287 Annals of Cardiac Anaesthesia Vol.

15:4 Oct-Dec-2012
Understanding traumatic blunt
cardiac injury
Ayman El-Menyar
1,2
, Hassan Al Thani
1
, Ahmad Zarour
1
, Rifat Latifi
1,2
1
Department of Surgery, Section of Trauma Surgery, Hamad Medical Corporation,
2
Clinical Medicine,
Weill Cornell Medical School, Qatar
Cardiac injuries are classifed as blunt and penetrating injuries. In both the injuries, the major issue is missing
the diagnosis and high mortality. Blunt cardiac injuries (BCI) are much more common than penetrating
injuries. Aiming at a better understanding of BCI, we searched the literature from J anuary 1847 to J anuary
2012 by using MEDLINE and EMBASE search engines. Using the key word Blunt Cardiac Injury, we
found 1814 articles; out of which 716 articles were relevant. Herein, we review the causes, diagnosis, and
management of BCI. In conclusion, traumatic cardiac injury is a major challenge in critical trauma care, but
the guidelines are lacking. A high index of suspicion, application of current diagnostic protocols, and prompt
and appropriate management is mandatory.
Key words: Blunt trauma, Blunt cardiac injury, Aortic injury
Received: 17-3-2012
Accepted: 29-6-2012
ABSTRACT
Review
Article
echocardiographic analysis, 24 prospective
studies, 20 retrospective studies, and 1
meta-analysis. Herein, we review the causes,
diagnosis, and management of BCI.
BLUNT CARDIAC INJURY
BCI ranges from asymptomatic myocardial
bruise to cardiac rupture and death.
[2-4]
BCIs
most often occur during motor vehicle crashes
(MVC). Based on the associated injuries,
intensity of chest injury, and complexity of
injuries the incidence of BCI varies from
20 to 76%. Falls and crush injuries are less
frequently associated with BCI. BCIs are
characterized by patchy areas of muscle
necrosis and hemorrhagic infiltrate(s), rupture
of small vessels, and hemorrhage into the
interstitium and around the muscle fibers.
[4]

Myocardial contusion has been reported in
60100% autopsy series of patients with BCI.
[3]

Commotio Cordis
Commotio Cordis is a rare type of BCI in
which low-impact chest trauma causes sudden
cardiac arrest, usually occurs from being struck
by a projectile during sports. Cardiac arrest
INTRODUCTION
Cardiac injuries are classified as blunt
and penetrating injuries. In both the type
of injuries, the major issue is missing the
diagnosis and high mortality. Blunt cardiac
injuries (BCIs) are much more common than
penetrating injuries. Penetrating trauma is seen
in urban trauma centers and predominantly
due to stab wounds, gunshot wounds, or less
commonly other iatrogenic instrumentation.
In penetrating injuries, up to 90% of victims
die before reaching hospital and resuscitation
is of limited benefit; therefore, survival
depends on rapid pre-hospital transport.
[1]

Aiming at better understanding of BCI, we
reviewed the literature from January 1847
to January 2012 by utilizing MEDLINE
and EMBASE search engines. Using the
key word Blunt Cardiac Injury, we found
1814 articles; out of which 716 articles were
relevant. Of the relevant articles, 559 were
published in English language; there were 100
reviews, 135 case reports (some case reports
were followed by review of the literature), 22
pediatric-related articles, 35 articles based on
Address for correspondence: Dr. Ayman El-Menyar, Weill Cornell Medical School, Clinical Medicine, Cardiologist and Clinical Research, Trauma Surgery,
Hamad General Hospital, PO Box 3050, Doha, Qatar. E-mail: aymanco65@yahoo.com
Access this article online
Website: www.annals.in
PMID:
***
DOI:
10.4103/0971-9784.101875
Quick Response Code:
288 Annals of Cardiac Anaesthesia Vol. 15:4 Oct-Dec-2012
El-Menyar, et al.: Traumatic blunt cardiac injury
appears to stem from blow during a period of electrical
vulnerability (10 to 30 ms before the peak of the T
wave). A direct blow to the precordium accounts for a
sizable number of cases. Patients involved in a MVC
with sudden deceleration, or who sustains significant
chest trauma or severe multiple trauma are at risk of
Commotio Cordis.
[5]

Cardiac Rupture
Between 1847 and 1952, 13 cases of rupture of
interventricular septum due to BCI were described.
[6]

