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Griffard J, Kodadek LM. Management of Blunt Chest Trauma. Surg Clin North Am 2024; 104:343-354. [PMID: 38453306 DOI: 10.1016/j.suc.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries.
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Affiliation(s)
- Jared Griffard
- Division of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, 330 Cedar Street, Boardman Building 310, New Haven, CT 06510, USA
| | - Lisa M Kodadek
- Division of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, 330 Cedar Street, Boardman Building 310, New Haven, CT 06510, USA.
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2
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Maayah M, Grubman S, Allen S, Ye Z, Park DY, Vemmou E, Gokhan I, Sun WW, Possick S, Kwan JM, Gandhi PU, Hu JR. Clinical Interpretation of Serum Troponin in the Era of High-Sensitivity Testing. Diagnostics (Basel) 2024; 14:503. [PMID: 38472975 DOI: 10.3390/diagnostics14050503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 03/14/2024] Open
Abstract
Cardiac troponin (Tn) plays a central role in the evaluation of patients with angina presenting with acute coronary syndrome. The advent of high-sensitivity assays has improved the analytic sensitivity and precision of serum Tn measurement, but this advancement has come at the cost of poorer specificity. The role of clinical judgment is of heightened importance because, more so than ever, the interpretation of serum Tn elevation hinges on the careful integration of findings from electrocardiographic, echocardiographic, physical exam, interview, and other imaging and laboratory data to formulate a weighted differential diagnosis. A thorough understanding of the epidemiology, mechanisms, and prognostic implications of Tn elevations in each cardiac and non-cardiac etiology allows the clinician to better distinguish between presentations of myocardial ischemia and myocardial injury-an important discernment to make, as the treatment of acute coronary syndrome is vastly different from the workup and management of myocardial injury and should be directed at the underlying cause.
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Affiliation(s)
- Marah Maayah
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Scott Grubman
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephanie Allen
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Zachary Ye
- Department of Internal Medicine, Temple University Medical Center, Philadelphia, PA 19140, USA
| | - Dae Yong Park
- Department of Internal Medicine, Cook County Hospital, Chicago, IL 60612, USA
| | - Evangelia Vemmou
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Ilhan Gokhan
- Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Wendy W Sun
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Stephen Possick
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Jennifer M Kwan
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
| | - Parul U Gandhi
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
- Department of Cardiology, Veterans Affairs Connecticut Health Care System, West Haven, CT 06516, USA
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT 06520, USA
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3
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Calzone MR, Grossman MD. Blunt cardiac injury in the hemodynamically stable patient. JAAPA 2024; 37:35-38. [PMID: 38270655 DOI: 10.1097/01.jaa.0000997692.54661.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
ABSTRACT Blunt cardiac injury (BCI) describes a spectrum of problems including severe, potentially life-threatening injuries from trauma. Pericardial effusion is an example of a BCI that has generally been assumed to imply serious underlying injury to the heart and should be considered hemopericardium until proven otherwise. A standard of care has been established to screen for BCI and treat hemodynamically unstable patients with an acute pericardial effusion presumably related to BCI. Less agreement exists on definitive treatment for hemodynamically stable patients with pericardial effusion after blunt cardiac trauma. This case study explores a new treatment for small to moderate hemopericardium in a stable patient after BCI.
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Affiliation(s)
- Mollie R Calzone
- At St. Luke's Hospital/Southcoast Health in New Bedford, Mass., Mollie R. Calzone practices in trauma surgery and acute care surgery and Michael D. Grossman is the chief of acute care surgery and trauma medical director. The authors have disclosed no potential conflicts of interest, financial or otherwise
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4
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Misir HD, Demir N, Kasimzade F, Yahşi C. A case of post traumatic mitral chordae rupture mimicking acute respiratory distress syndrome. World J Emerg Med 2024; 15:322-324. [PMID: 39050215 PMCID: PMC11265627 DOI: 10.5847/wjem.j.1920-8642.2024.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 02/29/2024] [Indexed: 07/27/2024] Open
Affiliation(s)
- Hülya Deniz Misir
- Intensive Care Department, Ankara Bilkent City Hospital, Ankara 06800, Turkiye
| | - Nalan Demir
- Intensive Care Department, University of Health Sciences Ankara Bilkent City Hospital, Ankara 06800, Turkiye
| | - Ferit Kasimzade
- Cardiovascular Surgery Department, Ankara Bilkent City Hospital, Ankara 06800, Turkiye
| | - Cansu Yahşi
- Pulmonary Medicine Department, University of Health Sciences Ankara Bilkent City Hospital, Ankara 06800, Turkiye
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Alfraidy D, Aldarsouni FG, Dagestani H, Al Ramahi GZ. An Emergency Adaptation of Anterolateral and Clamshell Thoracotomy for Blunt Traumatic Right Atrial Rupture: A Case Report. Cureus 2023; 15:e49208. [PMID: 38143623 PMCID: PMC10739582 DOI: 10.7759/cureus.49208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 12/26/2023] Open
Abstract
The high mortality rate of blunt cardiac injuries is primarily due to the condition's severity and the challenges associated with pre-hospital survival. The absence of definitive diagnostic modalities necessitates prompt and adaptable surgical intervention. We present an 18-year-old male who sustained a right atrial blunt traumatic cardiac rupture following a motor vehicle collision. Despite initial stabilization with blood products and vasopressors and the necessitated emergent surgical exploration, the case required various surgical techniques, including anterolateral followed by an extension to a clamshell thoracotomy and laparotomy to manage the complex cardiac rupture and associated injuries. Furthermore, it underscores the critical nature of surgical incision in such patients and its impact on the overall prognosis. The successful outcome, highlighted by intraoperative decision-making and proper postoperative care, demonstrates that with timely and adaptable surgical approaches, even the most severe cases of traumatic blunt cardiac ruptures can be managed effectively.
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Affiliation(s)
- Doaa Alfraidy
- Department of Surgery, King Saud University Medical City, Riyadh, SAU
| | | | - Hatoon Dagestani
- Department of Surgery, King Saud University Medical City, Riyadh, SAU
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Stanley ME, De Klerk P, Abbott B, Najibi M, Monaghan S, Hunter C, Sodha NR. Left Ventricular Septal Avulsion in the Setting of Blunt Cardiac Injury. Ann Thorac Surg 2023; 116:e9-e12. [PMID: 36063884 DOI: 10.1016/j.athoracsur.2022.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/25/2022] [Accepted: 08/21/2022] [Indexed: 11/18/2022]
Abstract
A 23-year-old man sustained blunt cardiac injury after a motor vehicle collision resulting in left ventricular septal avulsion, ruptured chordae tendineae, and moderate to severe tricuspid regurgitation that necessitated operative intervention. The patient underwent successful resection of a prolapsed avulsed septal wall segment and concomitant tricuspid valve repair.
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Affiliation(s)
- Madigan E Stanley
- Division of Cardiothoracic Surgery, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Pieter De Klerk
- Division of Cardiology, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Brian Abbott
- Division of Cardiology, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Mehran Najibi
- Division of Pathology, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Sean Monaghan
- Division of Trauma and Critical Care, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Caroline Hunter
- Division of Anesthesiology, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Neel R Sodha
- Division of Cardiothoracic Surgery, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island.
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Tsitsipanis C, Miliaraki M, Michailou M, Geromarkaki E, Spanaki AM, Nyktari V, Yannopoulos A, Moustakis N, Ilia S. Severe and Atypical Presentation of Takotsubo Cardiomyopathy in a Pediatric Patient after a Serious Crash Injury-Case Report and Literature Review. Pediatr Rep 2023; 15:396-402. [PMID: 37489410 PMCID: PMC10366713 DOI: 10.3390/pediatric15030036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/24/2023] [Accepted: 06/27/2023] [Indexed: 07/26/2023] Open
Abstract
Takotsubo cardiomyopathy is an uncommon clinical entity in children, resulting in severe but sometimes reversible systolic dysfunction of the left ventricle. This condition is triggered by multiple emotional or physical stressors, while neurogenic stress cardiomyopathy after brain injuries has become increasingly recognized in children over the past few years. We report the case of an 11-year-old child with an atypical clinical presentation after a serious car crash accident. An initial computed tomography scan revealed an acute epidural hematoma, which was immediately treated by an emergency craniotomy. During the patient's following pediatric intensive care unit hospitalization, severe hemodynamic instability was observed, leading to gradually higher doses of vasopressors for circulatory support. On echocardiography, the patient had signs of severe cardiac contractility compromise, with characteristic pattern of regional wall motion abnormalities of the left ventricle, which, in combination with seriously elevated cardiac enzymes, electrocardiographic (ECG) abnormalities and continuous thermodilution hemodynamic monitoring (PICCO) findings, led to intensification of inotropic support and to the diagnosis of takotsubo cardiomyopathy. Despite supportive measures, the patient developed multiorgan failure and succumbed to their serious illness. For this atypical case, extracorporeal membrane oxygenation (ECMO) was addressed as an option for the seriously failing heart, but due to the extremely high risk of intracranial bleeding, it could not be used for this patient's treatment. In conclusion, Takotsubo cardiomyopathy should be suspected in pediatric cases of cardiac dysfunction after serious injuries or stress conditions.
