Cardiac Trauma

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25 Cardiac Trauma

Cardiovascular trauma may be strongly suspected and sought immediately at the time of presentation, or, conversely, it may not be recognized at first because other trauma captures the attention. Cardiac wounds may be single or multiple.

Transthoracic echocardiography (TTE) can be performed with adequate images in most patients, but for a substantial number, local chest wall pain will prohibit some aspects of transthoracic scanning, as may subcutaneous emphysema, and abdominal pain or distention may prevent subcostal imaging.

A case can be made for transesophageal echocardiography (TEE) to identify or better define cardiac and aortic traumatic injuries that are not readily apparent on transthoracic scanning.

Cardiac trauma should be suspected in any patient with a wound, penetrating but also nonpenetrating, to the chest, precordium, neck, or upper abdomen. Some penetrating wounds elsewhere in the body may result in cardiac trauma when a projectile travels or migrates within the body.

Blunt Cardiac Trauma

Myocardial Sequelae

Myocardial damage is produced in the area underlying the impact, but also may occur elsewhere in the heart, often on the opposite wall.

Echocardiographic features of myocardial contusion include

• Increased end-diastolic wall thickness (edema and hematoma)

• Reduced systolic function

There is a spectrum of severity of myocardial contusion. Echocardiography is most likely to be sensitive to severe degrees of contusion, but some authors have questioned its sensitivity to less severe degrees of contusion.¹

Cardiac rupture may occur due to breakdown of myocardium post-contusion, due to violent compression of the heart, puncture by a rib, or coronary disruption or thrombosis from trauma. Ventricular septal defect,² free wall rupture, tamponade, and pseudoaneurysms have all occurred.

Valvular Sequelae

The aortic valve is most commonly injured,³ although any valve may be involved. Insufficiency results from damage to leaflets, chordae, or papillary muscles, or semilunar leaflet avulsion or retroversion.

Coronary Sequelae

Coronary sequelae include thrombosis,⁴ dissection, aneurysm, and fistulous communication.⁵

The left anterior descending and right coronary arteries are the most commonly affected.

Penetrating Cardiac Trauma

In the urban milieu, the missiles that most commonly penetrate the heart are knives and bullets.

Most (60–80%), but not all, of these wounds are fatal, often immediately.

The clinical presentation is usually tamponade or bleeding into the chest.

Left anterior stab wounds most often involve the right ventricle. Right anterior stab wounds may involve the right ventricle or atrium, and left lateral and posteriors stab wounds may involve the left ventricle.

Bullet wounds commonly involve the left ventricle.

Puncture of a cardiac chamber may result in the following:

• Pericardial effusion

• Pericardial tamponade

• Possible intracardiac communication/fistula

• Valve disruption

Penetrating cardiac wounds often are multiple.

Shunt flow within the heart may have unusual color flow characteristics if caused by a knife, as on one plane the defect is seen as thin, and on another it is seen as wide.

Coronary artery laceration may occur, resulting acutely in tamponade and later in myocardial infarction.

Missiles within the Heart

Localization of a missile (e.g., bullet, bullet fragment, shotgun pellet, shrapnel) is important, because the decision to operate is based partly on its location.

Echocardiography may help localize a missile within the heart by imaging the location and motion ⁶:

• If the missile resides on the anterior surface of the heart and does not move, it is most likely in the pericardium or pericardial space

• If it moves as the right ventricle moves, then it is most likely embedded in the right ventricle.

Some missiles may be free within a cardiac chamber.

Bullets and shotgun pellets are conspicuous by their tail of reverberations.

Blunt Aortic Trauma

As many as one sixth of motor vehicle deaths are caused by aortic rupture.

Eighty percent of patients with aortic rupture die outright.

Twenty percent get to the hospital; of those who survive to the hospital, 70% may survive.

From 2% to 5% of patients with partial tears will develop pseudo-aneurysms (usually saccular), and half of those aneurysms will expand.

Any high-speed sudden deceleration may produce shearing at the junction of mobile and fixed portions of the aorta. Rarely, blast injury may cause aortic rupture.

Ninety percent of blunt injuries to the aorta involve either:

• The isthmus at the insertion of the ligamentum arteriosum

• The aorta at the level of the diaphragm

• The origin of the innominate artery

• The ascending portion of the aorta.