The mechanism of injury and factors necessary to
produce rupture of the heart after blunt injury were
reported between 1935 and 1938. A full chamber in early
systole is more vulnerable if compressed over its outflow
tract; the myocardial fibers may rupture at a point away
from the area of direct contusion.
[6]
Between 1994 and
2009, several other mechanisms of blunt traumatic
cardiac rupture have been reported, and include
precordial impaction with cardiac squeeze between the
sternum and spine and rapid deceleration resulting in
disruption of the atria from their connections to the vena
cava and pulmonary veins.
[7,8]
Minimal force is required
for a deceleration type contusion injury that may occur
at a relatively low velocity of 20 miles/h.
[9,10]
Cardiac rupture is the most devastating BCI and the
incidence of the site of injury varies in various autopsy
series (Cardiac wall: 0.162%, Right ventricle: 1932%,
Right atrium: 1015%, Left ventricle: 544%, and Left
atrium: 17%).
[3,11]
Forces involved in BCI
Include compression of the heart between the spine and
sternum, abrupt pressure fluctuations in the chest and
abdomen, shearing from rapid deceleration and blast
injury, and fragments from rib fractures causing injury
to the heart. Table 1 summarizes the mechanism of BCI.
The right heart is most commonly injured.
[12]
This is
probably due to its position closest to the anterior chest
wall. High-pressure ventricular injuries appear to be as
common as low-pressure atrial injuries, but findings
may vary based on the type of study (i.e. clinical or
autopsy). In autopsy series, ventricular injuries are the
dominant findings. Aortic and mitral valve damage has
been reported as a complication of blunt chest injury.
[4]

The incidence of tricuspid or mitral valvular injury is
around 5% which include chordal rupture, anterior
papillary muscle and/ or leaflet tear.
[3,4]
Ismailov et al.
reported that BCI is independently associated with
11 and 3 times increase in the incidences of tricuspid
and aortic valve insufficiency, respectively.
[4]
Other
less common pathological findings in patients with
BCI include septal tears (Atrial septal defect: 7%
Ventricular septal defect : 4%) Coronary artery injury
and thrombosis (3%).
[3]

Indirect cardiac injury
Even if the heart is not directly involved in the trauma,
cardiac injury remains a possible concern. The stressful
impact of trauma may result in myocardial infarction
secondary to acute thrombosis or severe coronary
spasm (with patent coronary arteries). Also, significant
arrhythmia and stress-induced cardiomyopathy
(Takotsubo cardiomyopathy) have been reported in many
cases secondary to the fear and stress of trauma.
[13,14]
Blunt aortic injury
Blunt aortic injury (BAI) is a common cause of traumatic
pericardial tamponade. It should be considered in
patients with a deceleration or acceleration injury with
signs suggestive of mediastinal injury.
[15]
BAI is the
second most common cause of death in blunt trauma
patients.
[16]
Most patients with BAI die at the place of
injury, and only 1315% reach alive to hospitals.
[16,17]

The most common mechanism of BAI is motor vehicle
crash, pedestrian injury, and falls.
[15,18]
Cardiac herniation
It is a potentially fatal complication of BCI and
reported in 0.4% of severe blunt trauma.
[19,20]
Cardiac
herniation frequently results in early death, and thus
the diagnosis is mainly based on autopsy findings.
[20]

In a series of BCI, patients who survived to hospital
admission had favorable outcome with survival rate of
36.4-42.9%.
[21]
The high in-hospital mortality rate (up
to 64%) is probably a reflection of not only pericardial
rupture and cardiac herniation but also of the associated
injuries.
[19,22]
Pericardial effusion
Definite diagnosis of traumatic pericardial effusions is
not easy even with Focused Assessment with Sonography
for Trauma (FAST), repeat cardiac echocardiography,
and computed tomography (CT).
[23]
Patients who survive
to the hospital usually have minor tears in the low-
Table 1: Summary of the mechanism of BCI
Direct impact Commtio cordis
Myocardial contusion
Rapid deceleration Aortic tear, Cardiac rupture
Rapid deceleration or Compression Ruptured myocardium
289 Annals of Cardiac Anaesthesia Vol. 15:4 Oct-Dec-2012
El-Menyar, et al.: Traumatic blunt cardiac injury
pressure chamber with a blood clot that temporarily
stops the bleeding or have decompression of blood
into the pleural cavity because of a pleuropericardial
defect.
[23]
Compared with penetrating chest injuries,
cardiac injury is more easily neglected in blunt trauma,
especially when associated with head or abdominal
injury.
[23,24]
Huang et al. reported that 87.1% of traumatic
pericardial effusions were due to blunt trauma and
51.7% were associated with cardiac injury or rupture.
[23]
Associated injuries
In BCI, the most common associated injuries are:
rib fractures (1869%), lung contusion (658%), flail
chest (338%), sternal fracture (060%), head injury
(2073%), and abdominal solid organ injury (543%).
[3]

Delayed complications
Pericardial, myocardial or valvular injuries may present
late after trauma. Most patients with trauma of the aortic
valve suffer its disruption immediately after the initial
trauma; however, delayed rupture may occur.
[4,25]

