Blunt Cardiac Injury Flashcards
What condition is often suspected in patients with blunt thoracic injury and sternal fracture?
Myocardial contusion
Elevated cardiac enzymes/Abnormal ECG
In what types of injuries should blunt cardiac injury (BCI) be considered?
High-speed impacts to the thorax
motor-vehicle collisions
bicycle or motorcycle crashes
falls greater than 10 feet
blast injuries, assaults
crush injuries to the chest
What mechanisms can cause blunt cardiac injury (BCI)?
Direct precordial impact
compression or crush between the sternum and spine
deceleration/torsion force causing a cardiac tear at a fixed point (e.g., between the right atrium and vena cava).
How can an abrupt compression of the abdomen lead to blunt cardiac injury (BCI)?
causing a significant and sudden rise in venous pressure transmitted to the right heart, potentially resulting in cardiac rupture.
What combination of tests can rule out significant blunt cardiac injury (BCI)?
normal ECG and troponin I level on admission and 8 hours later
How is significant blunt cardiac injury (BCI) defined?
presence of cardiogenic shock
arrhythmias requiring treatment
posttraumatic structural deficits.
What does the initial chest radiograph help rule out in diagnosing blunt cardiac injury (BCI)?
Tension pneumothorax and/or hemothorax as sources of blood loss and hypotension
How can spinal cord injury be ruled out as a cause of hypotension before intubation?
By confirming movement of the lower extremities and checking for rectal tone during the physical examination
How does the FAST examination aid in diagnosing blunt cardiac injury (BCI)?
-determine cardiac activity in patients without vital signs
-identifies fluid in the pericardial sac in patients with vital signs.
What imaging is recommended for patients with abnormal ECGs on admission
A transthoracic echocardiogram (TTE) or transesophageal echocardiogram (TEE)
What characterizes Grade 1 blunt cardiac injury (BCI)?
ECG abnormalities
nonspecific ST or T-wave changes
premature atrial or ventricular contractions
or persistent sinus tachycardia.
What characterizes Grade 2 blunt cardiac injury (BCI)
Heart block or ischemic changes without cardiac failure
What characterizes Grade 3 blunt cardiac injury (BCI)?
Sustained arrhythmias
septal rupture
valvular incompetence
papillary muscle dysfunction
distal coronary artery occlusion without heart failure
or blunt pericardial laceration without cardiac herniation.
What characterizes Grade 4 blunt cardiac injury (BCI)?
Septal rupture
pulmonary or tricuspid incontinence
papillary muscle dysfunction
distal coronary artery occlusion with cardiac failure, rupture of the atria or right ventricle
or aortic/mitral valvular incompetence
What characterizes Grade 5 blunt cardiac injury (BCI)?
Proximal coronary artery occlusion
left ventricular perforation
or rupture of more than one chamber.
How should patients with Grade 1 blunt cardiac injury (BCI) be managed?
observed with continued monitoring until the ECG abnormalities have corrected
Within 24 hours.
How should patients with Grade 2 blunt cardiac injury (BCI) be managed?
monitored until ischemic changes resolve and the ECG returns to normal.
serial assessment of troponin levels
Within 48 hours Resolve
How should patients with Grade 3 blunt cardiac injury (BCI) and ventricular arrhythmias be managed?
monitored closely for progression to cardiac failure.
What should be checked in Grade 3 BCI patients with pericardial fluid?
evidence of pericardial tamponade
What types of injuries are associated with Grade 4 blunt cardiac injury (BCI)?
Septal rupture, valvular incompetence, or chamber rupture of the right ventricle, either atrium, or the right atrial appendage
How are Grade 4 BCI patients with valvular incompetence or papillary muscle dysfunction diagnosed?
reduced ejection fraction or dyskinesis, which can be identified on imaging
What evidence might Grade 4 BCI patients with distal coronary artery occlusion exhibit?
Signs of cardiac ischemia and inotropic compromise
Do Grade 4 BCI patients always require operative intervention?
