Transcript Blunt Cardiac Injury

Case – Fall of the Lumberjack
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22 yr old m in remote area of Northwest fell 40
feet when his ropes failed
Stuck chest/torso on a large limb prior impact
with ground
Conscious c/o chest/lower back/hip pain
Taken to camp infirmary, then by helicopter
In flight
– Developed tachycardia and SOB (sats 90%)
– BS bilaterally and BP stable
– Increased oxygen by FM 50%
– LR at 200 cc/hr
Case – Lumberjack 40 ft fall
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Arrived to trauma center 90 mins. later
Agitated and tachypnea (50 br/min)
O2 Sats 89% on 50% FM
BP 90/60, HR 120
Continued BS bilaterally
Management?
Case – Lumberjack 40 ft fall
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Intubated and bolus 1L LR
Initial CXR (poor) – no PTX, B infiltrative process
O2 Sats improved, BP 110/60
PE
– Tenderness anterior chest wall, no crepitus
– Heart sound normal, no rub or murmurs
Management ?
CXR
EKG
Hemodynamics
Case – Lumberjack 40 ft fall
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CT head – no contusion or bleed
CT abdomen – retroperitoneal blood collection
(700-1000 cc), no solid organ injury or free fluid
ECHO – dilated, moderately hypokinetic right
ventricle, no effusion
Diagnosis and further management?
Traps – Blunt Cardiac Injury
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Hypotension after trauma
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Hemorrhage
Tension PTX
Tamponade
Myocardial contusion
Neurogenic shock (high spinal cord injury)
? Gold standard of myocardial contusion
– 44 % of abnl ECHO, normal EKG/CPK’s
– 67% of abnl CPK’s, normal ECHO
Tricks – Blunt Cardiac Injury
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Rule out hemorrhage (hypotension)
Mechanism of injury and physical signs
– Any blow to the thorax or rapid deceleration
– Fractures of 1st/2nd ribs, multiple ribs
Multiple tests often required to diagnosis
blunt cardiac injury
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EKG
Cardiac Isoenzymes
PA catheter
Echo
Follow up – Lumberjack 40 ft fall
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Transferred to SICU
Transfusion PRBC/NS ( no pressors)
PVC’s during first 24 hrs.
Total CPK 4000, MB 4%
PA catheter used to monitor hydration
HD 3 – CXR improved and extubated
HD 7 – ECHO showed right ventricular dilation
and hypokinesis largely resolved.
Blunt Cardiac Injury
Bradley J. Phillips, MD
Burn-Trauma-ICU
Adults & Pediatrics
Incidence - BCI
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Most frequent, unsuspected visceral injury
responsible for death in accident victims
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On scene
– accounts for 25% of deaths
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Hospital
– 15-25% of all blunt chest trauma
Definition
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Old Terminology
– concussion = no anatomic cellular damage, but
functional damage seen on ECHO
– contusion = anatomic injury with release of
elevated CPK-MB or direct visualization at
surgery or autopsy
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Blunt cardiac injury = spectrum of injury
Myocardial contusion = trauma to myocardium
Pathophysiology
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Wide spectrum of injury
– * direct myocardial injury
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laceration/thrombosis coronary arteries
pericardial tears
rupture of wall leading to tamponade
septal rupture
valvular injury (aorta most common)
Emergent Management
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Cardiac rupture
Ventricular septal defect (VSD)
Atrial septal defect (ASD)
Valvular injury
Myocardial contusion
Cardiac Rupture
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Most severe form of BCI
Most frequent heart lesion found at autopsy in
patient dead at scene
Locations (common)
– historically reported anterior right ventricle
– experience demonstrate tear of R atrium at
junction of SVC and IVC (reach hospital)
Shock out of proportion to injury/fluid
resuscitation
Treatment = immediate sternotomy
Ventricular Septal Defect
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Incidence
– Parmeley et al (Circulation, 1958)
• 5-7 % VSD
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Diagnosis
– critically ill (VSD, myocardial and pulm injury)
– EKG changes and new murmur
– loud holosystolic murmur and thrill
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Treatment
– severe = immediate catherization/repair
– small = spontaneous repair
– moderate = repair 6-8 weeks post injury
Atrial Septal Defect
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Extremely rare
