Trauma: Cardiac Trauma

Cardiac/Pericardial Injury

AAST Heart Injury Scale

Myocardial Contusion/Blunt Cardiac Injury (BCI)

  • Most Common Complication: Arrhythmia
    • Most Common Arrhythmia: SVT
  • Most Common Cause of Death: VT/VF
  • Not Predicted by Sternal Fracture
  • Screening:
    • Initial Screen: ECG
      • Most Common Dysrhythmia: PVC’s
    • If ECG Abnormal: Echocardiogram & Telemetry for 24-48 Hours
      • May Forego Formal Echo if FAST is Able to Rule Out Pericardial Effusion or Other Causes of Shock
    • If Hemodynamically Unstable or Arrhythmia Persistent: Echocardiogram
      • Transesophageal Echo (TEE) May Be Preferred Over Transthoracic Echo (TTE) if Available
    • If Echo Abnormal: Send to ICU
    • CK-MB, CPK & Nuclear Imaging are Not Useful

Cardiac Laceration/Perforation

  • Most Common Injury:
    • Penetrating Trauma: Right Ventricle
      • Due to Anterior Position
    • Blunt Trauma: Right Atrium #1, Right Ventricle #2
  • Muscular Ventricle May Seal Lacerations Preventing Exsanguination Prior to Arrival
  • Tx: Median Sternotomy & Cardiorrhaphy (Primary Repair)
    • Use Non-Absorbable Monofilament Suture with Pledgets, Typically a Horizontal Mattress
    • With Anterior Injury, Posterior Heart Must Also Be Inspected

Coronary Artery Injury

  • Most Common Vessel Injured: Left Anterior Descending (LAD)
  • Tx:
    • Proximal/Middle: Cardiopulmonary Bypass & CABG
      • Use Saphenous Vein
      • *Consider Primary Repair if There is No Loss of Length
    • Distal: Ligation

Blunt Traumatic Pericardial Rupture (BTPR)

  • Can Cause Cardiac Herniation or Hemothorax
    • Heart Can Herniate into Pleural Cavity or Abdomen
  • Rupture Often Relieves Potential Tamponade
  • High Mortality Due to Associated Injuries & Often Discovered at Autopsy
    • Overall Survival Rate: 24%
    • Survival Rate if Isolated: 67%
  • Presentations:
    • Herniation Mimics Pericardial Tamponade Due to Decreased Venous Return
      • Consider if Unstable with HTX & Negative FAST but High Concern for Cardiac Injury
    • May See Sudden Loss of When Patient is Moved or Placed on a Stretcher Due to Herniation
    • May See an “Empty” Pericardial Cavity on Left Thoracotomy if Herniated into Right Pleural Cavity
  • Tx: Median Sternotomy
    • May Also Be Repaired by Laparotomy or Thoracotomy if Done for Other Reasons
    • Replace Heart into Pericardial Cavity if Displaced
    • Management of Pericardial Tear:
      • Primary Repair (Interrupted Nonabsorbable Suture) – Generally preferred
      • Can Use a Prosthetic Patch if Too Large to Close Primarily
      • Small Defects Can Be Left Alone if Herniation is Not Possible

Cardiorrhaphy with Pledgets 1

Cardiac Tamponade

Basics

Phases

  • I: Increased Pericardial Pressure
    • Output Maintained by Tachycardia, Increased SVR & Filling Pressure
  • II: Diminished Cardiac Output
  • III: Intrapericardial Pressure Approaches Ventricular Filling Pressure
    • See Cardiac Arrest from Profound Coronary Hypoperfusion

Presentation

  • Sx: Chest Pain & Dyspnea
  • Pulsus Paradoxus: Decreased BP > 10 During Inspiration (Normal < 10)
  • Beck’s Triad:
    • JVD
    • Muffled Heart Sounds
    • Hypotension with Narrow Pulse Pressure
  • Kussmaul’s Sign: JVD Upon Inspiration
  • First Sign: Decreased Right Atrium Filling

Diagnosis

  • Dx: Clinical vs Echo/FAST
  • Subxiphoid Pericardial Window
    • Diagnostic, Not Therapeutic
    • Rarely Preformed Now; But Consider if FAST Equivocal
    • Procedure:
      • 10 cm Midline Incision Over Xiphoid
      • Dissect toward Cardiac Impulses to Find Pericardium
      • Grasp Pericardium Between Two Alice Clamps
      • 1-2 cm Longitudinal Incision in Pericardium
      • Field Flooded with Fluid
    • Results:
      • Positive: Bloody Fluid
        • Clotted Blood May Be Dry on Incision
      • Negative: Clear/Straw-Colored Fluid

Treatment

  • Primary Tx: Median Sternotomy
  • Avoid Intubation Until in the OR & Already Prepped – May Crash After Anesthetic Induction
  • Pericardiocentesis: To Temporize for Transfer or If Acutely Unstable Prior to OR
    • Used More Often in Non-Traumatic Causes
    • Insertion: 18-Gauge Spinal Needle
      • Subxiphoid; Under Xiphoid & Toward Left Shoulder
      • Parasternal; Left 5th/6th Rib Space & Perpendicular
      • Apical; Left 5th/6th Rib Space, 5 cm Lateral & Toward Right Shoulder
    • *In General, In Trauma, Blood in the Pericardium Does Not Clot – Clotted Blood Would Indicate Aspiration of a Cardiac Chamber
  • ED Thoracotomy: For Traumatic & Sudden Decompensation
  • Non-Traumatic Tx: *See Cardiothoracic Surgery: Pericardial Effusion & Cardiac Tamponade

Cardiac Tamponade on FAST 2

References

  1. Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World J Emerg Surg. 2006 Mar 24;1:4. (License: CC BY-2.0)
  2. Gillman LM, Ball CG, Panebianco N, Al-Kadi A, Kirkpatrick AW. Clinician performed resuscitative ultrasonography for the initial evaluation and resuscitation of trauma. Scand J Trauma Resusc Emerg Med. 2009 Aug 6;17:34. (License: CC BY-2.0)