CARDIAC TRAUMAA primer on blunt and penetrating heart

trauma and pearls for emergency care

Jeremy Webb, M.D.PGY-3, Emergency MedicineWake Forest Baptist Health

Topics Covered

History: A Paradigm Shift

Blunt Cardiac Trauma

Penetrating Cardiac Trauma

Role of Emergency Department Thoracotomy

1829

1896

"Surgery of the heart has probably reached the limits set by nature to all surgery: no new method and no discovery can overcome the natural difficulties that attend a wound of the heart"

Paget, 1896

1902

Dr. Luther Hill

“the road to the heart is only 2 or 3 cm, in a direct line, but it has taken surgery nearly

2400 years to travel it."

- Harry Sherman, 1902

Blunt Cardiac Trauma

What are the mechanisms of injury?

What injury patterns can be seen?

Right heart > Left heart

Left heart valves > Right heart valves

Rupture: Atria > Ventricles

Location Pearls

History and Physical

Pulse?, Pain, Palpitations

Extremis? Tamponade? Heart Failure?

Associated injuries?

Pulsus ParadoxusPulse?, Pain, Palpitations

Extremis? Tamponade? Heart Failure?

Blunt Cardiac InjuryMyocardial Contusion

Role of ECG

Mandated if BCI suspected

Sensitivity? Specificity?

Common abnormalities in BCI

Dr. Steven W. Smith, Hennepin County Medical Center http://hqmeded-ecg.blogspot.com/search/label/myocardial%20contusion

The Role of Cardiac Enzymes

Controversial

Sensitivity? Specificity?

When to test?

Enzymes Made Simple

"Intermediate Risk" of BCI

ECG Changes

Hemodynamically Unstable

Medical work-up (syncope, ischemia)

Role of Radiology

Study of Choice: Echocardiography

Angiography as adjunct

Indications?

Radiography Made Simple

Hemodynamically Unstable: FAST

ECG or Enzyme Abnormalities

High Clinical Suspicion: Mechanism or associated injuries

BCI: Putting it All Together

Words from a Trauma Surgeon...

"Diagnosis is relatively simple: any trauma patient with a likely mechanism who has chest wall pain and a new arrhythmia or cardiac pump failure has a cardiac contusion. Atrial or ventricular arrhythmias are significant, but a ventricular one is significant because it can degenerate into v-tach or worse.

Enzyme measurements do not indicate severity of injury or outcome and should not be obtained.Remember, true cardiac contusion is rare! If suspected, telemetry is indicated, along with frequent vital signs. Cardiac enzymes should not be ordered, and any indication of cardiac problems (arrhythmia or failure) should be reported and treated promptly."

http://regionstraumapro.com/tagged/cardiac-contusion

Blunt Cardiac InjuryCommotio Cordis

Blunt Cardiac InjuryMyocardial Rupture

Blunt Cardiac InjuryCardiac Luxation

Penetrating Cardiac Trauma

Gunshot Wounds > Stab Wounds

Exsanguination, Tamponade

Mortality by Mechanism

Prehospital Considerations

SCOOP AND RUN SAVES LIVES!

Airway ConsiderationsThe laryngoscope as a murder weapon...

Airway ConsiderationsSympathetic Crash

Cause Tamponade

Air Embolism

Diagnosis and TreatmentPericardiocentesis NOPE

Subxiphoid Window FAST

Pre-Operative Resus LIMITED

!!! GET THEM TO AN OR QUICKLY !!!

Emergency Department Thoracotomy

When to make a stab wound of your own...

The liberal application of thoracotomy in the resuscitation of blunt trauma cannot be justified and should only be undertaken when there are documented signs of life in the emergency department or within five minutes prior to arrival; prolonged (>5 mins) CPR after blunt injury equates to fatality.

Emergency Thoracotomy – The Indications, Contraindications, and Evidence. Morgan BS, Garner JP. JR Army Med Corps 155(2): 87-93

Maintain high suspicion

Blunt Cardiac Trauma

Penetrating Cardiac Trauma

When to perform ED Thoractomy

Cardiac Trauma Review

Questions?

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