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Affiliation(s)
- Christos Tsitsipanis
- Neurosurgery Department, University Hospital of Heraklion, 70013 Heraklion, Greece
| | - Marianna Miliaraki
- Pediatric Intensive Care Unit, University Hospital of Heraklion, 70013 Heraklion, Greece
| | - Maria Michailou
- Pediatric Department, University Hospital of Heraklion, 70013 Heraklion, Greece
| | - Elisavet Geromarkaki
- Pediatric Intensive Care Unit, University Hospital of Heraklion, 70013 Heraklion, Greece
| | - Anna-Maria Spanaki
- Pediatric Intensive Care Unit, University Hospital of Heraklion, 70013 Heraklion, Greece
| | - Vasilia Nyktari
- Anaesthesiology Department, University Hospital of Heraklion, 70013 Heraklion, Greece
| | - Andreas Yannopoulos
- Neurosurgery Department, University Hospital of Heraklion, 70013 Heraklion, Greece
| | - Nikolaos Moustakis
- Neurosurgery Department, University Hospital of Heraklion, 70013 Heraklion, Greece
| | - Stavroula Ilia
- Pediatric Intensive Care Unit, University Hospital of Heraklion, 70013 Heraklion, Greece
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Kyriazidis IP, Jakob DA, Vargas JAH, Franco OH, Degiannis E, Dorn P, Pouwels S, Patel B, Johnson I, Houdlen CJ, Whiteley GS, Head M, Lala A, Mumtaz H, Soler JA, Mellor K, Rawaf D, Ahmed AR, Ahmad SJS, Exadaktylos A. Accuracy of diagnostic tests in cardiac injury after blunt chest trauma: a systematic review and meta-analysis. World J Emerg Surg 2023; 18:36. [PMID: 37245048 DOI: 10.1186/s13017-023-00504-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/19/2023] [Indexed: 05/29/2023] Open
Abstract
INTRODUCTION The diagnosis of cardiac contusion, caused by blunt chest trauma, remains a challenge due to the non-specific symptoms it causes and the lack of ideal tests to diagnose myocardial damage. A cardiac contusion can be life-threatening if not diagnosed and treated promptly. Several diagnostic tests have been used to evaluate the risk of cardiac complications, but the challenge of identifying patients with contusions nevertheless remains. AIM OF THE STUDY To evaluate the accuracy of diagnostic tests for detecting blunt cardiac injury (BCI) and its complications, in patients with severe chest injuries, who are assessed in an emergency department or by any front-line emergency physician. METHODS A targeted search strategy was performed using Ovid MEDLINE and Embase databases from 1993 up to October 2022. Data on at least one of the following diagnostic tests: electrocardiogram (ECG), serum creatinine phosphokinase-MB level (CPK-MB), echocardiography (Echo), Cardiac troponin I (cTnI) or Cardiac troponin T (cTnT). Diagnostic tests for cardiac contusion were evaluated for their accuracy in meta-analysis. Heterogeneity was assessed using the I2 and the QUADAS-2 tool was used to assess bias of the studies. RESULTS This systematic review yielded 51 studies (n = 5,359). The weighted mean incidence of myocardial injuries after sustaining a blunt force trauma stood at 18.3% of cases. Overall weighted mean mortality among patients with blunt cardiac injury was 7.6% (1.4-36.4%). Initial ECG, cTnI, cTnT and transthoracic echocardiography TTE all showed high specificity (> 80%), but lower sensitivity (< 70%). TEE had a specificity of 72.1% (range 35.8-98.2%) and sensitivity of 86.7% (range 40-99.2%) in diagnosing cardiac contusion. CK-MB had the lowest diagnostic odds ratio of 3.598 (95% CI: 1.832-7.068). Normal ECG accompanied by normal cTnI showed a high sensitivity of 85% in ruling out cardiac injuries. CONCLUSION Emergency physicians face great challenges in diagnosing cardiac injuries in patients following blunt trauma. In the majority of cases, joint use of ECG and cTnI was a pragmatic and cost-effective approach to rule out cardiac injuries. In addition, TEE may be highly accurate in identifying cardiac injuries in suspected cases.
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Affiliation(s)
| | - Dominik A Jakob
- Department of Emergency Medicine, Inselspital University Hospital of Bern, Bern, Switzerland
| | - Juliana Alexandra Hernández Vargas
- Department of Global Public Health and Bioethics, Julius Center for Health Sciences and Primary Care, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
| | - Oscar H Franco
- Department of Global Public Health and Bioethics, Julius Center for Health Sciences and Primary Care, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
| | - Elias Degiannis
- Department of Emergency Medicine, Inselspital University Hospital of Bern, Bern, Switzerland
- Department of Surgery, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Patrick Dorn
- Department of Thoracic Surgery, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Sjaak Pouwels
- Department of General, Abdominal and Minimally Invasive Surgery, Helios Klinikum Krefeld, Krefeld, Germany
| | - Bijendra Patel
- Department of General Surgery, Barts Cancer Institute, London, UK
| | - Ian Johnson
- Department of Anaesthesia & Intensive Care, Betsi Cadwaladr University Health Board, Bodelwyddan, Wales, UK
| | - Christopher John Houdlen
- Department of General Surgery, Betsi Cadwaladr University Health Board, Bangor, LL57 2PW, Wales, UK
| | - Graham S Whiteley
- Department of General Surgery, Betsi Cadwaladr University Health Board, Bangor, LL57 2PW, Wales, UK
| | - Marion Head
- Department of General Surgery, Betsi Cadwaladr University Health Board, Bangor, LL57 2PW, Wales, UK
| | - Anil Lala
- Department of General Surgery, Betsi Cadwaladr University Health Board, Bangor, LL57 2PW, Wales, UK
| | - Haroon Mumtaz
- Department of Trauma and Orthopaedic Surgery, Betsi Cadwaladr University Health Board, Bangor, Wales, UK
| | - J Agustin Soler
- Department of Trauma and Orthopaedic Surgery, Betsi Cadwaladr University Health Board, Bangor, Wales, UK
| | - Katie Mellor
- Department of General Surgery, Betsi Cadwaladr University Health Board, Bangor, LL57 2PW, Wales, UK
| | - David Rawaf
- Department of Surgery, South West London Orthopaedic Centre, London, UK
| | - Ahmed R Ahmed
- Department of General Surgery, Imperial College London, London, UK
| | - Suhaib J S Ahmad
- Department of Emergency Medicine, Inselspital University Hospital of Bern, Bern, Switzerland.
- Department of General Surgery, Betsi Cadwaladr University Health Board, Bangor, LL57 2PW, Wales, UK.
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital University Hospital of Bern, Bern, Switzerland
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Kelly KL, Lin PT, Basso C, Bois M, Buja LM, Cohle SD, d'Amati G, Duncanson E, Fallon JT, Firchau D, Fishbein G, Giordano C, Leduc C, Litovsky SH, Mackey-Bojack S, Maleszewski JJ, Michaud K, Padera RF, Papadodima SA, Parsons S, Radio SJ, Rizzo S, Roe SJ, Romero M, Sheppard MN, Stone JR, Tan CD, Thiene G, van der Wal AC, Veinot JP. Sudden cardiac death in the young: A consensus statement on recommended practices for cardiac examination by pathologists from the Society for Cardiovascular Pathology. Cardiovasc Pathol 2023; 63:107497. [PMID: 36375720 DOI: 10.1016/j.carpath.2022.107497] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022] Open
Abstract
Sudden cardiac death is, by definition, an unexpected, untimely death caused by a cardiac condition in a person with known or unknown heart disease. This major international public health problem accounts for approximately 15-20% of all deaths. Typically more common in older adults with acquired heart disease, SCD also can occur in the young where the cause is more likely to be a genetically transmitted process. As these inherited disease processes can affect multiple family members, it is critical that these deaths are appropriately and thoroughly investigated. Across the United States, SCD cases in those less than 40 years of age will often fall under medical examiner/coroner jurisdiction resulting in scene investigation, review of available medical records and a complete autopsy including toxicological and histological studies. To date, there have not been consistent or uniform guidelines for cardiac examination in these cases. In addition, many medical examiner/coroner offices are understaffed and/or underfunded, both of which may hamper specialized examinations or studies (e.g., molecular testing). Use of such guidelines by pathologists in cases of SCD in decedents aged 1-39 years of age could result in life-saving medical intervention for other family members. These recommendations also may provide support for underfunded offices to argue for the significance of this specialized testing. As cardiac examinations in the setting of SCD in the young fall under ME/C jurisdiction, this consensus paper has been developed with members of the Society of Cardiovascular Pathology working with cardiovascular pathology-trained, practicing forensic pathologists.