Delayed tricuspid and mitral valvular rupture may be
due to papillary muscle contusion with hemorrhage,
inflammation, and late necrosis, leading to disruption
over time.
[26]
Cardiac tamponade has been reported after
several days or weeks after minor blunt chest or isolated
abdominal trauma.
[27,28]
DIAGNOSIS OF BCI
The severity of the trauma does not necessarily correlate
with the degree of BCI. Moreover, there is no single test
that can be considered a gold standard when diagnosing
BCI. Different tests such as electrocardiogram (ECG),
sonographic and echocardiographic evaluation, and
cardiac biomarkers are currently used. The incidence of
BCI may vary due to diagnostic tools; however, all these
tests and mechanism of injury as well as clinical picture
need to be taken in consideration when diagnosing and
managing a patient with suspected BCI. Additionally,
BCI could be identified by using cardiac markers creatine
kinase and creatine kinase-MB in 19% of patients,
troponin in 1524%, transthoracic echocardiography
(TTE) in 326%, transesophageal echocardiogram (TEE)
in 2756%, and by ECG in 2956% of patients.
[4,29-31]
ECG
Although there is no single ECG sign pathognomonic
for BCI, the guidelines (level 1 evidence) recommends
performing 12-lead ECG on admission to all suspected
BCI patients.
[32,33]
ECG changes that indicate clinically
significant BCI are usually present at the time of
admission or occasionally within 24 h.
[3,34]
However,
it can be difficult to determine whether the ECG
abnormality is a primary event (e.g. an acute coronary
syndrome (ACS) that preceded trauma), a direct
result of cardiac injury, or a problem brought on by
the physiologic stress of severe trauma.
[2,34]
Several
studies concluded that in hemodynamically stable
young patients, normal ECG rules out the need for
further evaluation to detect BCI.
[3,35]
Patients with
unexplained tachycardia that persists over several
hours despite adequate fluid resuscitation and pain
control, or with a new bundle branch block, or with
significant arrhythmia, should be admitted for rhythm
monitoring and possible echocardiographic study. Life-
threatening ventricular arrhythmias were reported in
up to 16% of patients with BCI.
[4]
A 24 h monitoring
with ECG telemetry is required if a patient suspected of
having BCI is hemodynamically stable and has either
an abnormal ECG, or a history of cardiac disease, or is
55 years old.
[3,35]
Sonographic and echocardiographic evaluation
FAST provides the preferred initial approach for
sonographic evaluation.
[4,36-38]
It enables the trained
physician to rapidly and accurately determine the
presence of pericardial effusion and cardiac activity. After
excluding pericardial tamponade, an echocardiogram
is useful in trauma patients with signs of cardiac
dysfunction to diagnose the cause of dysfunction,
estimate the need for volume and/or inotropic support,
and identify other injuries requiring intervention
(Table 2 describes the cardiac injury scale).
[38]
Echocardiography can provide important information in
a patient who manifests signs consistent with significant
BCI. However, it has little utility as a screening tool
for clinically significant BCI in hemodynamically
stable patients.
[29,39]
It is recommended to obtain an
echocardiogram in any patient with blunt trauma
and unexplained persistent shock out of proportion
to apparent injuries or shock despite aggressive
resuscitation, and in any patient with signs consistent
with significant BCI. Echocardiographic signs include
abnormal cardiac wall motion, decreased cardiac
contractility, valvular dysfunction or rupture, septal
defects, intracardiac thrombus, and pericardial effusion
or rupture of the myocardium. However, findings may
be misleading in patients with prior chronic heart
disease and studies may be limited by the presence of
chest tubes, chest wall trauma, morbid obesity, pain,
and suboptimal views.
[3,10]
290 Annals of Cardiac Anaesthesia Vol. 15:4 Oct-Dec-2012
El-Menyar, et al.: Traumatic blunt cardiac injury
TEE is superior for investigating the cause of persistent
hemodynamic instability or other problems thought
to be related to BCI. It provides a clear view of wall
motion abnormalities and valvular and septal injuries.
Nowadays, TEE can be performed safely by anesthetists,
intensivists, and even accident and emergency
physicians. It improves sensitivity for injuries that
require intervention.
[3]
TEE is not only able to detect
myocardial injury missed by TTE but also superior to
TTE in visualizing thoracic aorta.
[10]
Cardiac biomarkers
The utility of cardiac biomarkers in the setting of
BCI remains unclear because of the lack of a gold
standard for diagnosis; moreover, there are several
biomarkers with different sources and cutoff values.
However, following blunt chest trauma, the diagnostic
value of troponin increases when it is combined with
the admission ECG; moreover, the use of troponin
as a screening test becomes more appreciated when
performed prior to echocardiography.
[3,10,34,40]
Collin
et al.
[41]
concluded, measuring troponin with a normal
ECG is not necessary and if the admission ECG has
minor abnormalities and the troponin at 4 to 6 hours
after injury is normal then the risk of BCI-related
complications is low. However, in the presence of
significant ECG abnormalities, a normal troponin value
may carry little benefit for risk stratification for cardiac
complications.
[3]
Instead of biomarkers, use of repeat
examinations, serial ECGs, and cardiac monitoring
during a brief course of observation (46 h) is more
valuable for screening for BCI, if doubt exists. The
patients with normal ECG and troponin can be safely
discharged if there are no other associated injuries.
[34]
Diagnosis of BAI
Chest X-ray is a valuable screening test.
[42]
A widened
mediastinum is the most frequent indication for
further investigations.
[43]
Angiography is the gold
standard diagnostic test for BAI.
[15,44]
CT of the chest is
a very useful diagnostic tool.
[45]
TEE is a very sensitive
screening test, but is usually followed by angiography.
[46]

