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