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Affiliation(s)
| | | | - Cristina Basso
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health - University of Padua, Padua, Italy
| | | | | | | | | | - Emily Duncanson
- Jesse E. Edwards Registry of Cardiovascular Disease, St. Paul, MN, USA
| | | | | | | | | | | | | | | | | | - Katarzyna Michaud
- University Center of Legal Medicine Lausanne - Geneva, Lausanne University Hospital and University of Lausanne, Switzerland
| | | | | | - Sarah Parsons
- Victorian Institute of Forensic Medicine, Melbourne, Australia
| | | | - Stefania Rizzo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health - University of Padua, Padua, Italy
| | | | | | - Mary N Sheppard
- St. George's Medical School, University of London, London, United Kingdom
| | | | | | - Gaetano Thiene
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health - University of Padua, Padua, Italy
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Pulido JA, Reyes M, Enríquez J, Padilla L, Pérez C, Cabrera‐Vargas LF, Lozada‐Martinez ID, Pedraza M, Narvaez‐Rojas AR. Predicting mortality in penetrating cardiac trauma in developing countries through a new classification: Validation of the Bogotá classification. Health Sci Rep 2022; 5:e915. [PMID: 36381412 PMCID: PMC9662691 DOI: 10.1002/hsr2.915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Penetrating chest trauma (PCT) represents 10% of worldwide mortality, with developing countries counting as some of the most affected by high mortality rates due to cardiac trauma. Colombia is considered one of the most violent countries due to the high mortality rate associated with war and crime, hence the validation of an own classification for penetrating cardiac injuries (PCI) is mandatory. Methods Retrospective cross‐sectional study which included adult patients with PCIs at a level 4 trauma center in Colombia, between January 2018 and April 2020. We used our own system (Bogotá Classification) and compared it with traditional systems (e.g., Ivatury's, OIS‐AAST), by analyzing the mechanism of injury (MOI), the hemodynamic status of the patient at admission, the inpatient management, the individual outcomes, and some demographic variables. Bivariate statistical analysis, spearman correlation, and logistic regression were performed. Results Four hundred and ninety‐nine patients were included. Bivariate analysis demonstrated a significant relationship between mortality and hemodynamic state, MOI, its location and degree of lesion, cardiac/vessel injury, cardiac tamponade, time between injury and medical care, fluid reanimation, as well as the Ivatury's classification and the new classification (p < 0.005). The adequate correlation between Ivatury's and Bogotá classification supports the latter's clinical utility for patients presenting with PCI. Likewise, logistic regression showed a statistically significant association among mortality rates (p < 0.005). Conclusions The Bogotá classification showed similar performance to the Ivatury's classification, correlating most strongly with mortality. This scale could be replicated in countries with similar social and economic contexts.
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Affiliation(s)
- Jean A. Pulido
- Department of Surgery, School of Medicine Universidad El Bosque Bogotá Colombia
| | - Mariana Reyes
- Department of Surgery, School of Medicine Universidad El Bosque Bogotá Colombia
| | - Jessica Enríquez
- Department of Surgery, School of Medicine Universidad El Bosque Bogotá Colombia
| | - Laura Padilla
- Department of Surgery, School of Medicine Universidad El Bosque Bogotá Colombia
| | - Carlos Pérez
- Department of Surgery, School of Medicine Universidad El Bosque Bogotá Colombia
| | - Luis F. Cabrera‐Vargas
- Department of Surgery, School of Medicine Universidad El Bosque Bogotá Colombia
- Department of Surgery, School of Medicine Pontificia Universidad Javeriana Bogotá Colombia
- Medical and Surgical Research Center, Future Surgeons Chapter Colombian Surgery Association Bogotá Colombia
| | - Ivan D. Lozada‐Martinez
- Medical and Surgical Research Center, Future Surgeons Chapter Colombian Surgery Association Bogotá Colombia
- International Coalition on Surgical Research Universidad Nacional Autónoma de Nicaragua Managua Nicaragua
- Grupo Prometheus y Biomedicina Aplicada a las Ciencias Clínicas, School of Medicine Universidad de Cartagena Cartagena Colombia
| | - Mauricio Pedraza
- Department of Surgery, School of Medicine Universidad El Bosque Bogotá Colombia
| | - Alexis R. Narvaez‐Rojas
- International Coalition on Surgical Research Universidad Nacional Autónoma de Nicaragua Managua Nicaragua
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Tang CC, Huang JF, Kuo LW, Cheng CT, Liao CH, Hsieh CH, Fu CY. The highest troponin I level during admission is associated with mortality in blunt cardiac injury patients. Injury 2022; 53:2960-2966. [PMID: 35750532 DOI: 10.1016/j.injury.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/28/2022] [Accepted: 06/08/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cardiac troponin I (cTnI) levels are usually measured in primary evaluations of blunt cardiac injury (BCI) patients. We evaluated the associations of cTnI levels with the outcomes of BCI patients at different times. METHODS From 2015 to 2019, blunt chest trauma patients with elevated cTnI levels were compared with patients without elevated cTnI levels using propensity score matching (PSM) to minimize selection bias. The cTnI levels at different times in the survivors and nonsurvivors were compared. RESULTS A total of 2,287 blunt chest trauma patients were included, and 57 (2.5%) of the patients had BCIs. PSM showed that patients with and without elevated cTnI levels had similar mortality rates (13.0% vs. 11.1%, p-value = 0.317], hospital lengths of stay (LOSs) [17.3 (14.4) vs. 15.5 (22.2) days, p-value = 0.699] and intensive care unit (ICU) LOSs [7.7 (12.1) vs. 6.4 (15.4) days, p-value = 0.072]. Among the BCI patients, nonsurvivors had a significantly higher highest cTnI level during the observation period than survivors. Additionally, patients who needed surgical intervention had significantly higher highest cTnI levels than patients who did not. CONCLUSIONS An elevated cTnI level is insufficient for the evaluation of BCI and the determination of the need for further treatment. The highest cTnI level during the observation period may be related to mortality and the need for surgery in BCI patients.
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Affiliation(s)
- Chia-Chun Tang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Jen-Fu Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Ling-Wei Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan.
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12
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Kumar A, Shiwalkar N, Bhate S, Keshavamurthy S. Management of Thoracic and Cardiac Trauma: A Case Series and Literature Review. Cureus 2022; 14:e26465. [PMID: 35800197 PMCID: PMC9246353 DOI: 10.7759/cureus.26465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 11/05/2022] Open
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Sampson B, Hammers J, Stram M. Forensic aspects of cardiovascular pathology. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00003-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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14
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Dou LW, Du Z, Zhu JH, Wang TB. Changes and significance of serum troponin in trauma patients: A retrospective study in a level I trauma center. World J Emerg Med 2022; 13:27-31. [PMID: 35003412 PMCID: PMC8677921 DOI: 10.5847/wjem.j.1920-8642.2022.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 10/12/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Elevated troponin I (TnI) is common among trauma patients. TnI is an indicator of myocardial injury, but clinical diagnosis of blunt cardiac injury cannot be based solely on an increase in TnI. Therefore, this study aims to explore the changes and clinical significance of serum TnI in trauma patients. METHODS The clinical data of consecutive trauma patients admitted to our trauma center between July 1, 2017 and July 31, 2020 were retrospectively analyzed. According to TnI levels within 24 hours of admission, patients were divided into the elevated and normal TnI groups. According to the TnI levels after 7 days of admission, a graph depicting a change in trend was drawn and then analyzed whether TnI was related to in-hospital mortality. RESULTS A total of 166 patients (69 and 97 cases with elevated and normal TnI, respectively) were included in this study. The average hospital stay, intensive care time, mechanical ventilation time, and in-hospital mortality were higher in the elevated TnI group than in the normal TnI group (P<0.05). The TnI level of trauma patients gradually increased after admission and peaked at 48 hours (7.804±1.537 ng/mL). Subsequently, it decreased, and then recovered to normal within 7 days. However, 13 patients did not recover. Logistic regression analysis revealed that abnormal TnI at 7 days was independently related to in-hospital mortality. CONCLUSIONS Trauma patients with elevated TnI levels may have a worse prognosis. Monitoring the changes in serum TnI is important, which can reflect the prognosis better than the TnI measured immediately after admission.