CT may be a first tool for the diagnosis of these multi-
traumatized patients. Multislice CT may be more useful
tool for identifying minor leaks and adjacent structural
injuries. The need for aortography would decrease by
56% if chest CT is used in the screening for BAI.
[47-49]
In
a previous study, chest CT was performed to evaluate
BAI in 677 patients with positive or equivocal findings
at chest radiography, the investigators concluded that
reliance on findings at admission CT before angiography
could save more than $365,000.
[49]
Helical CT is more
sensitive tool for BAI diagnosis; it has a sensitivity of
100%, as compared with 92% for angiography.
[50]
In
patients with blunt chest trauma in whom BAI was
ruled out by helical CT, none required procedures
for or died of injuries to the aorta or great vessels.
[51]

However, some studies reported a 28% rate of missed
diagnoses of BAI in patients who did not have a chest
CT scan on admission and therefore, helical CT has been
Table 2: Cardiac injury scale
Grade Injury description
I Blunt cardiac injury with minor ECG abnormality (nonspecifc ST or T wave changes, premature atrial or ventricular contraction, or
persistent sinus tachycardia)
Blunt or penetrating pericardial wound without cardiac injury, cardiac tamponade, or cardiac herniation
II Blunt cardiac injury with heart block or ischemic changes without cardiac failure
Penetrating tangential cardiac wound up to but not extending through endocardium without tamponade
III Blunt cardiac injury with sustained or multifocal ventricular contractions
Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid incompetence, papillary muscle dysfunction, or distal
coronary artery occlusion without cardiac failure
Blunt pericardial laceration with cardiac herniation
Blunt cardiac injury with cardiac failure
Penetrating tangential myocardial wound up to but not through endocardium with tamponade
IV Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid incompetence, papillary muscle dysfunction, or distal
coronary artery occlusion producing cardiac failure
Blunt or penetrating cardiac injury with aortic or mitral incompetence
Blunt or penetrating cardiac injury of the right ventricle, right or left atrium
V Blunt or penetrating cardiac injury with proximal coronary artery occlusion
Blunt or penetrating left ventricular perforation
Stellate injuries <50% tissue loss of the right ventricle, right or left atrium
VI Blunt avulsion of the heart
Penetrating wound producing >50% tissue loss of a chamber
Adapted from Ref. 38 with permission: Lippincott Williams and Wilkins, Inc.: Moore EE et al. Organ injury scaling. IV: Thoracic vascular, lung, cardiac,
and diaphragm. J Trauma 1994;36:299.
291 Annals of Cardiac Anaesthesia Vol. 15:4 Oct-Dec-2012
El-Menyar, et al.: Traumatic blunt cardiac injury
Figure 1: Evaluation of suspected blunt cardiac injury (with permission : Elsevier Limited: Schultz J M, Trunkey DD. Blunt cardiac injury. Crit Care Clin 2004;20:57-70)
BLUNT CARDIAC INJ URY PROTOCOL
Suspicion of BCI
Obtain Admission
12 Lead ECG
Abnormal ECG e.g. arrhythmia,
ST changes, ischemia, heart
block, unexplained ST
Normal ECG
Patient: Hemodynamically
stable, <55 years old, and has
no history of cardiac disease
No further evaluation for
BCI
Patient: Hemodynamically
unstable, and 55 years old,
OR has a history of cardiac
disease
Initiate cardiac monitoring
(24-48 hours)
Patient is hemodynamically unstable
Obtains Trans-thoracic OR Trans-
esophageal echocardiography to evaluate
cardiac function (TEE preferred)
Patient remains
hemodynamically stable
Discontinue monitoring
cardiac dysfunction, until proven otherwise. With
hypotension in the setting of isolated thoracic trauma,
clinicians should look for pericardial tamponade or a
tension pneumothorax in addition to hemorrhage.
Valve, septum, or ventricular wall injury
Patients with clinical or echocardiographic evidence
of severe cardiac injury (e.g. ruptured valve, septum,
ventricular wall or tamponade) require emergent
surgical consultation. In case of penetrating cardiac
injury, immediate surgical intervention is a priority
[Figure 4]. If possible, anesthesia and intubation
should be delayed in patients who require operative
intervention until just before sternotomy because
anesthesia induction may cause hemodynamic collapse.
Any patient suspected to have BCI with cardiac free-
wall rupture, septal rupture, coronary artery injury, or
valve injury should be seen by a cardiothoracic surgeon
without delay.
[55]
Figure 3 summarizes the management
of suspected blunt cardiac rupture.
recommended in all patients with a history of MVC at a
speed of 10 mph or faster for unrestrained drivers and
30 mph or faster for restrained drivers.
[52,53]
MANAGEMENT
Cardiac injury evaluation and management protocols
based on the hemodynamic status and the electrical
cardiac activity are shown in Figures 13.
[3,7,10]
We believe
in the simultaneous assessment; however, priority should
be given to the immediate clinical evaluation.
[3,7,10,54]
Initial stabilization
BCI is often associated with thoracic trauma, but can
occur in any patient with multiple trauma. Initial
evaluation proceeds according to standard Advanced
Trauma Life Support protocols, beginning with
stabilization of the patients airway, breathing, and
circulation. Clinicians should assume that hypotension
in the trauma patient results from hemorrhage, not
292 Annals of Cardiac Anaesthesia Vol. 15:4 Oct-Dec-2012
El-Menyar, et al.: Traumatic blunt cardiac injury
Unstable patients
In patients who may not survive to an operating room,
emergency resuscitative thoracotomy is the best option.
Pericardiocentesis can be an effective temporizing
measure and may be attempted. However, in the
setting of blunt trauma, thoracotomy rarely results in
successful resuscitation. If cardiac injury is suspected
in a hypotensive patient and FAST is unavailable, the
cardiothoracic surgery and cardiology services should be
consulted immediately. Such patients should be admitted
to a surgical service with cardiology consultation unless
operative management is clearly unnecessary.
Acute coronary syndrome
Acute coronary syndrome (ACS) may occur due to
coronary dissection or stress-induced thrombosis or
spasm. Ismailov and his colleagues
[56]
reported that
direct trauma to the heart is associated with a 2.6-fold
increased risk for acute myocardial infarction (AMI)
in persons 46 years of age. Moreover, in younger
patients who underwent coronary angiography after
trauma, BCI was associated with a 31-fold increased
risk for AMI. Sudden elevation of intra-aortic pressure
caused by sudden external impact to the abdomen
possibly result in rupture of the coronary vessel,
particularly if the aortic valve was closed during the
traumatic impact.
[56]
Catheterization with stenting may
be the best approach for treatment, although some
advocate bypass graft surgery. Thrombolytic agents
are best avoided, especially in patients who sustained
multiple injuries, unless both bypass surgery and
angiography are unavailable, and patients do not have
any contraindications to the use of thrombolytic agents.
Management should be determined in consultation
with cardiologist. Cardiothoracic surgery consultation
is needed in the rare event when a coronary artery
laceration or dissection is identified. For patients
with features suggestive of BCI and in whom cardiac
Figure 2: Algorithm for blunt chest trauma and cardiac trauma injury (with permission : BMJ Publishing Group Ltd.: Bansal MK et al. Myocardial contusion injury:
Redefning the diagnostic algorithm. Emerg Med J 2005;22:465-9)


























