Cardiac Trauma

Published on 21/06/2015 by admin

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Last modified 21/06/2015

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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

Pericardial Sequelae

image Pericardial effusions

image Pericardial tamponade

• Should prompt consideration of rupture of the aorta or of a cardiac chamber

image Pneumopericardium

• Apparent as bright echoes with far-field shadowing, usually anteriorly (in a supine patient) seen in systole.
• Pneumopericardium and subcutaneous emphysema often produce too much artifact for the heart to be visible from the chest wall surface—TEE may help as the esophagus courses between the pulmonary veins posteriorly and is partially extrapericardial, allowing visualization of the heart even with pneumopericardium.

image Pericardial rupture, with/without herniation

Myocardial Sequelae

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

image Echocardiographic features of myocardial contusion include

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

image 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

image 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

image 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

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

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

Penetrating Cardiac Trauma

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

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

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

image 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.

image Bullet wounds commonly involve the left ventricle.

image Puncture of a cardiac chamber may result in the following:

• Pericardial effusion
• Pericardial tamponade
• Possible intracardiac communication/fistula
• Valve disruption

image Penetrating cardiac wounds often are multiple.

image 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.

image 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.

image Echocardiography may help localize a missile within the heart by imaging the location and motion6:

• 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.

image Some missiles may be free within a cardiac chamber.

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

Blunt Aortic Trauma

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

image Eighty percent of patients with aortic rupture die outright.

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

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

image 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.

image Ninety percent of blunt injuries to the aorta involve either:

• The isthmus at the insertion of the ligamentum arteriosum
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