetrating cardiac injuries, while motor vehicular accidents and fall from height are attributable causes of blunt cardiac injury. Rapid transport of victim to trauma care facility, prompt recognition of cardiac trauma by clinical evaluation and focused assessment with sonography for trauma (FAST) examination, quick decision-making to perform emergency department thoracotomy, and/or shifting the patient expeditiously to the operating room for operative intervention with ongoing resuscitation are the key components for a successful outcome in cardiac injury victims with cardiac tamponade or exsanguinating hemorrhage. Blunt cardiac injury with arrhythmias, myocardial dysfunction, or cardiac failure may need continuous cardiac monitoring or anesthetic care for operative procedure of other associated injuries. This mandates a multidisciplinary approach working in concert with agreed local protocols and shared goals. An anesthesiologist has a pivotal role to play as a team leader or member in the trauma pathway of severely injured patients. They are not only involved in in-hospital care as a perioperative physician but also participate in the organizational aspects of prehospital trauma systems and training of prehospital care providers/paramedics. There is sparse literature available on the anesthetic management of cardiac injury (penetrating as well as blunt) patients. This narrative review discusses the comprehensive management of cardiac injury patients, focusing on the anesthetic concerns and is guided by our experience in managing cardiac injury cases at Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences, New Delhi. JPNATC is the only level 1 trauma center in north India, providing services to a population of approximately 30 million with around 9000 operations being performed annually.

Predictors of Mortality in Blunt Cardiac Injury: A Nationwide Analysis

INTRODUCTION

Blunt thoracic injury (BTI) is one of the most common causes of trauma admission in the United States and is uncommonly associated with cardiac injuries. Blunt cardiac injury (BCI) after blunt thoracic trauma is infrequent but carries a substantial risk of morbidity and sudden mortality. Our study aims to identify predictors of concomitant cardiac contusion among BTI patients and the predictors of mortality among patients presenting with BCI on a national level.

MATERIALS AND METHODS

We performed a 1-y (2017) analysis of the American College of Surgeons Trauma Quality Improvement Program. We included all adults (aged ≥ 18 y) with the diagnosis of BTI. We excluded patients who were transferred, had a penetrating mechanism of injury, and who were dead on arrival. Our primary outcomes were the independent predictors of concomitant cardiac contusions among BTI patients and the predictors of mortality among BCI patients. Our secondary outcome measures were in-hospital complications, differences in injury patterns, and injury severity between the survivors and nonsurvivors of BCI.

RESULTS

A total of 125,696 patients with BTI were identified, of which 2368 patients had BCI. Mean age was 52 ± 20 y, 67% were male, and median injury severity score was 14 [9-21]. The most common type of cardiac injury was cardiac contusion (43%). Age ≥ 65 y, higher 4-h packed red blood cell requirements, motor vehicle collision mechanism of injury, and concomitant thoracic injuries (hemothorax, flail chest, lung contusion, sternal fracture, diaphragmatic injury, and thoracic aortic injuries) were independently associated with concomitant cardiac contusion among BTI patients (P value < 0.05). Age ≥ 65 y, thoracic aortic injury, diaphragmatic injury, hemothorax, and a history of congestive heart failure were independently associated with mortality in BCI patients (P value < 0.05).

CONCLUSIONS

Predictors of concomitant cardiac contusion among BTI patients and mortality among BCI patients were identified. Guidelines on the management of BCI should incorporate these predictors for timely identification of high-risk patients.

Blunt Trauma to the Heart: A Review of Pathophysiology and Current Management

Blunt cardiac injury (BCI), defined as an injury to the heart from blunt force trauma, ranges from minor to life-threatening. The majority of BCIs are due to motor vehicle accidents; however, injuries caused by falls, blasts, and sports-related injuries also can be sources of BCI. A significant proportion of patients with BCI do not survive long enough to receive medical care, succumbing to their injuries at the scene of the accident. Additionally, patients with blunt trauma often have coexisting injuries (brain, spine, orthopedic) that can obscure the clinical picture; therefore, a high degree of suspicion often is required to diagnose BCI. Traditionally, hemodynamically stable injuries suspicious for BCI have been evaluated with electrocardiograms and chest radiographs, whereas hemodynamically unstable BCIs have received operative intervention. More recently, computed tomography and echocardiography increasingly have been utilized to identify injuries more rapidly in hemodynamically unstable patients. Transesophageal echocardiography can play an important role in the diagnosis and management of several BCIs that require operative repair. Close communication with the surgical team and access to blood products for potentially massive transfusion also play key roles in maintaining hemodynamic stability. With proper surgical and anesthetic care, survival in cases involving urgent cardiac repair can reach 66%-to-75%. This narrative review focuses on the types of cardiac injuries that are caused by blunt chest trauma, the modalities and techniques currently used to diagnose BCI, and the perioperative management of injuries that require surgical correction.