BLUNT CHEST TRAUMA
Patient transported to
emergency/trauma centre
Mechanism of injury: blunt chest trauma or cardiac trauma
Patients haemodynamically unstable
YES NO
ECHO
Admit to monitored bed
TEE TTE
Serial
ECGs
Chest
X- ray
Physical
exam
Cardiac
troponin
TEE can be
performed
pre-op or
intra-op with
follow-up
imaging
post
operatively
Observation monitored bed
Consider holter
monitor as outpatient
Abnormal study Normal study
Discharge
293 Annals of Cardiac Anaesthesia Vol. 15:4 Oct-Dec-2012
El-Menyar, et al.: Traumatic blunt cardiac injury
Figure 4: (a) Intraoperative picture of a right ventricular stab wound that was repaired by using pledgets in a young male who presented with cardiac tamponade
(courtesy Dr. Latif R). (b) Postmortem image of rupture of interventricular septum after blunt injury (with permission: Elsevier Limited) Pollock Be et al: Isolated
traumatic rupture of the interventricular septum due to blunt force. Am Heart J 1952;43:273-85)
a b
Figure 3: Protocol for management of suspected blunt cardiac rupture (with permission: Elsevier Limited : Nan YY et al. Blunt traumatic cardiac rupture: Therapeutic
options and outcomes. Injury 2009;40:938-45) FAST - Focused assessment with sonography for trauma; ER - Emergency room; OR - Operating room