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Affiliation(s)
- Li-wen Dou
- Emergency Department, Peking University People’s Hospital, Beijing 100044, China
| | - Zhe Du
- Trauma Center, Peking University People’s Hospital, Beijing 100044, China
| | - Ji-hong Zhu
- Emergency Department, Peking University People’s Hospital, Beijing 100044, China
| | - Tian-bing Wang
- Trauma Center, Peking University People’s Hospital, Beijing 100044, China
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15
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Patel KM, Kumar NS, Desai RG, Mitrev L, Trivedi K, Krishnan S. Blunt Trauma to the Heart: A Review of Pathophysiology and Current Management. J Cardiothorac Vasc Anesth 2021; 36:2707-2718. [PMID: 34840072 DOI: 10.1053/j.jvca.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/09/2021] [Accepted: 10/13/2021] [Indexed: 11/11/2022]
Abstract
Blunt cardiac injury (BCI), defined as an injury to the heart from blunt force trauma, ranges from minor to life-threatening. The majority of BCIs are due to motor vehicle accidents; however, injuries caused by falls, blasts, and sports-related injuries also can be sources of BCI. A significant proportion of patients with BCI do not survive long enough to receive medical care, succumbing to their injuries at the scene of the accident. Additionally, patients with blunt trauma often have coexisting injuries (brain, spine, orthopedic) that can obscure the clinical picture; therefore, a high degree of suspicion often is required to diagnose BCI. Traditionally, hemodynamically stable injuries suspicious for BCI have been evaluated with electrocardiograms and chest radiographs, whereas hemodynamically unstable BCIs have received operative intervention. More recently, computed tomography and echocardiography increasingly have been utilized to identify injuries more rapidly in hemodynamically unstable patients. Transesophageal echocardiography can play an important role in the diagnosis and management of several BCIs that require operative repair. Close communication with the surgical team and access to blood products for potentially massive transfusion also play key roles in maintaining hemodynamic stability. With proper surgical and anesthetic care, survival in cases involving urgent cardiac repair can reach 66%-to-75%. This narrative review focuses on the types of cardiac injuries that are caused by blunt chest trauma, the modalities and techniques currently used to diagnose BCI, and the perioperative management of injuries that require surgical correction.
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Affiliation(s)
- Kinjal M Patel
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ.
| | - Nakul S Kumar
- Cardiothoracic and Critical Care Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Ronak G Desai
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ
| | - Ludmil Mitrev
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ
| | - Keyur Trivedi
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ
| | - Sandeep Krishnan
- Adult Cardiothoracic Anesthesiology, Wayne State University School of Medicine Pontiac, MI
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16
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Zhu H, Zhang C, Zhao W, Xu X, Shi Y, Zhao G. A rare survival case of blunt left ventricular rupture caused by a low-energy pedestrian collision with a stationary forklift: a case report. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1028. [PMID: 34277828 PMCID: PMC8267266 DOI: 10.21037/atm-21-3031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/21/2021] [Indexed: 11/06/2022]
Abstract
Blunt cardiac rupture (BCR) is a rare injury with a high mortality rate. It is usually caused by high-energy traumatic accidents, such as motor vehicle collisions. For the first time, we report a rare case of BCR caused by a pedestrian collision with a stationary motor vehicle, which is a low-energy traumatic accident. This is also the first surgical survival BCR case to be reported of a contralateral ventricular rupture at the direct stress site. A 45-year-old formerly healthy Chinese woman, with no family history of heart disease, was walking in a hurry when she accidentally hit a forklift that was parked on the side of the road. The patient gradually lost consciousness, and was admitted to Hwa Mei Hospital Emergency Center 1 hour later. An ultrasound revealed a pericardial effusion about 1 cm deep and a small amount of peritoneal –35 effusion. Emergency computed tomography (CT) scans revealed a small amount of fluid accumulation in the right thoracic cavity, fractures of the 5th and 6th ribs on the right side, and pericardial effusion. The patient’s blood pressure remained unstable after 1 hour of endotracheal intubation, B-ultrasound-guided pericardiocentesis, and antishock therapy; thus, open-heart surgery was deemed necessary. A large amount of blood accumulation was found in the intact pericardium. There was a small blood clot at the apex of the left ventricle near the interventricular septum. The removal of the clot revealed a tear about 1 cm in diameter. The patient’s BCR was successfully repaired in the surgery. By the end of the 18-month follow-up period, the patient was found to have recovered well without significant complications. The internal mechanism of the case report was deceleration. Prompt diagnosis and emergency thoracotomy when BCR is suspected are key to rescuing patients, regardless of whether the accident is high energy or low energy, or if there is evidence of a direct force acting on the precordium, or the presence of pericardial rupture.
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Affiliation(s)
- Huangkai Zhu
- Department of Cardiothoracic Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences (Ningbo No. 2 Hospital), Ningbo, China.,Medical School of Ningbo University, Ningbo, China
| | - Chenxu Zhang
- Department of Cardiothoracic Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences (Ningbo No. 2 Hospital), Ningbo, China.,Medical School of Ningbo University, Ningbo, China
| | - Weidi Zhao
- Department of Cardiothoracic Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences (Ningbo No. 2 Hospital), Ningbo, China.,Medical School of Ningbo University, Ningbo, China
| | - Xiang Xu
- Department of Cardiothoracic Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences (Ningbo No. 2 Hospital), Ningbo, China
| | - Yiting Shi
- Department of Cardiothoracic Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences (Ningbo No. 2 Hospital), Ningbo, China
| | - Guofang Zhao
- Department of Cardiothoracic Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences (Ningbo No. 2 Hospital), Ningbo, China.,Medical School of Ningbo University, Ningbo, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
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17
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Longfellow E, Aberle C, Lamelas J, Fabbro M, Johnson E, Yu S, Augoustides JG, Fernando RJ. Traumatic Injury of the Tricuspid Valve-Navigating the Challenges in Diagnosis and Management. J Cardiothorac Vasc Anesth 2021; 36:906-914. [PMID: 34226110 DOI: 10.1053/j.jvca.2021.05.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Eric Longfellow
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Corinne Aberle
- Department of Cardiothoracic Surgery, Miller School of Medicine, University of Miami, Miami, FL
| | - Joseph Lamelas
- Department of Cardiothoracic Surgery, Miller School of Medicine, University of Miami, Miami, FL
| | - Michael Fabbro
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Eric Johnson
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Soojie Yu
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Scottsdale, AZ
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rohesh J Fernando
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC.