Emergency Surgery for Blunt Cardiac Injury: Experience in 43 Cases

BACKGROUND

Blunt cardiac injury (BCI) increases with traffic accidents and is an important cause of death in trauma patients. In particular, for patients who need surgical treatment, the mortality rate is extremely high unless the patient is promptly operated on. This study aimed to explore early recognition and expeditious surgical intervention to increase survival.

METHODS

All patients with BCIs during the past 15 years were reviewed, and those who underwent operative treatment were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome.

RESULTS

A total of 348 patients with BCIs accounted for 18.3% of 1903 patients with blunt thoracic injury (BTI). Of 348 patients, 43 underwent operative treatment. The main cause of injury was traffic accidents, with an incidence of 48.8%. Of them, steering wheel injuries occurred in 15 patients. In 26 patients, a preoperative diagnosis was obtained by echocardiography, CT scanning, etc. In the remaining 17, who had to undergo urgent thoracotomy without any preoperative imaging, a definitive diagnosis of BCI was proven during the operation. The volume of preoperative infusion or crystalloid was <1000 ml in 31 cases. Preoperative pericardiocentesis was not used in anyone. In 12 patients, the operation commenced within 1 h. Overall mortality was 32.6%. The death was caused by BCI in 9.

CONCLUSIONS

Facing a patient with BTI, a high index of suspicion for BCI must be maintained. To manage those requiring operations, early recognition and expeditious thoracotomy are essential. Preoperatively, limited fluid resuscitation is emphasized. We do not advocate preoperative pericardiocentesis.

Delayed cardiac tamponade following blunt chest trauma due to disruption of fourth costal cartilage with posterior dislocation

Cardiac tamponade is a recognised sequelae of non-penetrating and penetrating chest trauma. Delayed cardiac tamponade has been described following blunt chest trauma. We present a 29 year-old gentleman who had initially presented to peripheral district general hospital following direct blunt chest wall trauma. His initial trauma CT demonstrated a small mediastinal haematoma and large left haemopneumothorax and disruption/dislocation of the costal cartilage. He initially underwent a thoracoscopic procedure uneventfully. He then had worsening chest radiograph appearances with enlarging cardiac contours. Transthoracic echocardiography confirmed cardiac tamponade. He underwent creation of a pericardial window and excision of the protruding fourth costal cartilage.

Blunt Cardiac Injury: A Single-Center 15-Year Experience

In recent years, the incidence of blunt cardiac injury (BCI) has increased rapidly and is an important cause of death in trauma patients. This study aimed to explore early diagnosis and therapy to increase survival. All patients with BCI during the past 15 years were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome. The patients were divided into two groups according to the needs of their condition—nonoperative (Group A) and operative (Group B). Comparisons of the groups were performed. A total of 348 patients with BCI accounted for 18.3 per cent of 1903 patients with blunt thoracic injury. The main cause of injury was traffic accidents, with an incidence of 48.3 per cent. In Group A (n = 305), most patients sustained myocardial contusion, and the mortality was 6.9 per cent. In Group B (n = 43), including those with cardiac rupture and pericardial hernia, the mortality was 32.6 per cent. Comparisons of the groups regarding the shock rate and mortality were significant ( P < 0.01). Deaths directly resulting from BCI in Group B were greater than those in Group A ( P < 0.05). In all 348 patients, the mortality rate was 10.1 per cent. When facing a patient with blunt thoracic injury, a high index of suspicion for BCI must be maintained. To manage myocardial contusion, it is necessary to protect the heart, alleviate edema of the myocardium, and control arrhythmia with drugs. To deal with those requiring operation, early recognition and expeditious thoracotomy are essential.

Traumatic blunt cardiac injuries: An updated narrative review

Blunt cardiac injury (BCI) is defined as injuries sustained due to blunt trauma to the heart, and it remains unchanged for long time. The spectrum of BCI ranges from a minor "bruise" to specific postcontusion cardiac conditions such as free-wall rupture. This is a narrative review provides a continued and updates details regarding BCIs from 2008 to 2017. For this purpose, a narrative review of literature was conducted using appropriate database for retrieval of articles through systematic search methodology. Autopsy-based studies are very limited. It can be concluded that regardless of the variability in the spectrum of modalities and medical/surgical resources, BCIs diagnosis and management remain a puzzle and needs further prospective studies.

