BluntCardiacInjury

BenRoestenburg

90%ofBCI’sarelethalanddonotmakeittohospital.

Case– 68yearoldmale

Mechanism• CarvsTree• 80-100kmh• Steeringwheelimpact• Restraineddriver• Noairbags• Hitheadondoorpillar

Injuries• SternalFractures• RibFractures• Rightdistalradiusfracture• Maxillarysinusfracture• Faciallacerations• Abrasions

Signs• GCS15• Selfextricated• Stablevitals• Amnesticofevents• ?LOC

Events– first24hours

PrimaryandSecondarySurvey->STU• Ribfractures,sternalfracture,headlaceration• ECG– NormalSinus• CTHead/C-Spine- NAD• CardiacTroponinsatadmission,4hours,6hoursNAD(serial3’speakedat4)• Admittedforanalgesiaandobservation

METCall• Suddenonsetworseningchestpain• HR110RR24BP150/100Sats 92%RAT36.4• ECG– newRBBB• Type1RespiratoryFailure

BluntCardiacInjury

Papers

EpidemiologyIdentifiedin10%oftraumaadmissions• 50%MVArelated• 35%Pedestrian• 9%Motorcycle• Therestfromfalls/assaults/misc

PathophysiologyMajorityofBCI’sthatmakeittohospitalalivearelowseverity.• Distraction-avulsiontearinginrapiddecelerationofmobileventricles

• =Transmuralcardiacchamberrupture(34-69%)

• Majorityarerightventricle

PresentationsStructuralInjury• Intramuralhaematoma• Valvular injury• VSrupture• Coronary/MI

Electrical• Conductiondisturbances• Dysrhythmias

ScreeningforBCI• Mechanism• ECG– AllpatientsshouldgetanECG

• ’Classic’teachingisthatBCIcasesRBBB• Tachyarrhythmias (SinusandSVT)• PVCsmayoccur,butdifficultinisolationtointerpret• MostECGchangesaretransient,intermittent,evolving,andclinicallyirrelevant

• Newabnormalitiesrequireadmissionandmonitoring• Poorsensitivityforrightventricle,andlimitedspecificityifthereispre-existingcomorbidities.

• CardiacTroponins• Controversial• TogetherwithnormalECGhasnear100%NPV• LimitedPPV

• Echo• Persistenthaemodynamic instability

Troponins• TnI TnC TnT - 3typesallpresentinskeletalmuscle• cTnI Representscardiacmuscleinjury• Overlapbetweenchestwalldamageandcardiacmuscledamage• 30%crossreactivityofmonoclonalantibodyassays• NoclearlevelofcTnI thatindicatesinjurytomyocardium• cTnI >1ng/mL60%-70%ofthosepatientsactuallyhadadocumentedcardiacinjury-shouldbethenevaluatedwithECHO• CanbeusedtoruleoutifcTnI islessthan0.4ng/ml4tosix6hoursafterinjury

NPVofSerialTroponins2014SystematicReview(Guildetal)• 123JournalArticles,10included,1691Patients• SerialTroponinsatAdmission,4,6,12,24hours

Echo

• ECGchangeswithtroponinrise• Persistenthaemodynamicinstability

Heart2003 May; 89(5):485–489

Commotio Cordis

• SuddenCardiacDeathduetoblowtochestwall• TriggersVentricularFibrillation• Mechanism– 50kmhimpactwithsmalldenseobject,directlyovercardiacsilhouetteleftofsternum,10-30msecpriortothepeakoftheTwave,fromdepolarizationprimarilycausedbymechano-sensitiveionchannels• 15%survivalrate• Youngpatients,males

Applyingtoourpatient

ECGChanges– newRBBB• Admittedforobservationwithholtermonitoring• MaynothavebeennewRBBB?

SerialTroponinsNegative• BCIunlikely– iftakenaloneevidencewouldsuggestanNPVof98-100%• UnclearhowtointerpretinconjunctionwithabnormalECG.

CurrentManagementGuidelines

Level1Evidence• ECGperformedonpatientswithsuspectedBCI

Level2Evidence• IfECGhasabnormality->patientshouldbeadmittedforobservation• NormalECG+NormalTroponin=ruleout(optimaltimingyettobedetermined)• Echoforpatientswithhaemodynamic instabilityorpersistentnewarrythmia• Sternalfracturealonedoesnotpredictcardiacinjury• Creatininephosphokinasenotuseful• Nuclearmedicinestudiesaddlittleoverecho

Multidetector CT/CTAwithECG-gatecapabilityevolvingtobegoldstandard.

Clancyetal2012

Flow

El-Charmi MF,etal. TheJournalofEmergencyMedicine.Vol35,Issue2,August2008,Pages127-133

CaseClosure

• PatientwasadmittedtoICUforepiduraltopreventdevelopmentoftypeIIrespiratoryfailure.• PositivePressureVentilation• SerialECGs– NAD• Dischargedbacktoward• NoBCI• Dischargedhomewithanalgesia.

“anytraumapatientwithalikelymechanismwhohaschestwallpainandanewarrhythmiaorcardiac

pumpfailurehasacardiaccontusion”

- MichaelMcGonigal

References

1. Yousef,R,Carr,J.BluntCardiacTrauma:AReviewoftheCurrentKnowledgeandManagement.JAnnThoracicSugery.2014;98.

2. Guild,C,deShazo,M,Geraci,S.NegativePredictiveValueofCardiacTroponinforPredictingAdverseCardiacEventsFollowingBluntChestTrauma.SouthernMedicalJournal.107;1.2014

3. Clancy,K,Velopulos,C,Bilaniuk,J,Collier,B,Crowley,W,Kurek,S,Lui,F,Nayduch,D,Sangosanya,A,Tucker,B,Haut,E.Screeningforbluntcardiacinjury:AnEasternAssociationfortheSurgeryofTraumapracticemanagementguideline.JTraumaAcuteCareSurgery.73;52012.

4. El-Charmi MF,etal. TheJournalofEmergencyMedicine.Vol35,Issue2,August2008,Pages127-133