Cardiac Trauma

Cardiac Trauma
R2 Nattapat Serewiwattana
Introduction and Epidermiology
 Penetrating cardiac injury results when a foreign object enters
the body and pierces the pericardium or heart. Blunt cardiac
injury results from physical forces acting externally on the
body
 Detection of cardiac injuries is critical for patient survival.
Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D.

Meckler, David M. Cline. (2016). Tintinalli’s Emergency Medicine: A Comprehensive
Study Guide, 8th edition
Introduction and Epidermiology
 Penetrating cardiothoracic injury causes 25% of deaths
immediately following trauma, and the majority of these
fatalities involve either cardiac or great vessel injury
 Cardiac injury may account for up to approximately 10% of
deaths from gunshot wounds.
 The incidence of blunt cardiac injury has been reported to
range anywhere from 8% to 71%.

Penetrating cardiac trauma
 They are one of the leading causes of death in urban trauma,
accounting for a high rate of prehospital death and in-hospital
mortality
 Most patients who sustain cardiac injuries die before reaching
the hospital, and almost two thirds of patients with penetrating
cardiac injuries have no vital signs upon arrival to the trauma
bay.
Frank Sellke & Pedro J. del Nido & Scott J. Swanson. (2016). Sabiston and Spencer
Surgery of the Chest, 9th Edition
 The mechanism of injury clearly influences survival.
 In general, these injuries are one of two types: stab or
gunshot wounds.
 Penetrating cardiac injuries secondary to blunt trauma that
produces fragments of fractured rib or sternum are rare
 The incidence of occult injury has been reported to be as
high as 20% in asymptomatic patients with penetrating stab
wounds to the chest
 Rates of involvement of cardiac structures due to penetrating
injuries to the right ventricle, left ventricle, right atrium, and
left atrium are approximately 40%, 35%, 20%, and 5%,
respectively
 Knives tend to involve a single chamber, producing a single
slit-like defect that is often more amenable to medical and
surgical therapy than gunshot wounds

 Patients with stab wounds to the heart are 17 times more
likely to survive than those with gunshot wounds
 Atrial injuries are less common and generally less severe,
whereas multichamber injuries are associated with higher
mortality.

Judith E. Tintinalli, J. Stephan
Stapczynski, O. John Ma, Donald M.
Yealy, Garth D. Meckler, David M.
Cline. (2016). Tintinalli’s Emergency
Medicine: A Comprehensive Study
Guide, 8th edition
Blunt cardiac trauma
 Up to 20% of all motor vehicle collision deaths are due to
blunt cardiac injury
 The most common reported injury is “myocardial or
cardiac contusion.” These terms are nonspecific and have
been used to report a wide range of injuries

 Blunt cardiac injury can encompass cardiac dysfunction
(diminished contractility in the absence of dysrhythmia or
hemorrhage), dysrhythmias, specific injuries (septal
rupture, valvular injuries, myocardial infarction), and
cardiac rupture, the most devastating blunt cardiac injury

Judith E. Tintinalli, J. Stephan
Stapczynski, O. John Ma, Donald
M. Yealy, Garth D. Meckler,
David M. Cline. (2016).
Tintinalli’s Emergency Medicine:
A Comprehensive Study Guide,
8th edition
 a new classification for blunt cardiac injury has been
developed and is currently in use at major trauma centers
Frank Sellke & Pedro J. del