Most die within minutes of injury
– larger defects
– complications from hypoxemia
Valvular Injury
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Aortic insufficiency most common
– rupture of cusp or tear of commissural
attachment
– severe heart failure
– often manage acutely with titrating
preload/afterload
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Long-term treatment
– replace valves
– preferable to wait 6-8 weeks
Myocardial Contusion
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Incidence
– 90% of all admitted BCI
– 5-15 % of blunt chest trauma
– unstable ICU patients = as high as 75%
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Pathology
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subendothelial/interstitial hemorrhage
surrounding area of focal edema
myofibrillar degeneration
infiltration of PMN’s
resemble MI but more patchy
Myocardial Contusion
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Physiologic changes
– rhythm or conduction disturbances
– impair contractility in 10-20% of patients
• CO reduction directly related to contusion
– significant reduction in cardiac function if
• preexisting cardiac disease
• multiple injuries
• general anesthesia
Myocardial Contusion - Dysfunction
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Torres-Mirabal et al (Crit Care Med, 1982)
– Death from biventricular failure, cardiogenic
shock, L ventricular failure
– PA catheter only slight  CO and  wedge
– Fluid challenge = rapid increases in wedge
with little changes in CO
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Sutherland et al (Am J Cardio, 1986)
– RVEF reduced 29% (cardiac scintigraphy)
– compensated by increased RVEDV
Myocardial Contusion -ICU Monitoring
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Arrhythmia
Clinical evidence of heart failure
Multiple other injuries
Preexisting cardiac disease
General anesthesia
Clinical Presentation
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Arrhythmias
– tachycardia out of proportion of degree of
trauma or blood loss
– others = atrial fibrillation, PAC’s, PVC’s
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Signs/symptoms of MI
– chest pain (not relieved by HTG)
– increased CPK’s
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Hypotension
– persistent after volume resuscitation
Diagnostic Studies
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Physical exam/plain radiography
EKG
Cardiac enzymes
Echocardiography
Radionuclide Angiography
BCI - Physical Exam/Radiography
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External chest injury not present in up to 1/3
Sternal fracture not predictive for BCI
– Supportive
• Shapira et al, J Trauma, 1994
– less than 5% had cardiac damage
• Support by other studies
– Non-supportive
• Harley et al ( J Trauma, 1986)
– 91 % of sternal fx had RV dysfunction by RNA
EKG
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Best screening tool for BCI
Should be obtained on admission and repeated
12 to 24 hrs later
If no abnormalities at 24hrs, unlikely to develop
complications
New atrial fibrillation, multiple PVC’s, or
conduction disturbance more important than STT wave changes for diagnosing cardiac injury
Cardiac Enzymes - CPK-MB
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CPK-MB
– sources: skeletal muscle, pancreas, lung, colon,
liver, stomach, and small bowel
– peaks 18-24 after myocardial contusion
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Evidence
– no value in predicting outcome
– no correlation to severity of contusion
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Role in Trauma
– r/o MI in elderly or pts with h/o CAD
Cardiac Enzymes - Troponin
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Specific to myocardial tissue
Troponin T
– Ferjani et al, Chest,1997
• prospective 128 pts blunt chest trauma
• 29/128 BCI
• higher diagnostic value, but no important clinical
value
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Troponin I
– Salim et al, J Trauma, 2001
• 115 patients with blunt chest trauma
EKG/Trop I and Significant BCI
115 patients
Abnl EKG
58
Abnl Trop I
16
Sig BCI
10
No Sig BCI
6
Normal EKG
57
Normal Trop I
42
Sig BCI
6
Sensitivity
Specificity
PP value
NP value
No Sig BCI
36
Abnl Trop I
11
Sig BCI
3
No Sig BCI
8
Normal
Normal Trop
Trop II
45
46
Sig
Sig BCI
BCI
80
No Sig BCI
46
EKG Trop I EKG + TropI
84%
68%
100%
56%
85%
88%
28%
48%
62%
95%
93%
100%
Salim et al, J Trauma, 2001
Salim et al, J Trauma, 2001
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Results
– significant BCI (19 patients)
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arrhythmias (A fib 7, ST 3) < 24hrs
hypotension requiring pressors (7) < 24 hrs.