Lesions that may occur include the following:

• Aortic transsection

• Pseudoaneurysm

• Localized dissection

TEE has a major contribution to offer to the diagnosis of traumatic injury to the aorta.

Indications for Transesophageal Echocardiography in Cardiac Trauma

When the transthoracic echocardiographic study quality is not adequate

To exclude disruption of the aorta when other tests are equivocal

TEE is validated for the detection of traumatic disruption, but performing TEE in the setting of trauma may carry additional difficulties (e.g., cervical collar) and risks (e.g., loosened or broken teeth, cervical spine injury, possible esophageal injury).

BOX 25-1 Appropriateness Criteria and Indications for Cardiac Imaging Modalities for the Assessment of Cardiac Trauma

Transthoracic Echocardiography

ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography ⁷

Cardiac Trauma with TTE

Severe deceleration injury or chest trauma when valve injury, pericardial effusion, or cardiac injury are possible or suspected

Appropriateness criteria: A; median score: 9

Routine evaluation in the setting of mild chest trauma with no electrocardiographic changes or biomarker elevation

Appropriateness criteria: I; median score: 2

ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography

Conditions and Settings in which TEE Provides the Most Definitive Diagnosis in the Critically Ill and Injured

The hemodynamically unstable patient with suboptimal TTE images

The hemodynamically unstable patient on a ventilator

Major trauma or postoperative patients (unable to be positioned for adequate TTE)

Suspected aortic dissection

Suspected aortic injury

Other conditions in which TEE is superior

Recommendations for Echocardiography in the Critically Injured ^*

• Serious blunt or penetrating chest trauma (suspected pericardial effusion or tamponade)

• Mechanically ventilated multiple-trauma or chest-trauma patient

• Suspected pre-existing valvular or myocardial disease in the trauma patient

• The hemodynamically unstable multiple-injury patient without obvious chest trauma but with a mechanism of injury suggesting potential cardiac or aortic injury (deceleration or crush)

• Widening of the mediastinum, postinjury suspected aortic injury (TEE)

• Potential catheter, guidewire, pacer electrode, or pericardiocentesis needle injury with or without signs of tamponade

• Evaluation of hemodynamics in multiple-trauma or chest trauma patients with pulmonary artery catheter monitoring and data disparate with clinical situation

• Follow-up study on victims of serious blunt or penetrating trauma

• Suspected myocardial contusion in the hemodynamically stable patient with a normal ECG who has no abnormal cardiac/thoracic physical findings and/or lacks a mechanism of injury suggesting cardiovascular contusion

Transesophageal Echocardiography

ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography ⁷

Suspected acute aortic pathology including, but not limited to, dissection/transsection

Cardiac Computed Tomography

ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac CT ⁸

No specific entries

Nuclear

ACCF/ASNC/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging ⁹

No specific entries

Appropriateness criteria: A; appropriate; I, inappropriate; U, uncertain.

TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.

^* The use of TTE or TEE includes Doppler techniques when indicated and available and with appropriately trained and experienced sonographer and interpreter. TEE is indicated when TTE images are suboptimal. TEE often provides incremental information.

TABLE 25-1 Utility of Different Imaging Modalities and Cardiac Catheterization in the Assessment of Cardiac and Aortic Trauma

Modality	Pros	Cons/Caveats
Transthoracic Echocardiography	2D echocardiography • Portability and general availability are high, especially at trauma centers. • A ready means by which to establish the presence of pericardial fluid and tamponade • A fair test to identify myocardial contusion • Can identify some intracardiac traumatic lesions

• Concurrent hypovolemia can alter the signs of tamponade.

• The absence of a pericardial effusion does not exclude cardiac injury.

Doppler echocardiography: Is able to depict many cardiac flow disturbances (valvular disruption, VSDs, fistulae) secondary to penetrating and nonpenetrating trauma Transesophageal Echocardiography

• An excellent test for detection of the majority of cases of traumatic disruption of the aorta

• Can identify most specific intracardiac traumatic lesions

• Provides reliable imaging when TTE does not

• Concurrent maxillofacial trauma renders performing TEE more difficult, sometimes impossible.

Cardiac CT NA

• Although CT is the workhorse of general trauma imaging, especially of the aorta, the role of cardiac CT in trauma is unclear.