Nido & Scott J. Swanson.
(2016). Sabiston and
Spencer Surgery of the
Chest, 9th Edition
Investigations
Chest radiography
 The chest radiograph remains paramount in every trauma
victim and should be the central focus from which
potential life-threatening thoracic problems are suspected
 Fractures of the thoracic cage indicate significant energy
transfer to the patient; those of the upper ribs are
associated with trauma to the great vessels, and those of
the clavicle are associated with pulmonary or cardiac
contusions
Chest radiography
 Along the mediastinum, widening, pneumomediastinum,
or shifting are highly suggestive of aortic transection,
tracheobronchial or esophageal injuries, or tension
pneumothorax or hemothorax
Chest radiography
Adjunctive radiologic signs for major vascular injuries
 Widened mediastinum  Obliteration of the space
 Obliteration of the aortic knob between the pulmonary artery
and the aorta (obscuration of the
 Deviation of the trachea to the
aortopulmonary window)
right
 Depression of the left mainstem
 Deviation of the esophagus
bronchus (nasogastric tube) to the right
 Elevation of the right mainstem
 Widened paratracheal stripe
bronchus  Widened paraspinal interfaces
 Left hemothorax  Presence of a pleural or apical
 Fractures of the first or second cap
rib or scapula
Computed Tomography
 Not essential for every patient with chest trauma and
should not be performed in the severely hemodynamically
unstable patient or in the presence of obvious life-
threatening injuries
 May reveal injuries not seen clearly on plain radiographs
Computed Tomography
 It may be useful to screen all patients with blunt trauma
and to evaluate unusual or abnormal findings on an initial
chest radiograph
 Up to 75% of trauma patients with a normal physical
examination and chest radiograph will have an occult
injury diagnosed on chest CT, and 5% of these patients
will need intervention for their injuries
Computed Tomography
 CT angiography was found to be 90% to 95% sensitive
and to have a 99% to 100% negative predictive value,
making it useful as a screening modality for aortic and
great vessel injuries
Ultrasonography
 FAST can be useful to identify injuries to the heart and
fluid in the pericardium
 The E-FAST, or extended-FAST, that uses an extension of
the right and left upper quadrant views to include the right
and left hemithoraces—right and left longitudinal thoracic
views, respectively—can aid in the diagnosis of
hemothorax or pneumothorax
Echocardiography
 Over the past decade there has been a major shift toward
CT angiography than the Trans-esophageal
echocargiography(TEE) as the most prevalent diagnostic
modality in patient who suspected aortic or great vessels
injury
 The new role for TEE may be reserved for its ability to
detect and follow small intimal tears not seen on
angiography and intraoperative imaging before and after a
repair.
Angiography
 Conventional angiography was once the gold standard in
the diagnosis of aortic transection or injuries to the great
vessels
 At the present time, as many centers currently use highly
detailed, 3D aortic reconstructions alone for diagnosis and
operative planning. Others will obtain a conventional
aortogram if the results of the CT angiogram are equivocal
or if the study was technically inadequate.
Electrocardiogram
Judith E. Tintinalli, J. Stephan Stapczynski, O.

John Ma, Donald M. Yealy, Garth D. Meckler,
David M. Cline. (2016). Tintinalli’s Emergency
Medicine: A Comprehensive Study Guide, 8th
edition
Cardiac Biomarkers
 Although cardiac markers can be used to assist in the
diagnosis of myocardial trauma, the utility of cardiac
biomarkers in the setting of blunt cardiac injury remains
unclear
 The sensitivity and specificity of troponins for blunt
cardiac injury vary from 12% to 23% and 97% to 100%

Management
Resuscitative procedure
ED Thoracotomy
 ED thoracotomy clearly plays a role in penetrating
thoracic trauma, particularly in the setting of trauma
patients with cardiac tamponade from penetrating chest
injuries.
 The role of ED thoracotomy for patients with blunt
traumatic injuries is heavily debated and appears to be
limited
Frank Sellke & Pedro J. del
Nido & Scott J. Swanson. (2016).
Sabiston and Spencer Surgery of
the Chest, 9th Edition
ED Thoracotomy
 Patients with penetrating thoracic injuries who arrive
pulseless, but with myocardial electrical activity(PEA),
may be candidates for immediate resuscitative
thoracotomy.
 A qualified surgeon must be present at the time of the
patient’s arrival to determine the need and potential
for success of a resuscitative thoracotomy in the
emergency department (ED).
American Collage of Surgeons. (2012), ATLS Student course manual, 9th

Edition
ED Thoracotomy
 The therapeutic maneuvers that can be effectively
accomplished with a resuscitative thoracotomy are:
 Evacuation of pericardial blood causing tamponade
 Direct control of exsanguinating intrathoracic hemorrhage
 Open cardiac massage
 Cross-clamping of the descending aorta to slow blood loss below
the diaphragm and increase perfusion to the brain and heart
American Collage of Surgeons. (2012), ATLS Student course manual, 9th

Edition
ED Thoracotomy
 Candidates for ED thoracotomy include penetrating chest
trauma patients who are hemodynamically unstable and those
who demonstrated signs of life (palpable pulse, a blood pressure,
pupil reactivity, any purposeful movement, organized cardiac
rhythm, or any respiratory effort) either in the field or ED but
subsequently lost these signs of life.