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18
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Janicic D, Simatovic M, Roljic Z, Krupljanin L, Karabeg R. Urgent Surgical Treatment of Blunt Chest Trauma Followed by Cardiac and Pericardial Injuries. Med Arch 2021; 74:115-118. [PMID: 32577052 PMCID: PMC7296422 DOI: 10.5455/medarh.2020.74.115-118] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Introduction Widespread opinion that penetrating chest injuries are more urgent, in terms of treatment and care, contributed to underestimation of the urgency of blunt chest trauma, which in most cases is treated conservatively. It remains an open question frequency when the injuries of the heart and pericardium are not timely diagnosed and surgically treated. Aim To demonstrate the importance of well-timed surgical treatment of blunt chest trauma, when coupled with cardiac and pericardial injuries. Methods At the Thoracic Surgery Clinic of the University Clinical Centre Banja Luka, Bosnia and Herzego vina, during period of 10 years (01.01. 2008 - 31.01.2018.), the total of 66 patients were treated for urgent thoracotomy due to clinically and radiologically unclear findings after blunt chest trauma. In general, diagnostic examinations, apart from laboratory analysis, included radiological imaging and Multi Slice Computed Tomography (MSCT) of the chest, followed by an ultrasound of the heart in cases when sternum was injured or when pericardial tamponade was suspected. Results presented in the study where obtained from the retrospective analysis of patients data. This work presents a retrospective observational cross-sectional study, which results in the assessment of the correctness of a particular diagnostic test. Statistical methods used descriptive statistics, counting measures (frequencies and percentages), central tendency measures (arithmetic mean), variability measures (standard deviation). Results Sixty six patients were treated with urgent thoracotomy after a blunt trauma of the chest due to the unclear clinical and radiological finding. In the case of 11 patients (10 men and 1 woman), presenting 16.6% of the total sample, pericardial and cardiac injuries were detected and treated intraoperatively. Further, in the case of the one patient, pericardiotomy and suturing of the right heart chamber where performed, with the creation of a pericardial window. Transthoracic echocardiogram was not used as the primary screening module, but rather as a diagnostic test for patients who had unexplained hypotension and arrhythmia. Radiographs of the chest showed cardiomegaly with or without epicardial fat pad sign suggesting a pericardial effusion. Conclusion Blunt cardiac and pericardial injuries represent a serious therapeutic problem, which, if not treated properly, result in a high mortality rate. Echocardiography is the primary diagnostic method for initial detection of pericardial effusion. Pericardial fluid first accumulates posterior to the heart, when the patient is examined in the supine position. As the effusion increases, it extends laterally and with large effusions the echo-free space expands to surround the entire heart. The size of the effusion may be graded as small ( echo free spaces in diastole <10 mm, corresponding to approxymately 300 ml), moderate (10-20 mm, corresponding to 500 ml), and large ( >20 mm, corresponding to >700 ml). When the ability of the pericardium to stretch is exceeded by rapid or massive accumulation of fluid, any additional fluid causes the pressure with the pericardial sac. Early recognition, pericardiotomy with pericardial window creation and/or ventricular rupture suture remain the "gold standard" in the treatment of blunt cardiac and pericardial injuries.
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Affiliation(s)
- Dusan Janicic
- Clinic for Thoracic Surgery, University Clinical Center Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Milan Simatovic
- Clinic for General and Abdominal Surgery, University Clinical Center Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Zoran Roljic
- Clinic for Vascular Surgery, University Clinical Center Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Ljiljana Krupljanin
- Clinic for Thoracic Surgery, University Clinical Center Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Reuf Karabeg
- Private Clinic "Karabeg" Sarajevo, Bosnia and Herzegovina.,Faculty of Medicine,University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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19
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TONG FANG, LAN FENGCHONG, CHEN JIQING, LI XIONG. EFFECT OF STEERING WHEEL HEIGHT AND INCLINATION ANGLE ON BLUNT CARDIAC INJURY DURING THE THORAX-TO-STEERING WHEEL IMPACT. J MECH MED BIOL 2021. [DOI: 10.1142/s0219519421500135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Blunt cardiac injury (BCI) in the traffic accidents usually causes serious consequences like heart failure or even death, and the impact of steering wheel to the thorax is one of the main causes of blunt heart injury. Therefore, more realistic heart models are needed to predict the biomechanical response and related injury of the heart during a thorax-to-steering wheel impact. This study developed three-dimensional finite element (FE) models of lungs, aorta and heart, and validated the models through published cadaver tests by comparing the contact force and intracardiac pressures in four heart chambers. Then, various simulations of thorax-to-steering wheel impact were carried out at different impact heights (lower, middle and higher) and different inclination angles of steering wheel (15∘, 30∘, 45∘ and 60∘) to investigate the effects of impact height and inclination angle on heart injury. The result showed that (1) the biomechanical response of the heart model was agree with the test data; (2) the contact force, myocardial stress and intracardiac pressure were decreased when the inclination angle was increased; (3) when the impact height was middle and the inclination angle of steering wheel was 15∘, the myocardial stress and intracardiac pressure were both maximum which indicated that the blunt heart injury was more likely to occur in this condition.
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Affiliation(s)
- FANG TONG
- School of Mechanical and Automotive Engineering, South China University of Technology, 510640 Guangzhou, P. R. China
- Guangdong Provincial Key Laboratory of Automotive Engineering, South China University of Technology, 510640 Guangzhou, P. R. China
| | - FENGCHONG LAN
- School of Mechanical and Automotive Engineering, South China University of Technology, 510640 Guangzhou, P. R. China
- Guangdong Provincial Key Laboratory of Automotive Engineering, South China University of Technology, 510640 Guangzhou, P. R. China
| | - JIQING CHEN
- School of Mechanical and Automotive Engineering, South China University of Technology, 510640 Guangzhou, P. R. China
- Guangdong Provincial Key Laboratory of Automotive Engineering, South China University of Technology, 510640 Guangzhou, P. R. China
| | - XIONG LI
- School of Mechanical and Automotive Engineering, South China University of Technology, 510640 Guangzhou, P. R. China
- Guangdong Provincial Key Laboratory of Automotive Engineering, South China University of Technology, 510640 Guangzhou, P. R. China
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20
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Abstract
BACKGROUND Blunt cardiac injury (BCI) increases with traffic accidents and is an important cause of death in trauma patients. In particular, for patients who need surgical treatment, the mortality rate is extremely high unless the patient is promptly operated on. This study aimed to explore early recognition and expeditious surgical intervention to increase survival. METHODS All patients with BCIs during the past 15 years were reviewed, and those who underwent operative treatment were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome. RESULTS A total of 348 patients with BCIs accounted for 18.3% of 1903 patients with blunt thoracic injury (BTI). Of 348 patients, 43 underwent operative treatment. The main cause of injury was traffic accidents, with an incidence of 48.8%. Of them, steering wheel injuries occurred in 15 patients. In 26 patients, a preoperative diagnosis was obtained by echocardiography, CT scanning, etc. In the remaining 17, who had to undergo urgent thoracotomy without any preoperative imaging, a definitive diagnosis of BCI was proven during the operation. The volume of preoperative infusion or crystalloid was <1000 ml in 31 cases. Preoperative pericardiocentesis was not used in anyone. In 12 patients, the operation commenced within 1 h. Overall mortality was 32.6%. The death was caused by BCI in 9. CONCLUSIONS Facing a patient with BTI, a high index of suspicion for BCI must be maintained. To manage those requiring operations, early recognition and expeditious thoracotomy are essential. Preoperatively, limited fluid resuscitation is emphasized. We do not advocate preoperative pericardiocentesis.
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21
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Beyer CA, Hoareau GL, Kashtan HW, Wishy AM, Caples C, Spruce M, Grayson JK, Neff LP, Williams TK, Johnson MA. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in a swine model of hemorrhagic shock and blunt thoracic injury. Eur J Trauma Emerg Surg 2020; 46:1357-1366. [PMID: 31576422 DOI: 10.1007/s00068-019-01185-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 07/08/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE While resuscitative endovascular balloon occlusion of the aorta (REBOA) is contraindicated in patients with aortic injuries, this technique may benefit poly-trauma patients with less extreme thoracic injuries. The purpose of this study was to characterize the effects of thoracic injury on hemodynamics during REBOA and the changes in pulmonary contusion over time in a swine model. METHODS Twelve swine were anesthetized, instrumented, and randomized to receive either a thoracic injury with 5 impacts to the chest or no injury. All animals underwent controlled hemorrhage of 25% blood volume followed by 45 min of Zone 1 REBOA. Animals were then resuscitated with shed blood, observed during a critical care period, and euthanized after 6 h of total experimental time. RESULTS There were no differences between the groups at baseline. The only difference after 6 h was a lower hemoglobin in the thoracic trauma group (8.4 ± 0.8 versus 9.4 ± 0.6 g/dL, P = 0.04). The average proximal mean arterial pressures were significantly lower in the thoracic trauma group during aortic occlusion [103 (98-108) versus 117 (115-124) mmHg, P = 0.04]. There were no differences between the pulmonary contusion before REBOA and at the end of the experiment in size (402 ± 263 versus 356 ± 291 mL, P = 0.782) or density (- 406 ± 127 versus - 299 ± 175 HFU, P = 0.256). CONCLUSIONS Thoracic trauma blunted the proximal arterial pressure augmentation during REBOA but had minimal impacts on resuscitative outcomes. This initial study indicates that REBOA does not seem to exacerbate pulmonary contusion in swine, but blunt thoracic injuries may attenuate the expected rises in proximal blood pressure during REBOA.
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Affiliation(s)
- Carl A Beyer
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA.