cardiogenic shock on inotropes (1) < 24 hrs.
hemopericardium with drainage (1) HD6
Criticism
– ? change in management (all ICU admitted)
– sinus tachycardia not judged abnormal EKG
– initial Trop I negative (4/19 patients)
Echocardiography
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Most useful of tests for diagnosis/therapy
– normal ECHO rules out significant contusion
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Findings with contusion
– usually R ventricular dyskinesis
– occasionally see thrombus attached
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TEE vs. TTE
– TEE more sensitive if TTE inadequate
– TEE useful to exclude causes of hypovolemia
• r/o hypovolemia, tamponade
Radionuclide Angiography
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Studies
– Harley and Mena, J Trauma 1986
• 11/12 sternal fx abnormal study
• none had abnormal CPK-MB, only 4 abnl EKG
– Sutherland et al, Am J Cardiol, 1983
• similar findings (Harley and Mena study)
• only 1/3 had abnormal CPK-MB or EKG
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Conclusion
– excessively sensitive
– no clinical significance
– no added value to ECHO study
Therapy - Myocardial Contusion
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Recognition
Monitoring
Support
Special considerations
– PA catheter
– Anesthesia
– Thrombus
Cardiac Monitoring
Study
Monitoring Required
Frazee et al, J Trauma 1986
Brune et al,J Int Care Med, 1988
Hiatt et al, J Trauma, 1988
Baxter et al, Am J Surg, 1989
Foil et al, Am J Surg, 1990
Healey et al, J Trauma, 1990
Fabian et al, J Trauma, 1991
McCarthy et al, CV Interv Rad 1991
Cachecho et al, J Trauma, 1992
Biffl et al, Am J Surg 1994
Abnormal EKG/ ECHO
Abnormal EKG or unstable
Abnormal EKG
Abnormal EKG or CK-MB
Abnormal EKG
Abnormal EKG
Not routinely applicable
Abnormal EKG
Abnormal EKG
Abnormal EKG
BCI - Hypotension
Volume Resuscitation
R/O Mechanical Problem
(ie. tamponade, tension PTX)
Inotropic Support
Dopamine (1st line)
Dobutamine (2nd line)
Milrinone (3rd line)
Intra-aortic Balloon Pump
IABP
Extra-Corporeal Membrane Oxygenation
ECMO
Anesthesia and Myocardial Contusion
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Dictums
– no GA < 1 month of contusion
– required PA catheter for emergent OR
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Evidence
– Fabian et al, J Trauma 1988
• no problem with GA
– Ross et al, Arch Surg, 1989
• PA catheter for OR
– Krasna et al, Sem Thor CV Surg, 1992
• safe for emergent OR
– Feghali et al, Chest, 1995
• ? invasive monitoring, no problems
Complications - Delayed
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Pericarditis
– 2-4 weeks post trauma
– signs/symptoms
• chest pain, fever, effusion
• EKG ST-T c/w pericarditis
– treatment
• salicylates, rest
• steroids for severe cases
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Aneurysms
– unusual and occurs with large areas of necrosis
– symptoms of CHF, emboli, dysrhythmias
– treatment (asymptomatic/symptomatic) = resection
Recommendations
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Admission EKG with suspected BCI (L I)
– abnormal EKG = continuous monitoring 24 hrs
– normal EKG = risk of BCI is insignificant
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Tropinin I (LII)
– consider if planning ED discharge
– if Trop I neg/EKG neg no clinical sig BCI
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Imaging study -Echocardiography (L II)
– hemodynamically unstable
– if TTE is suboptimal, TEE should be done
– nuclear medicine studies add little to Echo
Recommendations
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Level III data
– presence of sternal fx does not predict BCI
– CPK or troponin are not useful in predicting which
pts will or will not have complications related to
BCI
– Patients with CAD, hemodynamically instability, or
abnormal EKG can be safely operated on with
appropriate monitoring
Questions…?
Bradley J. Phillips, MD
SBH-UTMB