ED Thoracotomy
 Resuscitative ED thoracotomy is likely to be futile in patients under
the following clinical scenarios:
 (1) no pulse or blood pressure in the field
 (2) asystole is the presenting rhythm and there is no pericardial tamponade
 (3) prolonged pulselessness (>15 minutes) at any time
 (4) other massive, nonsurvivable injuries
 (5) blunt traumatic cardiac arrest

Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano. (2013). Trauma, 7th edition
Pericardiocentesis
 Pericardiocentesis is a prelude to formal thoracotomy if
there are inevitable delays to definitive surgery (i.e.,
transport to trauma center).
 Use of US guidance of the needle increases accuracy and
is a class I American College of Cardiology/American
Heart Association recommendation for critically injured
patients

F. Charles Brunicardi, Dana K. Andersen, Timothy R. Billiar, David L. Dunn, John G.
Hunter, Jeffrey B. Matthews, Raphael E. Pollock. (2014). Schwartz's Principles of Surgery,
10th Edition
Management
Non-operative Management
 Patients with an abnormal ECG (e.g., arrhythmia, ST changes,
ischemic changes, heart block) should be admitted for
continuous ECG monitoring for at least 48 hours.
 Conversely, a prolonged hospital stay with cardiac monitoring is
no longer required if the initial ECG and echocardiogram are
normal and most patients are discharged after 12 hours.
Operative management
 Required in 5% to 10%
 Chamber ruptures
 simple cardiorrhaphy and a running suture
 Valvular injuries
 Valve repair/replacement, chordae reattachment
 VSD
 Septal repair in large defect or associated with LV aneurysm
 Pericardial tears with associated cardiac herniation
 Direct repair
Management
 All patients with penetrating thoracic trauma and

echocardiograms or FAST scan pericardial views that
demonstrate free pericardial fluid or that suggest clotted
lacerations should be explored surgically
 Based on poor outcomes in patients who are initially

managed nonoperatively.
 One study showed that two of threepatients in clinically
stable condition and with ultrasound suggesting clotted
laceration subsequently became unstable, and only one of
these patients survived
 Today, management of penetrating injuries to the heart

follows standard principles of cardiac surgery.
 If cardiac injury is suspected and time allows, transfer to
the operating room with median sternotomy is performed.
Minimally invasive procedures
 Laparoscopic or VATS approach for performing pericardial

windows in stable patients
 if persistent hemorrhage is appreciated, formal exploration should
use a median sternotomy to gain better exposure to the heart and
great vessels
References
 Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy,
Garth D. Meckler, David M. Cline. (2016). Tintinalli’s Emergency
Medicine: A Comprehensive Study Guide, 8th edition
 Frank Sellke & Pedro J. del Nido & Scott J. Swanson. (2016). Sabiston
and Spencer Surgery of the Chest, 9th Edition
 F. Charles Brunicardi, Dana K. Andersen, Timothy R. Billiar, David L.
Dunn, John G. Hunter, Jeffrey B. Matthews, Raphael E. Pollock. (2014).
Schwartz's Principles of Surgery, 10th Edition
 American Collage of Surgeons. (2012), ATLS Student course manual, 9th
Edition
 Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano. (2013). Trauma,
7th edition

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Cardiac Trauma

Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D.

Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D.

Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D.

Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D.

Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D.

Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D.

Frank Sellke & Pedro J. del

Judith E. Tintinalli, J. Stephan Stapczynski, O.

Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D.

American Collage of Surgeons. (2012), ATLS Student course manual, 9th

American Collage of Surgeons. (2012), ATLS Student course manual, 9th

Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D.

Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D.

Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D.

 All patients with penetrating thoracic trauma and

 Based on poor outcomes in patients who are initially

 Today, management of penetrating injuries to the heart

 Laparoscopic or VATS approach for performing pericardial

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