Blunt Chest Trauma
No recordable BP Recordable BP
FAST (+) FAST or CT (+) FAST/CT (-)
Subxiphoid Drainage at ER
No response
Response
Go to
resuscitation at
ER
To OR for
suspicions of
cardiac lesions
Repeat Echo by
cardiac
consultation (+)
To OR for non-
cardiac surgery
Pericardial decompression
Exploratory sternotomy
Cardiac repair
Cardiopulmonary bypass
Extracorporal life support
Cardiac lesions as
an Intra-operative
finding
Intra-operative
TEE (+)
Heart lesion with
poor exposure from
original incision
Heart lesion with
good exposure from
original incision
Cardiac repair via
original incision
(eg. Thoracotomy)
294 Annals of Cardiac Anaesthesia Vol. 15:4 Oct-Dec-2012
El-Menyar, et al.: Traumatic blunt cardiac injury
biomarkers are found to be elevated, cardiology
consultation is obtained and the patient is admitted for
cardiac monitoring and further evaluation. A screening
echocardiogram and cardiac biomarkers do not appear
to add to the management of the hemodynamically
stable patient without clinical features suggestive of
significant BCI.
[3,4]
Cardiac dysfunction and arrhythmia
Echocardiography is warranted in patients with BCI
for clinical findings of hypotension, heart failure, or
arrhythmia.
[3]
Patients without identifiable injury but
with persistent cardiac dysfunction (e.g. hypotension)
are admitted for cardiac monitoring. Cardiology
consultation is needed for patients with hemodynamic
instability likely due to cardiac injury. In the presence
of arrhythmia, most physicians initiate standard
advanced cardiac life support (ACLS) protocols when
applicable. In patients with a complex arrhythmia
(e.g. high-grade conduction block, new-onset atrial
fibrillation, supraventricular or ventricular tachycardia)
following BCI, it is appropriate to perform a bedside
echocardiogram to look for wall motion abnormalities or
injuries that require emergent surgery. Clinicians should
assume that hemorrhage is the cause of tachycardia
in the trauma patient until proven otherwise. Floor
telemetry is appropriate for the patient with minor
abnormalities (e.g. intermittent premature ventricular
or atrial contractions), no significant concomitant
injuries, and normal hemodynamics. All other patients
should have a higher level of monitoring (e.g. cardiac
intensive care unit). BCI of either ventricle usually
resolves without significant consequences within a year
after injury, particularly if no acute complication occur
during the index admission.
[57]
Tamponade
Pericardial effusion is the most common feature of
BCI. It can be diagnosed clinically by the presence of
hypotension, distended jugular veins, muffled heart
sounds and/or by ultrasound. Tamponade that results
from an atrial tear may be amenable to pericardiocentesis
with periodic drainage using a pigtail catheter until
definitive surgical repair can be performed.
Blunt Aortic Injury
Modalities of BAI repair include direct suture repair,
placement of a prosthetic graft, and endoluminal
stenting.
[58-60]
Protective measures against distal
ischemia, such as hypothermia, are helpful.
[61]
However,
hypothermia may disable coagulation profiles even
more in the multi-traumatized patients. Therefore, close
communication between the surgical and anesthesia
teams is the key for successful management.
[12,62]
CONCLUSION
Although traumatic cardiac injury is a challenge in
critical trauma care, guidelines are lacking. A high
index of suspicion, application of current diagnostic
protocols, and prompt and appropriate management is
important for a successful outcome.
REFERENCES
1. Kang N, Hsee L, Rizoli S, Alison P. Penetrating cardiac injury: Overcoming
the limits set by Nature. Injury 2009;40:919-27.
2. Elie MC. Blunt cardiac injury. Mt Sinai J Med 2006;73:542.
3. Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin 2004;20:57-70.
4. Ismailov RM, Weiss HB, Ness RB, Lawrence BA, Miller TR. Blunt cardiac
injury associated with cardiac valve insufficiency: Trauma links to
chronic disease? Injury 2005;36:1022.
5. Marshall DT. The spectrum of findings in cases of sudden death due
to blunt cardiac trauma-commotio cordis. Am J Forensic Med Pathol
2008;29:1-4.
6. Pollock Be, Markelz RA, Shuey HE. Isolated traumatic rupture of the
interventricular septum due to blunt force. Am Heart J 1952;43:273-85.
7. Nan YY, Lu MS, Liu KS, Huang YK, Tsai FC, Chu JJ, et al. Blunt
traumatic cardiac rupture: Therapeutic options and outcomes. Injury
2009;40:938-45.
8. Kato K, Kushimoto S, Mashiko K, Henmi H, Yamamoto Y, Otsuka T.
Blunt traumatic rupture of the heart: An experience in Tokyo. J Trauma
1994;36:859-63.
9. Fegheli NT, Prisant LM. Blunt myocardial injury. Chest 1995;108:1673-7.
10. Bansal MK, Maraj S, Chewaproug D, Amanullah A. Myocardial contusion
