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    Abstract
   Introduction
   Blunt Cardiac Injury
   Diagnosis of BCI
   Ecg
   Management
   Conclusion
    References
    Article Figures
    Article Tables

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Table of Contents
REVIEW ARTICLE  
Year : 2012  |  Volume : 15  |  Issue : 4  |  Page : 287-295
Understanding traumatic blunt cardiac injury


1 Department of Surgery, Section of Trauma Surgery, Hamad Medical Corporation; Department of Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
2 Department of Surgery, Section of Trauma Surgery, Hamad Medical Corporation, Doha, Qatar

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Date of Submission17-Mar-2012
Date of Acceptance29-Jun-2012
Date of Web Publication1-Oct-2012
 

   Abstract 

Cardiac injuries are classified as blunt and penetrating injuries. In both the injuries, the major issue is missing the diagnosis and high mortality. Blunt cardiac injuries (BCI) are much more common than penetrating injuries. Aiming at a better understanding of BCI, we searched the literature from January 1847 to January 2012 by using MEDLINE and EMBASE search engines. Using the key word "Blunt Cardiac Injury," we found 1814 articles; out of which 716 articles were relevant. Herein, we review the causes, diagnosis, and management of BCI. In conclusion, traumatic cardiac injury is a major challenge in critical trauma care, but the guidelines are lacking. A high index of suspicion, application of current diagnostic protocols, and prompt and appropriate management is mandatory.

Keywords: Blunt trauma, Blunt cardiac injury, Aortic injury

How to cite this article:
El-Menyar A, Al Thani H, Zarour A, Latifi R. Understanding traumatic blunt cardiac injury. Ann Card Anaesth 2012;15:287-95

How to cite this URL:
El-Menyar A, Al Thani H, Zarour A, Latifi R. Understanding traumatic blunt cardiac injury. Ann Card Anaesth [serial online] 2012 [cited 2019 Oct 16];15:287-95. Available from: http://www.annals.in/text.asp?2012/15/4/287/101875



   Introduction Top


Cardiac injuries are classified as blunt and penetrating injuries. In both the type of injuries, the major issue is missing the diagnosis and high mortality. Blunt cardiac injuries (BCIs) are much more common than penetrating injuries. Penetrating trauma is seen in urban trauma centers and predominantly due to stab wounds, gunshot wounds, or less commonly other iatrogenic instrumentation. In penetrating injuries, up to 90% of victims die before reaching hospital and resuscitation is of limited benefit; therefore, survival depends on rapid pre-hospital transport. [1]

Aiming at better understanding of BCI, we reviewed the literature from January 1847 to January 2012 by utilizing MEDLINE and EMBASE search engines. Using the key word "Blunt Cardiac Injury," we found 1814 articles; out of which 716 articles were relevant. Of the relevant articles, 559 were published in English language; there were 100 reviews, 135 case reports (some case reports were followed by review of the literature), 22 pediatric-related articles, 35 articles based on echocardiographic analysis, 24 prospective studies, 20 retrospective studies, and 1 meta-analysis. Herein, we review the causes, diagnosis, and management of BCI.


   Blunt Cardiac Injury Top


BCI ranges from asymptomatic myocardial bruise to cardiac rupture and death. [2],[3],[4] BCIs most often occur during motor vehicle crashes (MVC). Based on the associated injuries, intensity of chest injury, and complexity of injuries the incidence of BCI varies from 20 to 76%. Falls and crush injuries are less frequently associated with BCI. BCIs are characterized by patchy areas of muscle necrosis and hemorrhagic infiltrate(s), rupture of small vessels, and hemorrhage into the interstitium and around the muscle fibers. [4] Myocardial contusion has been reported in 60-100% autopsy series of patients with BCI. [3]

Commotio Cordis
Commotio Cordis is a rare type of BCI in which low-impact chest trauma causes sudden cardiac arrest, usually occurs from being struck by a projectile during sports. Cardiac arrest appears to stem from blow during a period of electrical vulnerability (10 to 30 ms before the peak of the T wave). A direct blow to the precordium accounts for a sizable number of cases. Patients involved in a MVC with sudden deceleration, or who sustains significant chest trauma or severe multiple trauma are at risk of Commotio Cordis. [5]