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA.
| | - Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
| | - Harris W Kashtan
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA
| | - Andrew M Wishy
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA
| | - Connor Caples
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA
| | - Marguerite Spruce
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA
| | - John K Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
| | - Lucas P Neff
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Timothy K Williams
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Michael A Johnson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Fairfield, CA, USA
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, USA
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22
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Domanin M, Antonelli B, Crotti S, D'Alessio I, Fornoni G, Bottino N, Settembrini AM, Marongiu I, Suriano G, Tagliabue P, Carrara A, Alagna L, Trimarchi S, Pesenti A, Rossi G. Concurrent Thoracic Endovascular Aortic Repair and Liver Transplant: Multidisciplinary Management of Multiple Posttraumatic Lesions. Ann Vasc Surg 2020; 72:662.e7-662.e14. [PMID: 33227463 DOI: 10.1016/j.avsg.2020.09.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/21/2020] [Accepted: 09/24/2020] [Indexed: 01/19/2023]
Abstract
Association of thoracic and abdominal injuries in patients with major trauma is common. Under emergency conditions, it is often difficult to promptly perform a certain diagnosis and identify treatment priorities of life-threatening lesions. We present the case of a young man with combined thoracic and abdominal injuries after a motorcycle accident. Primary evaluation through echography and X-ray showed fluid within the hepatorenal recess and an enlarged mediastinum. Volume load, blood transfusions, and vasoactive agents were initiated to sustain circulation. Despite hemodynamic instability, we decided to perform computed tomographic angiography (CTA) scan that revealed a high-grade traumatic aortic pseudoaneurysm, multiple and severe areas of liver contusion, and a small amount of hemoperitoneum, without active bleeding spots. The patient was successfully submitted to thoracic endovascular aortic repair (TEVAR). Immediately after the end of the successful TEVAR, signs of massive abdominal bleeding revealed. Immediate explorative laparotomy was performed showing massive hepatic hemorrhage. After liver packing and Pringle's maneuver, control of bleeding was lastly obtained with hemostatic devices and selective cross-clamping of the right hepatic artery. The patient was then transferred to intensive care unit where, despite absence of further hemorrhage, hemodynamic instability, anuria, severe lactic acidosis together with liver necrosis indices appeared. A new CTA demonstrated massive parenchymal disruption within the right lobe of the liver and multiple hematomas in the left lobe. Considering the high-grade lesions of the hepatic vascular tree and liver failure, patient was listed for emergency liver transplantation (LT). LT occurred few hours later, and patient's clinical conditions rapidly improved even if the subsequent clinical course was characterized by a severe fungal infection because of immunosuppression. Evaluation of life-threatening lesions and treatment priorities, availability of different excellence skills, and multidisciplinary collaboration have a key role to achieve clinical success in such severe cases.
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Affiliation(s)
- Maurizio Domanin
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Vascular Surgery Unit, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Barbara Antonelli
- General Surgery and Liver Transplant Unit, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefania Crotti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione I.R.C.C.S. S Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilenia D'Alessio
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Gianluca Fornoni
- General Surgery and Liver Transplant Unit, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Bottino
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione I.R.C.C.S. S Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Ines Marongiu
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione I.R.C.C.S. S Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Grazia Suriano
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione I.R.C.C.S. S Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Tagliabue
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione I.R.C.C.S. S Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Carrara
- Department of Pathophysiology and Transplantation, School of Medicine and Surgery, University of Milan, Milan, Italy; Department of General and Emergency Surgery, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Laura Alagna
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Santi Trimarchi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Vascular Surgery Unit, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione I.R.C.C.S. S Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, School of Medicine and Surgery, University of Milan, Milan, Italy
| | - Giorgio Rossi
- General Surgery and Liver Transplant Unit, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, School of Medicine and Surgery, University of Milan, Milan, Italy
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23
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Stojanovska J, Hurwitz Koweek LM, Chung JH, Ghoshhajra BB, Walker CM, Beache GM, Berry MF, Colletti PM, Davis AM, Hsu JY, Khosa F, Kicska GA, Kligerman SJ, Litmanovich D, Maroules CD, Meyersohn N, Syed MA, Tong BC, Villines TC, Wann S, Wolf SJ, Kanne JP, Abbara S. ACR Appropriateness Criteria® Blunt Chest Trauma-Suspected Cardiac Injury. J Am Coll Radiol 2020; 17:S380-S390. [PMID: 33153551 DOI: 10.1016/j.jacr.2020.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/01/2020] [Indexed: 12/20/2022]
Abstract
Blunt cardiac injuries range from myocardial concussion (commotio cordis) leading to fatal ventricular arrhythmias to myocardial contusion, cardiac chamber rupture, septal rupture, pericardial rupture, and valvular injuries. Blunt injuries account for one-fourth of the traumatic deaths in the United States. Chest radiography, transthoracic echocardiography, CT chest with and without contrast, and CT angiography are usually appropriate as the initial examination in patients with suspected blunt cardiac injury who are both hemodynamically stable and unstable. Transesophageal echocardiography and CT heart may be appropriate as examination in patients with suspected blunt cardiac injuries. This publication of blunt chest trauma-suspected cardiac injuries summarizes the literature and makes recommendations for imaging based on the available data and expert opinion. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | | | | | | | - Garth M Beache
- University of Louisville School of Medicine, Louisville, Kentucky
| | - Mark F Berry
- Stanford University Medical Center, Stanford, California; The Society of Thoracic Surgeons
| | | | - Andrew M Davis
- The University of Chicago Medical Center, Chicago, Illinois; American College of Physicians
| | - Joe Y Hsu
- Kaiser Permanente, Los Angeles, California
| | - Faisal Khosa
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | | | | | | | - Mushabbar A Syed
- Stritch School of Medicine Loyola University Chicago, Maywood, Illinois; Society for Cardiovascular Magnetic Resonance
| | - Betty C Tong
- Duke University School of Medicine, Durham, North Carolina; The Society of Thoracic Surgeons
| | - Todd C Villines
- University of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Samuel Wann
- Wisconsin Heart Hospital, Milwaukee, Wisconsin; Nuclear cardiology expert
| | - Stephen J Wolf
- Denver Health MC/UPI, Denver, Colorado; American College of Emergency Physicians
| | - Jeffrey P Kanne
- Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
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Elkbuli A, Meneses E, Kinslow K, McKenney M, Boneva D. Successful management of gunshot wound to the chest resulting in multiple intra-abdominal and thoracic injuries in a pediatric trauma patient: A case report and literature review. Int J Surg Case Rep 2020; 76:372-376. [PMID: 33080529 PMCID: PMC7575832 DOI: 10.1016/j.ijscr.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/02/2020] [Accepted: 10/02/2020] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Trauma remains the leading cause of mortality in the pediatric population. Penetrating thoracic injuries can result in devastating trauma to multiple organ systems. When these injuries occur, prompt diagnosis and swift treatment of internal organ injury are of utmost importance. CASE PRESENTATION A 13-year-old male presented to our Trauma Center after sustaining a gunshot wound (GSW) to the left chest. Despite his hemodynamic stability on presentation, CT scan revealed multiple injuries including splenic and renal lacerations. Exploratory laparotomy resulted in splenectomy, but no intervention was performed for the renal laceration. Instead, clinical monitoring alone was sought. Patient was discharged on hospital day 13 in stable condition. DISCUSSION Pediatric penetrating injuries secondary to GSWs can impact multiple organ systems. Despite hemodynamic stability on presentation, adequate staging of internal damage with CT allowed a targeted approach. In our case, non-operative management of the renal injury was implemented after hemorrhage control of his additional injuries. Failure to have done so would have inevitably complicated his overall management and made kidney salvage not feasible. CONCLUSION Prompt diagnosis and treatment are required in order to prevent significant morbidity and mortality in the pediatric patient from GSW-mediated penetrating thoracic injuries. Despite hemodynamic stability on presentation, patients should be emergently assessed for severe injury, with immediate surgical management as needed. Failure to do so could lead to rapid clinical deterioration, and inability to enact other conservative measures that lead to positive outcomes.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA.
| | - Evander Meneses
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Kyle Kinslow
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Dessy Boneva
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; Department of Surgery, University of South Florida, Tampa, FL, USA
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Biondi NL, Bhandari M, Bhyan P. Transient Right Bundle Branch Block Resulting From a Blunt Cardiac Injury During a Motor Vehicle Accident. Cureus 2020; 12:e10534. [PMID: 33094074 PMCID: PMC7574995 DOI: 10.7759/cureus.10534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Blunt chest trauma (BCT) has become increasingly more prevalent in recent years. As a result, the incidence of blunt cardiac injury (BCI), or cardiac or myocardial contusion, has also increased. The sequelae of BCI often are undiagnosed due to variability in the clinical presentation. This case highlights a transient right bundle branch block (RBBB) following a motor vehicle accident (MVA), resulting in BCI. Right-sided cardiac injuries predominate BCI owing to the anterior location of the right ventricle within the thoracic cage; however, the pathophysiologic mechanisms underlying the electrocardiographic manifestations are vaguely understood. In this case, a 66-year-old female sustained a BCI resulting in a transient RBBB. The patient fully recovered following a three-day hospitalization with complete recovery of normal cardiac conduction.
