S21C259 - Cardiac Trauma

Question 1

Types of penetrating injuries to the heart:

Answer 1

Pericardial: tamponade, pericarditis, pneumopericardium, constrictive pericarditis
Myocardial damage: laceration, penetration, perforation, FB, structural defect (aneurysm, septal defect, aorticocardiac fistula)
Valvular: leaflet/cusp injury, papillary msc, or chordae tendinae laceration
Coronary artery: laceration, thrombosis, AV fistula, aneurysm
Emoblism: FB, thrombus (septic/sterile)
Infective endocarditis
Rhythm/conduction disturbance

Question 2

Cardiac Tamponage

Answer 2

• more likely to occur with a stab than a GSW

- Sx: tachy, narrow pulse pressure, incr CVP, hypotension and if more severe becks triad and pulsus paradoxus

Question 3

Blunt cardiac injury

Answer 3

• potential injuries: arrhythmias, free wall rupture, laceration of coronary artery and subequent extracardiac hemorrhage
• commotio cordis: sudden death from blunt trauma to chest wall, often occurs in young athletes, causes v fib

Question 4

ED Thoracotomy

Answer 4

-left anterolateral approach
-incision in left 4th/5th intercostal space in a single stroke through all layers of the intercostal musculature, sternum to posterior axillary line, then use blunt tipped scissors to cut through the rest
-insert a finochietto retractor with crank positioned near the bed
-open retractor
-displace left lung, then identify phrenic nerve on pericardial sac, make an icision anterior and superior to the phrenic nerve
-remove clots from pericardial sac
-inspect heart, plug holes with finger or staple with normal skin staplers or place a foley catheter
-can place a purse string suture around the catheter
OR can use a horizontal mattress with plegets taking care not to suture any coronary arteries
-if no injury identified, extend incision to right side (clam shell) and repeat
-cross clamp aorta if abdominal bleeding

Question 5

Pericardiocentesis

Answer 5

• as little as removing 5-10cc of fluid can increase stroke volume by 25-50%
• subxiphoid approach: direct needle toward left shoulder or left scapula tip and aspirate while advancing, if it aspirates really easily you may be in the Right ventricle

Question 6

Injury to thoracic vessels

Answer 6

• in blunt trauma the prox desc Ao is commonly injured
• subclavian artery is usually injured by a clavicular # or 1st rib #
• aim for BP 100-120 systolic and HR of 60

Question 7

Wide mediastinum

Answer 7

> 8cm