Cardiac Rupture
Between 1847 and 1952, 13 cases of rupture of interventricular septum due to BCI were described. [6] The mechanism of injury and factors necessary to produce rupture of the heart after blunt injury were reported between 1935 and 1938. A full chamber in early systole is more vulnerable if compressed over its outflow tract; the myocardial fibers may rupture at a point away from the area of direct contusion. [6] Between 1994 and 2009, several other mechanisms of blunt traumatic cardiac rupture have been reported, and include precordial impaction with cardiac squeeze between the sternum and spine and rapid deceleration resulting in disruption of the atria from their connections to the vena cava and pulmonary veins. [7],[8] Minimal force is required for a deceleration type contusion injury that may occur at a relatively low velocity of 20 miles/h. [9],[10]

Cardiac rupture is the most devastating BCI and the incidence of the site of injury varies in various autopsy series (Cardiac wall: 0.16-2%, Right ventricle: 19-32%, Right atrium: 10-15%, Left ventricle: 5-44%, and Left atrium: 1-7%). [3],[11]

Forces involved in BCI
Include compression of the heart between the spine and sternum, abrupt pressure fluctuations in the chest and abdomen, shearing from rapid deceleration and blast injury, and fragments from rib fractures causing injury to the heart. [Table 1] summarizes the mechanism of BCI.
Table 1: Summary of the mechanism of BCI

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The right heart is most commonly injured. [12] This is probably due to its position closest to the anterior chest wall. High-pressure ventricular injuries appear to be as common as low-pressure atrial injuries, but findings may vary based on the type of study (i.e. clinical or autopsy). In autopsy series, ventricular injuries are the dominant findings. Aortic and mitral valve damage has been reported as a complication of blunt chest injury. [4] The incidence of tricuspid or mitral valvular injury is around 5% which include chordal rupture, anterior papillary muscle and/ or leaflet tear. [3],[4] Ismailov et al. reported that BCI is independently associated with 11 and 3 times increase in the incidences of tricuspid and aortic valve insufficiency, respectively. [4] Other less common pathological findings in patients with BCI include septal tears (Atrial septal defect: 7% Ventricular septal defect : 4%) Coronary artery injury and thrombosis (3%). [3]

Indirect cardiac injury
Even if the heart is not directly involved in the trauma, cardiac injury remains a possible concern. The stressful impact of trauma may result in myocardial infarction secondary to acute thrombosis or severe coronary spasm (with patent coronary arteries). Also, significant arrhythmia and stress-induced cardiomyopathy (Takotsubo cardiomyopathy) have been reported in many cases secondary to the fear and stress of trauma. [13],[14]

Blunt aortic injury
Blunt aortic injury (BAI) is a common cause of traumatic pericardial tamponade. It should be considered in patients with a deceleration or acceleration injury with signs suggestive of mediastinal injury. [15] BAI is the second most common cause of death in blunt trauma patients. [16] Most patients with BAI die at the place of injury, and only 13-15% reach alive to hospitals. [16],[17] The most common mechanism of BAI is motor vehicle crash, pedestrian injury, and falls. [15],[18]

Cardiac herniation
It is a potentially fatal complication of BCI and reported in 0.4% of severe blunt trauma. [19],[20] Cardiac herniation frequently results in early death, and thus the diagnosis is mainly based on autopsy findings. [20] In a series of BCI, patients who survived to hospital admission had favorable outcome with survival rate of 36.4-42.9%. [21] The high in-hospital mortality rate (up to 64%) is probably a reflection of not only pericardial rupture and cardiac herniation but also of the associated injuries. [19],[22]

Pericardial effusion
Definite diagnosis of traumatic pericardial effusions is not easy even with Focused Assessment with Sonography for Trauma (FAST), repeat cardiac echocardiography, and computed tomography (CT). [23] Patients who survive to the hospital usually have minor tears in the low-pressure chamber with a blood clot that temporarily stops the bleeding or have decompression of blood into the pleural cavity because of a pleuropericardial defect. [23] Compared with penetrating chest injuries, cardiac injury is more easily neglected in blunt trauma, especially when associated with head or abdominal injury. [23],[24] Huang et al. reported that 87.1% of traumatic pericardial effusions were due to blunt trauma and 51.7% were associated with cardiac injury or rupture. [23]

Associated injuries
In BCI, the most common associated injuries are: rib fractures (18-69%), lung contusion (6-58%), flail chest (3-38%), sternal fracture (0-60%), head injury (20-73%), and abdominal solid organ injury (5-43%). [3]