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Affiliation(s)
- Nicholas L Biondi
- Internal Medicine, Campbell University School of Osteopathic Medicine, Buies Creek, USA.,Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, USA
| | - Manoj Bhandari
- Cardiolgy, Cape Fear Valley Medical Center, Fayetteville, USA
| | - Poonam Bhyan
- Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, USA
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Gao JM, Li H, Wei GB, Liu CP, Du DY, Kong LW, Li CH, Yang J, Yang Q. Blunt Cardiac Injury: A Single-Center 15-Year Experience. Am Surg 2020. [DOI: 10.1177/000313482008600432] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In recent years, the incidence of blunt cardiac injury (BCI) has increased rapidly and is an important cause of death in trauma patients. This study aimed to explore early diagnosis and therapy to increase survival. All patients with BCI during the past 15 years were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome. The patients were divided into two groups according to the needs of their condition—nonoperative (Group A) and operative (Group B). Comparisons of the groups were performed. A total of 348 patients with BCI accounted for 18.3 per cent of 1903 patients with blunt thoracic injury. The main cause of injury was traffic accidents, with an incidence of 48.3 per cent. In Group A (n = 305), most patients sustained myocardial contusion, and the mortality was 6.9 per cent. In Group B (n = 43), including those with cardiac rupture and pericardial hernia, the mortality was 32.6 per cent. Comparisons of the groups regarding the shock rate and mortality were significant ( P < 0.01). Deaths directly resulting from BCI in Group B were greater than those in Group A ( P < 0.05). In all 348 patients, the mortality rate was 10.1 per cent. When facing a patient with blunt thoracic injury, a high index of suspicion for BCI must be maintained. To manage myocardial contusion, it is necessary to protect the heart, alleviate edema of the myocardium, and control arrhythmia with drugs. To deal with those requiring operation, early recognition and expeditious thoracotomy are essential.
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Affiliation(s)
- Jin-Mou Gao
- Department of Cardiothoracic Surgery, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Hui Li
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Gong-Bin Wei
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Chao-Pu Liu
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Ding-Yuan Du
- Department of Cardiothoracic Surgery, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Ling-Wen Kong
- Department of Cardiothoracic Surgery, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Chang-Hua Li
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Jun Yang
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
| | - Qian Yang
- Department of Traumatology, Central Affiliated Hospital of Chongqing University, Chongqing Emergency Medical Center, Chongqing, China
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Keskpaik T, Starkopf J, Kirsimägi Ü, Mihnovitš V, Lomp A, Raamat EM, Saar S, Talving P. The role of elevated high-sensitivity cardiac troponin on outcomes following severe blunt chest trauma. Injury 2020; 51:1177-1182. [PMID: 31955863 DOI: 10.1016/j.injury.2019.12.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 12/14/2019] [Accepted: 12/30/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Blunt cardiac injuries (BCI) result in poor outcomes following chest trauma. Admission ECG and troponin levels are frequently obtained in patients with suspected BCI, nevertheless, the prognostic value of cardiac troponins remains controversial. The purpose of the current study was to review the prognostic value of elevated high-sensitivity cardiac troponin T (hs-cTnT) in patients with severe blunt chest injuries. We hypothesized that elevated hs-cTnT result in poor outcomes in this subgroup of severe trauma patients. METHODS After IRB approval, all consecutive patients with Injury Severity Score (ISS) > 15 and chest Abbreviated Injury Scale (AIS) score ≥3 admitted to the major trauma centers between 1/2015 and 6/2017 were retrospectively reviewed. Primary outcomes were in-hospital and one-year mortality. Secondary outcomes included ventilator days and Glasgow Outcome Scale (GOS) score at hospital discharge. RESULTS Overall, 147 patients were included. Mean age was 49.0 (19.1) years and 75% were male. Serum troponin levels on admission were accrued in 82 (56%) patients with elevated and normal hs-cTnT levels found in 54 (66%) and in 28 (34%) patients, respectively. Elevated hs-cTnT group had significantly higher ISS and lactate level, and lower systolic blood pressure on admission. In-hospital mortality was significantly higher in patients with elevated hs-cTnT levels compared to patients with normal hs-cTnT levels (26% vs. 4%, p = 0.02). Hs-cTnT level > 14 ng/L was significantly associated with extended ventilator days and lower GOS score at hospital discharge. CONCLUSION Blunt chest trauma victims with elevated hs-cTnT levels experience significantly poorer adjusted outcomes compared to patients with normal levels. Compliance with EAST practice management guidelines following severe blunt chest trauma was not fully complied in our study cohort that warrants prospective performance improvement measures.
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Affiliation(s)
- Triinu Keskpaik
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Estonia; Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Estonia.
| | - Joel Starkopf
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Estonia; Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Estonia.
| | - Ülle Kirsimägi
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Estonia.
| | - Vladislav Mihnovitš
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Estonia.
| | - Andrus Lomp
- Department of Anesthesiology and Intensive Care, Tartu University Hospital, Estonia.
| | | | - Sten Saar
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Estonia; Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Estonia
| | - Peep Talving
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Estonia; Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Estonia.
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Fernando RJ, Anderson BY, Augoustides JG, Zhou E, Radvansky B, Marchant BE, Morris BE, Weiss SJ, Patel PA. Traumatic Rupture of the Left Atrial Appendage: Perioperative Management and Echocardiographic Challenges. J Cardiothorac Vasc Anesth 2020; 34:1074-1081. [DOI: 10.1053/j.jvca.2019.12.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 12/30/2019] [Indexed: 12/25/2022]
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Tran HV, Charles M, Garrett RC, Kempe PW, Howard CA, Khorgami Z. Ten-Year Trends in Traumatic Cardiac Injury and Outcomes: A Trauma Registry Analysis. Ann Thorac Surg 2020; 110:844-848. [PMID: 32032572 DOI: 10.1016/j.athoracsur.2019.12.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 10/02/2019] [Accepted: 12/17/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cardiac injury is a significant cause of death in patients with traumatic injuries. The Oklahoma Trauma Registry collects data from acute care hospitals in Oklahoma. This study investigated the trends and outcomes of traumatic cardiac injury in Oklahoma over a 10-year period. METHODS The Oklahoma Trauma Registry tracks patients with major severity and one of the following criteria: hospital stay 48 hours or longer, death on arrival or in the hospital, hospital transfer, intensive care unit admission, or surgery. Cardiac injuries were identified from data acquired 2005 to 2014. Characteristics, mechanisms of injury, associated injuries, and outcomes were analyzed. Results were further divided into blunt vs penetrating injuries and operative vs nonoperative management. RESULTS Of 107,549 patients, 426 patients suffered cardiac injury, and 160 patients suffered penetrating trauma. Commonly associated injuries were rib fractures, pneumothorax, hemothorax, and intraabdominal injuries. Of blunt cardiac injuries, 26.7% had spinal fractures. Operative management occurred in 16.9%. Overall mortality rate was 35.7% (51.9% in penetrating and 26.3% in blunt injuries). Mortality was higher for patients who had operative management but was similar in penetrating and blunt cardiac injury. Over 10 years, the percentage of cardiac injury decreased. However, mortality in patients who suffered a cardiac injury increased, correlating with an increase in proportion of penetrating cardiac injury. CONCLUSIONS Traumatic cardiac injury, particularly penetrating injury, continues to be a significant source of mortality. Analysis of state-base trauma registries can identify trends in causes of injury and death, serving as a reference point for quality improvement, therapeutic triage, and preventative action plans.