injury: Redefining the diagnostic algorithm. Emerg Med J 2005;22:465-9.
11. Brathwaite CE, Rodriguez A, Turney SZ, Dunham CM, Cowley R. Blunt
traumatic cardiac rupture. A 5-year experience. Ann Surg 1990;212:701-4.
12. Kutsukata N, Sakamoto Y, Mashiko K, Ochi M. Morphological evaluation
of areas of damage in blunt cardiac injury and investigation of traffic
accident research. Gen Thorac Cardiovasc Surg 2012;60:31-5.
13. El-Menyar A, Shaikh N. Necrotizing fasciitis causing severe myocardial
dysfunction with ST-segment elevation in a young man. Am J Emerg
Med 2010;28:260.e3-5.
14. Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo
or stress cardiomyopathy): A mimic of acute myocardial Infarction. Am
Heart J 2008;155:408-17.
15. Nagy K, Fabian T, Rodman G, Fulda G, Rodriguez A, Mirvis S. Guidelines
for the diagnosis and management of blunt aortic injury: An EAST Practice
Management Guidelines Work Group. J Trauma 2000;48:1128-43.
16. Fabian TC, Richardson JD, Croce MA, Smith JS Jr, Rodman G Jr, Kearney PA,
et al. Prospective study of blunt aortic injury: Multicenter Trial of the
American Association for the Surgery of Trauma. J Trauma 1997;42:374-80.
17. Cameron PA, Dziukas L, Hadj A, Hooper S, Tatoulis J. Aortic Transection.
Aust NZ J Surg 1998;68:264-7.
18. Katyal D, McLellan BA, Brenneman FD, Boulanger BR, Sharkey PW,
Waddell JP. Lateral impact motor vehicle collisions: Significant cause of
blunt traumatic rupture of the thoracic aorta. J Trauma 1997;42:769-72.
19. Sherren PB, Galloway R, Healy M. Blunt traumatic pericardial rupture
and cardiac herniation with a penetrating twist: Two case reports.
Scand J Trauma Resusc Emerg Med 2009;17:64.
20. Fulda G, Brathwaite CE, Rodriguez A, Turney SZ, Dunham CM,
Cowley RA. Blunt traumatic rupture of the heart and the pericardium:
A ten-year experience (1979-1989). J Trauma 1991;31:167-73.
295 Annals of Cardiac Anaesthesia Vol. 15:4 Oct-Dec-2012
El-Menyar, et al.: Traumatic blunt cardiac injury
Cite this article as: El-Menyar A, Al Thani H, Zarour A, Latif R. Understanding
traumatic blunt cardiac injury. Ann Card Anaesth 2012;15:287-95.
Source of Support: Nil, Confict of Interest: None declared.
21. Farhataziz N, Landay M. Pericardial rupture after blunt chest trauma.
J Thorac Imaging 2005;20:50-2.
22. Sohn JH, Sohn JW, Seo JB, Do KH, Lee JS, Kim DK, et al. Pericardial
rupture and cardiac herniation after blunt trauma: A case diagnosed
using cardiac MRI. Br J Radiol 2005;78:447-9.
23. Huang YK, Lu MS, Liu KS, Liu EH, Chu JJ, Tsai FC, et al. Traumatic
pericardial effusion: Impact of diagnostic and surgical approaches.
Resuscitation 2010;81:1682-6.
24. Degiannis E, Loogna P, Doll D, Bonanno F, Bowley DM, Smith MD.
Penetrating cardiac injuries: Recent experience in South Africa. World
J Surg 2006;30:1258-64.
25. Parry GW, Wilkinson GA. Traumatic aortic regurgitation. Injury
1997;28:679-80.
26. Khurana S, Puri R, Wong D, Dundon BK, Brown MA, Worthley MI,
et al. Latent tricuspid valve rupture after motor vehicle accident and
routine echocardiography in all chest-wall traumas. Tex Heart Inst J
2009;36:615-7.
27. Hermens JA, Wajon EM, Grandjean JG, Haalebos MM, von Birgelen C.
Delayed cardiac tamponade in a patient with previous minor blunt
chest trauma. Int J Cardiol 2009;131:e124-6.
28. Dunsire MF, Field J, Valentine S. Delayed diagnosis of cardiac tamponade
following isolated blunt abdominal trauma. Br J Anaesth 2001;87:309-12.
29. Karalis DG, Victor MF, Davis GA, McAllister MP, Covalesky VA,
Ross JJ Jr, et al. The role of echocardiography in blunt chest trauma: A
transthoracic and transesophageal echocardiographic study. J Trauma
1994;36:53-8.
30. Helling TS, Duke P, Beggs CW, Crouse LJ. A prospective evaluation of
68 patients suffering blunt chest trauma for evidence of cardiac injury.
J Trauma 1989;29:961-5.
31. Weiss RL, Brier JA, OConnor W, Ross S, Brathwaite CM. The usefulness
of transesophageal echocardiography in diagnosing cardiac contusions.
Chest 1996;109:73-7.
32. Pasquale NK, Clarke J. Screening of blunt cardiac injury.1998. The
Eastern Association for the Surgery of Trauma. Available at: http://www.
east.org/tpg/chap2.pdf. Accessed August 31, 2003.
33. Paone RF, Peacock JB, Smith DL. Diagnosis of myocardial contusion.
South Med J 1993;86:867-70.
34. Salim A, Velmahos GC, Jindal A, Chan L, Vassiliu P, Belzberg H, et al.
Clinically significant blunt cardiac trauma: Role of serum troponin levels
combined with electrocardiographic findings. J Trauma 2001;50:237-43.
35. Illig KA, Swierzewski MJ, Feliciano DV, Morton JH. A rational screening
and treatment strategy based on the electrocardiogram alone for
suspected cardiac contusion. Am J Surg 1991;162:537-43.
36. Nagy KK, Krosner SM, Roberts RR, Joseph KT, Smith RF, Barrett J.