Delayed complications
Pericardial, myocardial or valvular injuries may present late after trauma. Most patients with trauma of the aortic valve suffer its disruption immediately after the initial trauma; however, "delayed" rupture may occur. [4],[25] Delayed tricuspid and mitral valvular rupture may be due to papillary muscle contusion with hemorrhage, inflammation, and late necrosis, leading to disruption over time. [26] Cardiac tamponade has been reported after several days or weeks after minor blunt chest or isolated abdominal trauma. [27],[28]


   Diagnosis of BCI Top


The severity of the trauma does not necessarily correlate with the degree of BCI. Moreover, there is no single test that can be considered a gold standard when diagnosing BCI. Different tests such as electrocardiogram (ECG), sonographic and echocardiographic evaluation, and cardiac biomarkers are currently used. The incidence of BCI may vary due to diagnostic tools; however, all these tests and mechanism of injury as well as clinical picture need to be taken in consideration when diagnosing and managing a patient with suspected BCI. Additionally, BCI could be identified by using cardiac markers creatine kinase and creatine kinase-MB in 19% of patients, troponin in 15-24%, transthoracic echocardiography (TTE) in 3-26%, transesophageal echocardiogram (TEE) in 27-56%, and by ECG in 29-56% of patients. [4],[29],[30],[31]


   Ecg Top


Although there is no single ECG sign pathognomonic for BCI, the guidelines (level 1 evidence) recommends performing 12-lead ECG on admission to all suspected BCI patients. [32],[33] ECG changes that indicate clinically significant BCI are usually present at the time of admission or occasionally within 24 h. [3],[34] However, it can be difficult to determine whether the ECG abnormality is a primary event (e.g. an acute coronary syndrome (ACS) that preceded trauma), a direct result of cardiac injury, or a problem brought on by the physiologic stress of severe trauma. [2],[34] Several studies concluded that in hemodynamically stable young patients, normal ECG rules out the need for further evaluation to detect BCI. [3],[35] Patients with unexplained tachycardia that persists over several hours despite adequate fluid resuscitation and pain control, or with a new bundle branch block, or with significant arrhythmia, should be admitted for rhythm monitoring and possible echocardiographic study. Life-threatening ventricular arrhythmias were reported in up to 16% of patients with BCI. [4] A 24 h monitoring with ECG telemetry is required if a patient suspected of having BCI is hemodynamically stable and has either an abnormal ECG, or a history of cardiac disease, or is ≥55 years old. [3],[35]

Sonographic and echocardiographic evaluation
FAST provides the preferred initial approach for sonographic evaluation. [4],[36],[37],[38] It enables the trained physician to rapidly and accurately determine the presence of pericardial effusion and cardiac activity. After excluding pericardial tamponade, an echocardiogram is useful in trauma patients with signs of cardiac dysfunction to diagnose the cause of dysfunction, estimate the need for volume and/or inotropic support, and identify other injuries requiring intervention ([Table 2] describes the cardiac injury scale). [38]
Table 2: Cardiac injury scale

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Echocardiography can provide important information in a patient who manifests signs consistent with significant BCI. However, it has little utility as a screening tool for clinically significant BCI in hemodynamically stable patients. [29],[39] It is recommended to obtain an echocardiogram in any patient with blunt trauma and unexplained persistent shock out of proportion to apparent injuries or shock despite aggressive resuscitation, and in any patient with signs consistent with significant BCI. Echocardiographic signs include abnormal cardiac wall motion, decreased cardiac contractility, valvular dysfunction or rupture, septal defects, intracardiac thrombus, and pericardial effusion or rupture of the myocardium. However, findings may be misleading in patients with prior chronic heart disease and studies may be limited by the presence of chest tubes, chest wall trauma, morbid obesity, pain, and suboptimal views. [3],[10]

TEE is superior for investigating the cause of persistent hemodynamic instability or other problems thought to be related to BCI. It provides a clear view of wall motion abnormalities and valvular and septal injuries. Nowadays, TEE can be performed safely by anesthetists, intensivists, and even accident and emergency physicians. It improves sensitivity for injuries that require intervention. [3] TEE is not only able to detect myocardial injury missed by TTE but also superior to TTE in visualizing thoracic aorta. [10]