Cardiac MRI NA

• Affords little to most cases of cardiac trauma

Nuclear NA

• Affords little to most cases of cardiac trauma

Chest Radiography Standard initial test that yields considerable information

• Unlikely to recognize specific cardiac injury; more likely to recognize complications of cardiac injuries

• Pulmonary contusion and aspiration findings may confound the recognition of heart failure.

• Without a lateral view, it is difficult to localize projectiles within the heart.

• Will not image nonradiopaque projectiles

• Mediastinal hematomas are not synonymous with traumatic disruption of the aorta.

Cardiac Catheterization

• Contrast aortography is an established/standard test to evaluate traumatic aortic disruption.

• Catheterization and aortography are the vehicles by which to perform TEVAR for traumatic disruption of the aorta.

NA

2D, two-dimensional; NA, not applicable; TEE, transesophageal echocardiography; TEVAR, thoracic endovascular aortic repair; TTE, transthoracic echocardiography; VSD, ventral septal defect.

Figure 25-1 Stab wound in the apical area. The top images show parasternal long-axis views (diastole on the left, systole on the right). A small pericardial effusion is present. The diastolic image reveals a very small left atrium consistent with hypovolemia, possibly from the chest wound. In the middle images (diastole on the left, systole on the right), there is a thick pericardial clot under the left ventricle (LV). The LV cavity completely obliterates in systole. The lower images (diastole on the left, systole on the right) reveal a jet of flow at the very tip of the septum, seen in diastole and not in systole. Surgical inspection and review revealed a laceration of the left anterior descending coronary artery (LAD) at the apex, leading to intrapericardial hemorrhage and clot. LAD flow is more pulsatile in diastole, which is why the jet could be visualized in diastole, not systole.

Figure 25-2 Transesophageal echocardiographic image of a patient with stab wounds to the right and left anterior chest. The knife has sliced the mid-septum obliquely, resulting in a ventricular septal defect, revealed by color flow mapping. The right ventricle is dilated. There is no pericardial effusion, despite the penetrating trauma.

Figure 25-3 Stab wound to the left parasternum. Left: Parasternal short-axis view with color flow mapping demonstrating a jet of flow across the septum into the right ventricle. Right: Spectral Doppler demonstrates high-velocity flow through the traumatic ventricular septal defect.

Figure 25-4 Stab wound to the lower anterior left parasternum. Upper left: Posterior long-axis view shows a small- to moderate-sized pericardial effusion. Upper right: Parasternal short-axis image at the base of the heart. There is a turbulent jet in the posterior aortic root and part of the right atrium (RA). The RA is minimally compressed. Middle images: Apical four-chamber views (A4CVs) show a moderate-sized pericardial effusion with compression of the right ventricular (RV) wall, and a peculiar appearance to the RV free wall. Lower left: A4CV with color Doppler demonstrating a jet into the RA that extends into the RV. Lower right: The flow sampled in the jet is nearly continuous. A stab wound through the RV free wall, through the tricuspid orifice, and into the RA nicked the right sinus of Valsalva and produced an aortic-to-RA fistula with continuous flow.

Figure 25-5 Stab wound to the left lateral chest, with the patient in shock. Transesophageal echocardiography images. Upper images: A soft tissue mass is seen moving in association with the anterior mitral leaflet. Middle images: A soft tissue mass is moving with the anterior mitral leaflet. The right middle image strongly suggests a decapitated papillary muscle. Lower images: View of the traumatically severed papillary muscle (left) and resultant severe mitral regurgitation (right).

Figure 25-6 Gunshot injury to the right lateral chest seen on a transesophageal image. There is a small pericardial effusion, and an epicardial rind of clot (containing specular echoes). There is a prominent reverberation artifact arising from a gunshot pellet.

Figure 25-7 Gunshot to the leg, with embolization of the bullet via the profunda femoris vein into the right heart. The bullet is seen as an echogenic mass along the right lateral wall of the right ventricular cavity.

Figure 25-8 Stab wound to the mid–left anterior chest, resulting in left anterior descending coronary artery laceration/transaction and left-sided hemothorax. Left: Preoperative images; right: postoperative images. Upper images: diastolic; lower images: systolic. Note how preoperatively the septum does not thicken and the end-systolic cavity is large. Conversely, note how postoperatively the septum thickens and the end-systolic cavity size is small.

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