Determining which patients require evaluation for blunt cardiac injury
following blunt chest trauma. World J Surg 2001;25:108-11.
37. Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, et al.
Focused cardiac ultrasound in the emergent setting: A consensus
statement of the American Society of Echocardiography and American
College of Emergency Physicians. J Am Soc Echocardiogr 2010;23:1225.
38. Moore EE, Malangoni MA, Cogbill TH, Shackford SR, Champion HR,
Jurkovich GJ, et al. Organ injury scaling. IV: Thoracic vascular, lung,
cardiac, and diaphragm. J Trauma 1994;36:299.
39. Wisner DH, Reed WH, Riddick RS. Suspected myocardial contusion.
Triage and indications for monitoring. Ann Surg 1990;212:82-6.
40. Mori F, Zuppiroli A, Ognibene A, Favilli S, Galeota G, Peris A, et al. Cardiac
contusion in blunt chest trauma: A combined study of transesophageal
echocardiography and cardiac tropinin I determination. Ital Heart J
2001;2:222-7.
41. Collins JN, Cole FJ, Weireter LJ, Riblet JL, Britt LD. The usefulness of
serum Troponin levels in evaluating cardiac injury [discussion]. Am Surg
2001;67:821-6.
42. Mirvis SE, Bidwell JK, Buddemeyer EU, Diaconis JN, Pais SO, Whitley JE,
et al. Value of chest radiography in excluding traumatic aortic rupture.
Radiology 1987;163:487-93.
43. Pastershank SP, Chow KC. Blunt trauma to the aorta and its major
branches. J Can Assoc Radiol 1974;25:202-10.
44. Sturm JT, Hankins DG, Young G. Thoracic aortography following blunt
chest trauma. Am J Emerg Med 1990;8:92-6.
45. Durham RM, Zuckerman D, Wolverson M, Heiberg E, Luchtefeld WB,
Herr DJ, et al. Computed tomography as a screening exam in patients
with suspected blunt aortic injury. Ann Surg 1994;220:699-704.
46. Vignon P, Guret P, Vedrinne JM, Lagrange P, Cornu E, Abrieu O, et al. Role
of transesophageal echocardiography in the diagnosis and management
of traumatic aortic disruption. Circulation 1995;15:2959-68.
47. Melton SM, Kerby JD, McGiffin D, McGwin G, Smith JK, Oser, et al. The
evolution of chest computed tomography for the definitive diagnosis of
blunt aortic injury: A single-center experience. J trauma. 2004;56:243-50.
48. Raptopoulos V, Sheiman RG, Phillips DA, Davidoff A, Silva WE. Traumatic
aortic tear: Screening with chest CT. Radiology 1992;182:667-73.
49. Mirvis SE, Shanmuganathan K, Miller BH, White CS, Turney SZ. Traumatic
aortic injury: Diagnosis with contrast-enhanced thoracic CTfive-year
experience at a major trauma center. Radiology 1996;200:413-22.
50. Fabian TC, Davis KA, Gavant ML, Croce MA, Melton SM, Patton JH Jr,
et al. Prospective study of blunt aortic injury: Helical CT is diagnostic and
antihypertensive therapy reduces rupture. Ann Surg 1998;227:666-76.
51. Ellis JD, Mayo JR. Computed tomography evaluation of traumatic
rupture of the thoracic aorta: An outcome study. Can Assoc Radiol J
2007;58:22-6.
52. Exadaktylos AK, Duwe J, Eckstein F, Stoupis C, Schoenfeld H,
Zimmermann H, et al. The role of contrast-enhanced spiral CT imaging
versus chest X-rays in surgical therapeutic concepts and thoracic
aortic injury: A 29-year Swiss retrospective analysis of aortic surgery.
Cardiovasc J S Afr 2005;16:162-5.
53. Neschis DG, Scalea TM, Flinn WR,Griffith BP. Blunt Aortic Injury. N Engl
J Med 2008;359:1708-16.
54. Lancey RA, Monahan TS. Correlation of clinical characteristics and
outcomes with injury scoring in blunt cardiac trauma. J Trauma
2003;54:509.
55. Brown J, Grover FL. Trauma to the heart. Chest Surg Clin N Am
1997;7:325-41.
56. Ismailov RM, Ness RB, Weiss HB, Lawrence BA, Miller TR. Trauma
associated with acute myocardial infarction in a multi-state hospitalized
population. Int J Cardiol 2005;105:141.
57. Sturaitis M, McCallum D, Sutherland G, Cheung H, Driedger AA,
Sibbald WJ. Lack of significant long-term sequelae following traumatic
myocardial contusion. Arch Intern Med 1986;146:1765-9.
58. Schmidt CA, Wood MN, Razzouk AJ, Killeen JD, Gan KA. Primary repair of
traumatic aortic rupture: A preferred approach. J Trauma 1992;32:588-92.
59. Von Oppell UO, Brink J, Hewitson J, Pinho P, Zilla P. Acute traumatic
rupture of the thoracic aorta. A comparison of techniques. S Afr J Surg
1996;34:19-24.
60. Von Oppell UO, Brink J, Hewitson J, Pinho P, Zilla P. Delayed Treatment
of Traumatic Rupture of the Thoracic Aorta With Endoluminal Covered
Stent. Circulation 1999;99:498-504.
61. Antunes MJ. Acute traumatic rupture of the aorta: Repair by simple
aortic cross clamping. Ann Thorac Surg 1987;44:257-9.
62. Van Norman GA, Pavlin EG, Eddy AC and Pavlin DJ. Hemodynamic and
metabolic effects of aortic unclamping following emergency surgery
for traumatic thoracic aortic tear in shunted and unshunted patients.
J Trauma 1991;31:1007-16.
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