No, they usually do not require surgery unless there is a chamber rupture.
How should pericardial tamponade be detected and confirmed?
Detected by initial FAST examination and confirmed by CT scan
What is the definitive care for pericardial tamponade in this context?
Transthoracic pericardiocentesis followed by a prompt left anterior thoracotomy
What caused the engorged purple liver in this patient with pericardial tamponade?
Impaired hepatic venous return due to the tamponade.
Which heart chambers are most commonly ruptured in BCI?
The right atrium or ventricle (65%), followed by the left ventricle
What is commotio cordis?
Sudden death from cardiac arrest without any anatomic structural damage to the heart, typically after a blunt blow to the chest
In young people during competitive sporting
blunt impact induces ventricular fibrillation during a vulnerable phase of ventricular excitability, such as cardiac repolarization.
often refractory to CPR and defibrillation
What is the next step if a patient with blunt thoracic trauma presents without vital signs?
A FAST examination should be done to determine if there is cardiac activity. If absent, no further action is taken
What should be done for a normotensive patient after blunt thoracic trauma?
A FAST examination should be performed as part of the secondary survey
followed by ECG and troponin measurements if no pericardial fluid is detected
What is the next step if the ECG and troponin are normal in a patient after blunt thoracic trauma
No further tests or monitoring for BCI is indicated
What should be done if the ECG and/or troponin are abnormal with findings such as tachycardia, arrhythmia, or ST elevation?
The patient should be admitted to the ICU, and the ECG and troponin levels should be repeated in 6 hours. An echocardiogram should be done within the first 24 hours
How are patients with BCI typically managed if their echocardiogram is abnormal?
The echocardiogram should be repeated in 48 to 72 hours, and treatment is supportive, including β-blockers for tachycardia and ventilatory support for pulmonary injury.
What should be excluded first when a patient with blunt thoracic trauma presents with hypotension?
Spinal cord injury
tension pneumothorax
or other sites of hemorrhage, including the chest or fractures.
How does a FAST examination help in hypotensive patients with blunt thoracic trauma
determine if there is fluid in the pericardial sac.
What should be done if pericardial fluid is present and the patient is stable?
A CT of the chest is recommended to distinguish between serous fluid (e.g., from renal failure) and blood.
What is the recommended action if pericardial fluid appears to be blood and the patient is stable?
Immediate surgery is indicated.
What is the next step if a hypotensive patient with pericardial fluid is unstable?
Pericardiocentesis should be performed on the way to the operating room
What is the recommended surgical approach for blunt cardiac injury (BCI) requiring repair?
left anterolateral thoracotomy for rapid access and pericardiotomy.
What is the recommended surgical repair for atrial or atrial appendage injuries in BCI?
A simple primary repair using 2-0 silk sutures on a noncutting needle, with digital pressure to control bleeding.
What surgical option is available if a left thoracotomy limits access to the heart?
The incision can be extended across the sternum into the right chest, creating a clamshell thoracotomy.
What might cause blood in the pericardial sac without heart rupture in blunt cardiac injury (BCI)?
Bleeding from the pericardial sac itself.
How should the pericardium be managed postoperatively if there is bleeding from the pericardial sac?
The pericardium should be approximated, leaving a 3-4 cm opening in the nonapical part to allow egress of postoperative pericardial blood.
What other injuries often accompany BCI and require definitive management?
Severe pulmonary injuries.
What type of injuries may require cardiopulmonary bypass for repair in BCI?
Rupture of a heart valve or papillary muscle, which may be detected on echocardiogram
cardiopulmonary bypass > repair of any chamber rupture
What surgical approaches are recommended for blunt cardiac injury (BCI) that requires repair?
definitive median sternotomy or a left thoracotomy.
How is the pericardium opened during surgery for BCI?
opened parallel to the phrenic nerve.
What is the next step after opening the pericardium in BCI surgery?
blood is evacuated, and the heart is examined for injury