Blunt cardiac rupture due to kicking on the lateral side of the right chest

Blunt cardiac rupture can be caused by an indirect blow to the heart during sports. Clinicians should consider the possibility of cardiac injury regardless of the severity of trauma. Confirming the diagnosis and reaching a decision to operate as soon as possible is the only way to rescue the patient.

Dynamin-related protein 1-mediated mitochondrial fission contributes to post-traumatic cardiac dysfunction in rats and the protective effect of melatonin

Mechanical trauma (MT) causes myocardial injury and cardiac dysfunction. However, the underlying mechanism remains largely unclear. This study investigated the role of mitochondrial dynamics in post-traumatic cardiac dysfunction and the protective effects of melatonin. Adult male Sprague Dawley rats were subjected to 5-minute rotations (200 revolutions at a rate of 40 rpm) to induce MT model. Melatonin was administrated intraperitoneally 5 minute after MT. Mitochondrial morphology, myocardial injury, and cardiac function were determined in vivo. There was smaller size of mitochondria and increased number of mitochondria per μm² in the hearts after MT when the secondary myocardial injury was induced. Melatonin treatment at the dose of 30 mg/kg reduced serine 616 phosphorylation of Drp1 and inhibited mitochondrial Drp1 translocation and mitochondrial fission in the hearts of rats subjected to MT, which contributed to the reduction of myocardial injury and the improvement of cardiac function. In vitro, H9c2 cells cultured in 20% traumatic plasma (TP) for 12 hour showed enhanced mitochondrial fission, mitochondrial membrane potential (∆Ψm) loss, mitochondrial cytochrome c release, and decreased mitochondrial complex I-IV activities. Pretreatment with melatonin (100 μmol/L) efficiently inhibited TP-induced mitochondrial fission, ∆Ψm loss, cytochrome c release, and improved mitochondrial function. Melatonin's protective effects were attributed to its role in suppressing plasma TNF-α overproduction, which was responsible for Drp1-mediated mitochondrial fission. Taken together, our results demonstrate for the first time that abnormal mitochondrial dynamics is involved in post-traumatic cardiac dysfunction. Melatonin has significant pharmacological potential in protecting against MT-induced cardiac dysfunction by preventing excessive mitochondrial fission.

Role of H-FABP values in determining the etiologic factors of the cardiac injuries

Introduction

Cardiac injury resulting from blunt thoracic trauma is a frequent clinical occurrence which is difficult to diagnose. Our purpose in this study was to research whether H-FABP, which is a new marker for the diagnosis of cardiac injury, can be used in this patient group.

Methods

50 patients with blunt thoracic injury who were admitted to our emergency service within a period of 8 months and 50 cases as controls were included in our study.

Results

Of the 50 patients with blunt thoracic injury in our study, 88% were male while 12% were female. The average age of the patients was 43 ± 15.15. While 27 (54%) of the 50 patients with blunt thoracic injury had cardiac injury, 23 (46%) did not have cardiac injury. The results of the statistical analyses showed a significant association between thorax trauma and cTnI, CPK, CPKMB and H-FABP (p<0.05). While there was a significant association between cardiac injury resulting from thoracic trauma and cTnI, ECG and TTE (p<0.05), there was no significant association between CPK, CPKMB and H-FABP (p>0.05).

Conclusion

In thoracic traumas, cardiac injury diagnosis can be made as a result of the assessment with Troponin-I, ECG and ECHO. For cardiac injury diagnosis, wide scale prospective studies are needed for H-FABP use.

Traumatic cardiac injury: Experience from a level-1 trauma centre

PURPOSE

Traumatic cardiac injury (TCI) is a challenge for trauma surgeons as it provides a short thera- peutic window and the management is often dictated by the underlying mechanism and hemodynamic status. The current study is to evaluate the factors influencing the outcome of TCI.

METHODS

Prospectively maintained database of TCI cases admitted at a Level-1 trauma center from July 2008 to June 2013 was retrospectively analyzed. Hospital records were reviewed and statistical analysis was performed using the SPSS version 15.

RESULTS

Out of 21 cases of TCI, 6 (28.6%) had isolated and 15 (71.4%) had associated injuries. Ratio be- tween blunt and penetrating injuries was 2:1 with male preponderance. Mean ISS was 31.95. Thirteen patients (62%) presented with features suggestive of shock. Cardiac tamponade was present in 12 (57%) cases and pericardiocentesis was done in only 6 cases of them. Overall 19 patients underwent surgery. Perioperatively 8 (38.1%) patients developed cardiac arrest and 7 developed cardiac arrhythmia. Overall survival rate was 71.4%. Mortality was related to cardiac arrest (p = 0.014), arrhythmia (p = 0.014), and hemorrhagic shock (p =0.04). The diagnostic accuracy of focused assessment by sonography in trauma (FAST) was 95.24%.