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Affiliation(s)
- Hoang-Vu Tran
- Department of Surgery, College of Medicine, University of Oklahoma, Tulsa, Oklahoma
| | - Michael Charles
- Department of Surgery, St. John Medical Center, Tulsa, Oklahoma
| | | | - Paul W Kempe
- Department of Surgery, St. John Medical Center, Tulsa, Oklahoma
| | - C Anthony Howard
- Department of Surgery, College of Medicine, University of Oklahoma, Tulsa, Oklahoma.
| | - Zhamak Khorgami
- Department of Surgery, College of Medicine, University of Oklahoma, Tulsa, Oklahoma
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30
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Van Lieshout EMM, Verhofstad MHJ, Van Silfhout DJT, Dubois EA. Diagnostic approach for myocardial contusion: a retrospective evaluation of patient data and review of the literature. Eur J Trauma Emerg Surg 2020; 47:1259-1272. [PMID: 31982920 PMCID: PMC8321993 DOI: 10.1007/s00068-020-01305-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/14/2020] [Indexed: 11/25/2022]
Abstract
Purpose Myocardial contusion can be a life-threatening condition in patients who sustained blunt thoracic trauma. The diagnostic approach remains a subject of debate. The aim of this study was to determine the sensitivity and specificity of echocardiography, electrocardiography, troponins T and I (TnT and TnI), and creatine kinase muscle/brain (CK-MB) for identifying patients with a myocardial contusion following blunt thoracic trauma. Methods Sensitivity and specificity were first determined in a 10-year retrospective cohort study and second by a systematic literature review with meta-analysis. Results Of the 117 patients in the retrospective study, 44 (38%) were considered positive for myocardial contusion. Chest X-ray, chest CT scan, electrocardiograph, and echocardiography had poor sensitivity (< 15%) but good specificity (≥ 90%). Sensitivity to cardiac biomarkers measured at presentation ranged from 59% for TnT to 77% for hs-TnT, specificity ranged from 63% for CK-MB to 100% for TnT. The systematic literature review yielded 28 studies, with 14.5% out of 7242 patients reported as positive for myocardial contusion. The pooled sensitivity of electrocardiography, troponin I, and CK-MB was between 62 and 71%, versus only 45% for echocardiography and 38% for troponin T. The pooled specificity ranged from 63% for CK-MB to 85% for troponin T and 88% for echocardiography. Conclusion The best diagnostic approach for myocardial contusion is a combination of electrocardiography and measurement of cardiac biomarkers. If abnormalities are found, telemonitoring is necessary for the early detection of life-threatening arrhythmias. Chest X-ray and CT scan may show other thoracic injuries but provide no information on myocardial contusion. Electronic supplementary material The online version of this article (10.1007/s00068-020-01305-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Dirk Jan T Van Silfhout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Eric A Dubois
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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Fugazzola P, Ansaloni L, Benni M, Circelli A, Coccolini F, Gamberini E, Nanni A, Russo E, Tomasoni M, Agnoletti V. At the heart of organ donation. Case reports of organ donation after cardiac death in two patients with successfully repaired AAST grade V cardiac injuries. World J Emerg Surg 2019; 14:60. [PMID: 31889990 PMCID: PMC6923827 DOI: 10.1186/s13017-019-0279-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 11/22/2019] [Indexed: 11/21/2022] Open
Abstract
Background Trauma victims could be an important source of organs. This article presents two cases of successful organ donation and transplant, after Maastricht category III cardiac death in patients with successfully repaired AAST grade V traumatic cardiac injuries. Case presentation The first donor was an adult patient with self-inflicted heart stab wound and non-survivable burn injury. The second one was an adult patient with blunt cardiac and abdominal trauma and an anoxic brain injury due to a car accident. The cardiac injury was promptly repaired in both patients. In the first case, adequate organ perfusion ante-mortem was achieved thanks to venoarterial extracorporeal membrane oxygenation and intensive care unit support. The above procedure allowed successful organ donation and transplantation even after Maastricht category III cardiac death. This is the first case reported where, for organ donation purposes, it was made necessary first thing to avoid the immediate death of the patient, due to a rare and frequently not survivable cardiac injury. The challenge of preserving organ perfusion, due to major burn injury effects, was faced afterwards. Conclusions The outcomes of these two cases suggest that a repaired heart injury should not be considered as an absolute contraindication to organ donation, even if it is associated with non-survivable major burns. Therefore, cardiac death could provide an opportunity for these kinds of patients to contribute to the pool of potential organ donors.
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Affiliation(s)
- Paola Fugazzola
- 1Unit of Emergency and General Surgery, Bufalini Hospital, Viale Ghirotti 286, 47521 Cesena (FC), Italy
| | - Luca Ansaloni
- 1Unit of Emergency and General Surgery, Bufalini Hospital, Viale Ghirotti 286, 47521 Cesena (FC), Italy
| | - Marco Benni
- 2Intensive Care Unit, Bufalini Hospital, Viale Ghirotti 286, Cesena, Italy
| | | | - Federico Coccolini
- 3General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Emiliano Gamberini
- 2Intensive Care Unit, Bufalini Hospital, Viale Ghirotti 286, Cesena, Italy
| | - Andrea Nanni
- 2Intensive Care Unit, Bufalini Hospital, Viale Ghirotti 286, Cesena, Italy
| | - Emanuele Russo
- 2Intensive Care Unit, Bufalini Hospital, Viale Ghirotti 286, Cesena, Italy
| | - Matteo Tomasoni
- 1Unit of Emergency and General Surgery, Bufalini Hospital, Viale Ghirotti 286, 47521 Cesena (FC), Italy
| | - Vanni Agnoletti
- 2Intensive Care Unit, Bufalini Hospital, Viale Ghirotti 286, Cesena, Italy
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Ballocco I, Pinna Parpaglia ML, Corda F, Serra G, Corda A. Left atrial thrombosis secondary to blunt cardiac injury in two dogs. VETERINARY RECORD CASE REPORTS 2019. [DOI: 10.1136/vetreccr-2018-000803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Isabella Ballocco
- Department of Veterinary MedicineVeterinary Teaching HospitalUniversity of SassariSassariItaly
| | | | - Francesca Corda
- Department of Veterinary MedicineVeterinary Teaching HospitalUniversity of SassariSassariItaly
| | - Giovanna Serra
- Department of Veterinary MedicineVeterinary Teaching HospitalUniversity of SassariSassariItaly
| | - Andrea Corda
- Department of Veterinary MedicineVeterinary Teaching HospitalUniversity of SassariSassariItaly
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Bıçakçı N, Karaboğa I, Dökmeci AH, Güzel S, Fidanol Erboğa Z. Cardioprotective effect of caffeic acid phenethyl ester on cardiac contusion following blunt chest trauma in rats. Biotech Histochem 2019; 94:442-448. [PMID: 30929510 DOI: 10.1080/10520295.2019.1586999] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
We investigated the effects of caffeic acid phenethyl ester (CAPE) on cardiac damage after blunt chest injury. Forty male adult Wistar albino rats were divided into four groups; control, cardiac contusion, cardiac contusion + CAPE, and CAPE. CAPE, 10 mmol/kg, was administered intraperitoneally for 7 days following cardiac contusion. Heart tissue and blood were obtained at the end of the experimental period. Cardiac histopathology was determined using hematoxylin & eosin (H & E) staining. Expression of tumor necrosis factor-alpha (TNF-α) in cardiomyocytes was determined using immunohistochemistry. Cardiac apoptosis was determined using the TUNEL method. Serum creatine kinase (CK), creatine kinase-muscle/brain (CK-MB) and lactate dehydrogenase (LDH) levels were determined using spectrophotometric methods. The serum cardiac troponin I (C-TI) level was measured using the ELISA method. Myofibril loss was detected in the cardiomyocytes of the cardiac contusion group. Increased apoptosis and TNF-α expression were observed in the cardiac contusion group compared to the control group. Increased CK, CK-MB, LDH and C-TI levels were found in the cardiac contusion group. We found that CAPE administration improved myocardial function. Compared to the cardiac contusion group, CK, CK-MB, LDH and C-TI levels decreased significantly in the cardiac contusion + CAPE group. Administration of CAPE significantly inhibited apoptosis and cardiac TNF-α expression. Our findings demonstrate the therapeutic effects of CAPE for cardiac contusion damage after blunt chest trauma.
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Affiliation(s)
- N Bıçakçı
- School of Health, Department of Emergency and Disaster Management, Tekirdag Namık Kemal University , Tekirdag , Turkey
| | - I Karaboğa
- School of Health, Department of Emergency and Disaster Management, Tekirdag Namık Kemal University , Tekirdag , Turkey
| | - A H Dökmeci
- School of Health, Department of Emergency and Disaster Management, Tekirdag Namık Kemal University , Tekirdag , Turkey
| | - S Güzel
- Department of Medical Biochemistry, Faculty of Medicine, Tekirdag Namık Kemal University , Tekirdag , Turkey
| | - Z Fidanol Erboğa
- Department of Histology and Embryology, Faculty of Medicine, Tekirdag Namık Kemal University , Tekirdag , Turkey
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