Cardiac biomarkers
The utility of cardiac biomarkers in the setting of BCI remains unclear because of the lack of a gold standard for diagnosis; moreover, there are several biomarkers with different sources and cutoff values. However, following blunt chest trauma, the diagnostic value of troponin increases when it is combined with the admission ECG; moreover, the use of troponin as a screening test becomes more appreciated when performed prior to echocardiography. [3],[10],[34],[40] Collin et al.[41] concluded, "measuring troponin with a normal ECG is not necessary and if the admission ECG has minor abnormalities and the troponin at 4 to 6 hours after injury is normal then the risk of BCI-related complications is low." However, in the presence of significant ECG abnormalities, a normal troponin value may carry little benefit for risk stratification for cardiac complications. [3] Instead of biomarkers, use of repeat examinations, serial ECGs, and cardiac monitoring during a brief course of observation (4-6 h) is more valuable for screening for BCI, if doubt exists. The patients with normal ECG and troponin can be safely discharged if there are no other associated injuries. [34]

Diagnosis of BAI
Chest X-ray is a valuable screening test. [42] A widened mediastinum is the most frequent indication for further investigations. [43] Angiography is the gold standard diagnostic test for BAI. [15],[44] CT of the chest is a very useful diagnostic tool. [45] TEE is a very sensitive screening test, but is usually followed by angiography. [46] CT may be a first tool for the diagnosis of these multi-traumatized patients. Multislice CT may be more useful tool for identifying minor leaks and adjacent structural injuries. The need for aortography would decrease by 56% if chest CT is used in the screening for BAI. [47],[48],[49] In a previous study, chest CT was performed to evaluate BAI in 677 patients with positive or equivocal findings at chest radiography, the investigators concluded that reliance on findings at admission CT before angiography could save more than $365,000. [49] Helical CT is more sensitive tool for BAI diagnosis; it has a sensitivity of 100%, as compared with 92% for angiography. [50] In patients with blunt chest trauma in whom BAI was ruled out by helical CT, none required procedures for or died of injuries to the aorta or great vessels. [51] However, some studies reported a 28% rate of missed diagnoses of BAI in patients who did not have a chest CT scan on admission and therefore, helical CT has been recommended in all patients with a history of MVC at a speed of 10 mph or faster for unrestrained drivers and 30 mph or faster for restrained drivers. [52],[53]


   Management Top


Cardiac injury evaluation and management protocols based on the hemodynamic status and the electrical cardiac activity are shown in [Figure 1],[Figure 2] and [Figure 3]. [3],[7],[10] We believe in the simultaneous assessment; however, priority should be given to the immediate clinical evaluation. [3],[7],[10],[54]
Figure 1: Evaluation of suspected blunt cardiac injury (with permission : Elsevier Limited: Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin 2004;20:57-70)

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Figure 2: Algorithm for blunt chest trauma and cardiac trauma injury (with permission : BMJ Publishing Group Ltd.: Bansal MK et al. Myocardial contusion injury: Redefining the diagnostic algorithm. Emerg Med J 2005;22:465-9)

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Figure 3: Protocol for management of suspected blunt cardiac rupture (with permission: Elsevier Limited : Nan YY et al. Blunt traumatic cardiac rupture: Therapeutic options and outcomes. Injury 2009;40:938-45) FAST - Focused assessment with sonography for trauma; ER - Emergency room; OR - Operating room

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Initial stabilization
BCI is often associated with thoracic trauma, but can occur in any patient with multiple trauma. Initial evaluation proceeds according to standard Advanced Trauma Life Support protocols, beginning with stabilization of the patient's airway, breathing, and circulation. Clinicians should assume that hypotension in the trauma patient results from hemorrhage, not cardiac dysfunction, until proven otherwise. With hypotension in the setting of isolated thoracic trauma, clinicians should look for pericardial tamponade or a tension pneumothorax in addition to hemorrhage.

Valve, septum, or ventricular wall injury
Patients with clinical or echocardiographic evidence of severe cardiac injury (e.g. ruptured valve, septum, ventricular wall or tamponade) require emergent surgical consultation. In case of penetrating cardiac injury, immediate surgical intervention is a priority [Figure 4]. If possible, anesthesia and intubation should be delayed in patients who require operative intervention until just before sternotomy because anesthesia induction may cause hemodynamic collapse. Any patient suspected to have BCI with cardiac free-wall rupture, septal rupture, coronary artery injury, or valve injury should be seen by a cardiothoracic surgeon without delay. [55] [Figure 3] summarizes the management of suspected blunt cardiac rupture.
Figure 4: (a) Intraoperative picture of a right ventricular stab wound that was repaired by using pledgets in a young male who presented with cardiac tamponade (courtesy Dr. Latifi R). (b) Postmortem image of rupture of interventricular septum after blunt injury (with permission: Elsevier Limited) Pollock Be et al: Isolated traumatic rupture of the interventricular septum due to blunt force. Am Heart J 1952;43:273-85)

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Unstable patients
In patients who may not survive to an operating room, emergency resuscitative thoracotomy is the best option. Pericardiocentesis can be an effective temporizing measure and may be attempted. However, in the setting of blunt trauma, thoracotomy rarely results in successful resuscitation. If cardiac injury is suspected in a hypotensive patient and FAST is unavailable, the cardiothoracic surgery and cardiology services should be consulted immediately. Such patients should be admitted to a surgical service with cardiology consultation unless operative management is clearly unnecessary.