CONCLUSION

High index of clinical suspicion based on the mechanism of injury, meticulous examination by FAST and early intervention could improve the overall outcome.

Troponin T in Patients with Traumatic Chest Injuries with and without Cardiac Involvement: Insights from an Observational Study

BACKGROUND

Serum troponin T (TnT) is a common marker of myocardial injury. However, its implication in the absence of clinical evidence of cardiac reason is not well established.

AIMS

The aim of this study was to identify the implications of positive TnT in traumatic chest injury (TCI) patients regardless of the cardiac involvement.

MATERIALS AND METHODS

We conducted a retrospective analysis of all TCI patients admitted to level 1 trauma center between 2008 and 2011. Patients who underwent TnT testing were divided into two groups: Group 1 (positive TnT) and Group 2 (negative TnT). The two groups were analyzed and compared, and multivariate regression analyses were performed to identify predictors of TnT positivity and mortality.

RESULTS

Out of 993 blunt TCI patients, 19.3% had positive TnT (Group 1). On comparison to Group 2, patients in Group 1 were 5 years younger and more likely to have head, cardiac, hepatic, splenic, and pelvic injuries, in addition to lung contusion. Positive TnT was associated with higher Injury Severity Score (ISS) (P = 0.001), higher chest Abbreviated Injury Score (AIS) (P = 0.001), and longer hospital stay (P = 0.03). In addition, Group 1 patients were more likely to undergo chest tube insertion, exploratory laparotomy, mechanical ventilation, and tracheostomy. Twenty patients had cardiac involvement, and of them 14 had positive TnT. Among 973 patients who showed no evidence of cardiac involvement, 178 had positive TnT (18.3%). There were 104 deaths (60% in Group 1). On multivariate regression analysis, the predictors of hospital mortality were positive TnT, head injury, and high ISS, whereas, the predictors of TnT positivity were cardiac, hepatic, and pelvic injuries; higher ISS; and age.

CONCLUSIONS

Positive TnT in blunt TCI patients is a common challenge, particularly in polytrauma cases. Patients with positive TnT tend to have the worst outcome even in the absence of clinical evidence of acute cardiac involvement. Positive TnT is also a reflection of the severity of chest or extrathoracic injuries; however, further prospective studies are warranted.

Cardiac Injuries: A Review of Multidetector Computed Tomography Findings

Trauma is the leading cause of death in United States in the younger population. Cardiac trauma is common following blunt chest injuries and is associated with high morbidity and mortality. This study discusses various multidetector computed tomography (MDCT) findings of cardiac trauma. Cardiac injuries are broadly categorized into the most commonly occurring blunt cardiac injury and the less commonly occurring penetrating injury. Signs and symptoms of cardiac injury can be masked by the associated injuries. Each imaging modality including chest radiographs, echocardiography, magnetic resonance imaging and MDCT has role in evaluating these patients. However, MDCT is noninvasive; universally available and has a high spatial, contrast, and temporal resolution. It is a one stop shop to diagnose and evaluate complications of cardiac injury. MDCT is an imaging modality of choice to evaluate patients with cardiac injuries especially the injuries capable of causing hemodynamic instability.

Critical Care for the Patient With Multiple Trauma

Trauma remains the leading cause of death worldwide and the leading cause of death in those less than 44 years old in the United States. Admission to a verified trauma center has been shown to decrease mortality following a major injury. This decrease in mortality has been a direct result of improvements in the initial evaluation and resuscitation from injury as well as continued advances in critical care. As such, it is vital that intensive care practitioners be familiar with various types of injuries and their associated treatment strategies as well as their potential complications in order to minimize the morbidity and mortality frequently seen in this patient population.

Sudden cardiac death in athletes: where do we stand

We aimed to review the literature to explore the magnitude of sudden cardiac death (SCD) in young athletes. Although SCD in athletes is not a common event, it represents a tragedy of the apparently fit young population. SCD varies according to countries, age groups, and sex. In addition, it varies in the underlying causes and the screening tool. Therefore, we are in need for further research efforts. Guidelines, public and physician awareness, and education regarding the warning signs are integral part in the strategy to reduce SCD tragedy. However, all these requirements raise concern for cost-effectiveness in some countries for proper implementation.