Acute coronary syndrome
Acute coronary syndrome (ACS) may occur due to coronary dissection or stress-induced thrombosis or spasm. Ismailov and his colleagues [56] reported that direct trauma to the heart is associated with a 2.6-fold increased risk for acute myocardial infarction (AMI) in persons ≥46 years of age. Moreover, in younger patients who underwent coronary angiography after trauma, BCI was associated with a 31-fold increased risk for AMI. Sudden elevation of intra-aortic pressure caused by sudden external impact to the abdomen possibly result in rupture of the coronary vessel, particularly if the aortic valve was closed during the traumatic impact. [56] Catheterization with stenting may be the best approach for treatment, although some advocate bypass graft surgery. Thrombolytic agents are best avoided, especially in patients who sustained multiple injuries, unless both bypass surgery and angiography are unavailable, and patients do not have any contraindications to the use of thrombolytic agents. Management should be determined in consultation with cardiologist. Cardiothoracic surgery consultation is needed in the rare event when a coronary artery laceration or dissection is identified. For patients with features suggestive of BCI and in whom cardiac biomarkers are found to be elevated, cardiology consultation is obtained and the patient is admitted for cardiac monitoring and further evaluation. A screening echocardiogram and cardiac biomarkers do not appear to add to the management of the hemodynamically stable patient without clinical features suggestive of significant BCI. [3],[4]

Cardiac dysfunction and arrhythmia
Echocardiography is warranted in patients with BCI for clinical findings of hypotension, heart failure, or arrhythmia. [3] Patients without identifiable injury but with persistent cardiac dysfunction (e.g. hypotension) are admitted for cardiac monitoring. Cardiology consultation is needed for patients with hemodynamic instability likely due to cardiac injury. In the presence of arrhythmia, most physicians initiate standard advanced cardiac life support (ACLS) protocols when applicable. In patients with a complex arrhythmia (e.g. high-grade conduction block, new-onset atrial fibrillation, supraventricular or ventricular tachycardia) following BCI, it is appropriate to perform a bedside echocardiogram to look for wall motion abnormalities or injuries that require emergent surgery. Clinicians should assume that hemorrhage is the cause of tachycardia in the trauma patient until proven otherwise. Floor telemetry is appropriate for the patient with minor abnormalities (e.g. intermittent premature ventricular or atrial contractions), no significant concomitant injuries, and normal hemodynamics. All other patients should have a higher level of monitoring (e.g. cardiac intensive care unit). BCI of either ventricle usually resolves without significant consequences within a year after injury, particularly if no acute complication occur during the index admission. [57]

Tamponade
Pericardial effusion is the most common feature of BCI. It can be diagnosed clinically by the presence of hypotension, distended jugular veins, muffled heart sounds and/or by ultrasound. Tamponade that results from an atrial tear may be amenable to pericardiocentesis with periodic drainage using a pigtail catheter until definitive surgical repair can be performed.

Blunt Aortic Injury
Modalities of BAI repair include direct suture repair, placement of a prosthetic graft, and endoluminal stenting. [58],[59],[60] Protective measures against distal ischemia, such as hypothermia, are helpful. [61] However, hypothermia may disable coagulation profiles even more in the multi-traumatized patients. Therefore, close communication between the surgical and anesthesia teams is the key for successful management. [12],[62]


   Conclusion Top


Although traumatic cardiac injury is a challenge in critical trauma care, guidelines are lacking. A high index of suspicion, application of current diagnostic protocols, and prompt and appropriate management is important for a successful outcome.

 
   References Top

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Correspondence Address:
Ayman El-Menyar
Weill Cornell Medical School, Clinical Medicine, Cardiologist and Clinical Research, Trauma Surgery, Hamad General Hospital, PO Box 3050, Doha
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DOI: 10.4103/0971-9784.101875

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]

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