Blunt Cardiac Trauma

Persistent Hypoxia After Blunt Thoracic Trauma due to Flail Tricuspid Valve Leaflet and Patent Foramen Ovale

Structural cardiac injury after blunt trauma is uncommon but usually life-threatening. While tricuspid injury is very rare and potentially lethal, the right heart can accommodate larger volumes and higher pressures in acute tricuspid insufficiency and facilitate initial stabilization prior to definitive valvular repair. ECMO may be used to ameliorate resulting right heart failure. The traumatic force required to cause cardiac structural injury is also associated with pulmonary complications related to pneumothorax, hemothorax, effusion, acute pain secondary to rib fractures, and pulmonary contusions causing hypoxia. We present an unusual case of hypoxia in a trauma patient caused by acute tricuspid regurgitation with pre-existing patent foramen ovale.

Accuracy of diagnostic tests in cardiac injury after blunt chest trauma: a systematic review and meta-analysis

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.

Sternal fractures and thoracic injury: an analysis of 288 sternal fractures attending a major trauma centre

INTRODUCTION

Sternal fractures (SF) are uncommon injuries usually associated with a significant mechanism of injury. Concomitant injury is likely, and a risk of mortality is substantial.

AIM

Our aim in this study was to identify the risk factors for mortality in patients who had sustained sternal fractures.

METHODS

We conducted a single centre retrospective review of the trust's Trauma Audit and Research Network Database, from May 2014 to July 2021. Our inclusion criteria were any patients who had sustained a sternal fracture. The regions of injury were defined using the Abbreviated Injury Score. Pearson Chi-Squared, Fisher Exact tests and multivariate regression analyses were performed using IBM SPSS.

RESULTS

A total of 249 patients were identified to have sustained a SF. There were 19 patients (7.63%) who had died. The most common concomitant injuries with SF were Rib fractures (56%), Lung Contusions (31.15%) and Haemothorax (21.88%). There was a significant increase in age (59.93 vs 70.06, p = .037) and admission troponin (36.34 vs. 100.50, p = .003) in those who died. There was a significantly lower GCS in those who died (10.05 vs. 14.01, p < .001). On multi regression analysis, bilateral rib injury (p = 0.037, OR 1.104) was the only nominal variable which showed significance in mortality.

CONCLUSION

Sternal Fractures are uncommon but serious injuries. Our review has identified that bilateral rib injuries, increase in age, low GCS, and high admission troponin in the context of SF, were associated with mortality.

Evaluating the Utility of High Sensitivity Troponin in Blunt Cardiac Injury

INTRODUCTION

Screening for blunt cardiac injury (BCI) includes obtaining a serum troponin level and an electrocardiogram for patients diagnosed with a sternal fracture. Our institution has transitioned to the use of a high sensitivity troponin I (hsTnI). The aim of this study was to determine whether hsTnI is comparable to troponin I (TnI) in identifying clinically significant BCI.

MATERIALS AND METHODS

Trauma patients presenting to a level I trauma center over a 24-mo period with the diagnosis of sternal fracture were screened for BCI. Any initial TnI more than 0.04 ng/mL or hsTnI more than 18 ng/L was considered positive for potential BCI. Clinically significant BCI was defined as a new-bundle branch block, ST wave change, echocardiogram change, or need for cardiac catheterization.

RESULTS

Two hundred sixty five patients with a sternal fracture were identified, 161 underwent screening with TnI and 104 with hsTnI. For TnI, the sensitivity and specificity for detection of clinically significant BCI was 0.80 and 0.79, respectively. For hsTnI, the sensitivity and specificity for detection of clinically significant BCI was 0.71 and 0.69, respectively. A multivariate analysis demonstrated the odds ratio for significant BCI with a positive TnI was 14.4 (95% confidence interval, 3.9-55.8, P < 0.0001) versus an odds ratio of 5.48 (95% confidence interval 1.9-15.7, P = 0.002) in the hsTnI group.

CONCLUSIONS

The sensitivity of hsTnI is comparable to TnI for detection of significant BCI. Additional investigation is needed to determine the necessity and interval for repeat testing and the need for additional diagnostic testing.

Cardiac contusions in the acute care setting: Historical background, evaluation and management

INTRODUCTION

Albeit described since 1763, cardiac contusions is still an under-recognised clinical condition in the acute care setting. This evidence-based review aims to provide an overview of the topic by focusing on etiopathogenesis, classification and clinical presentation of patients with cardiac contusions, as well as on the diagnostic work-up and therapy options available for this subset population in the acute care setting.

METHODS

A targeted research strategy was performed using PubMed, MEDLINE, Embase and Cochrane Central databases up to June 2022. The literature search was conducted using the following keywords (in Title and/or Abstract): ("cardiac" OR "heart" OR "myocardial") AND ("contusion"). All available high-quality resources written in English and containing information on epidemiology, etiopathogenesis, clinical findings, diagnosis and management of cardiac contusions were included in our research.

RESULTS

Biochemical samples of cardiac troponins together with a 12‑lead ECG appear to be sufficient screening tools in hemodynamically stable subjects, while cardiac ultrasound provides a further diagnostic clue for patients with hemodynamic instability or those more likely to have a significant cardiac contusion.

CONCLUSIONS

The management of patients with suspected cardiac contusion remains a challenge in clinical practice. For this kind of patients a comprehensive diagnostic approach and a prompt emergency response are required, taking into consideration the degree of severity and clinical impairment of associated traumatic injuries.

Extracellular vesicles as mediators and markers of acute organ injury: current concepts

Due to the continued high incidence and mortality rate worldwide, there is a need to develop new strategies for the quick, precise, and valuable recognition of presenting injury pattern in traumatized and poly-traumatized patients. Extracellular vesicles (EVs) have been shown to facilitate intercellular communication processes between cells in close proximity as well as distant cells in healthy and disease organisms. miRNAs and proteins transferred by EVs play biological roles in maintaining normal organ structure and function under physiological conditions. In pathological conditions, EVs change the miRNAs and protein cargo composition, mediating or suppressing the injury consequences. Therefore, incorporating EVs with their unique protein and miRNAs signature into the list of promising new biomarkers is a logical next step. In this review, we discuss the general characteristics and technical aspects of EVs isolation and characterization. We discuss results of recent in vitro, in vivo, and patients study describing the role of EVs in different inflammatory diseases and traumatic organ injuries. miRNAs and protein signature of EVs found in patients with acute organ injury are also debated.

Survivor of Right Atrial Appendage Rupture Following Blunt Chest Trauma

A 20-year-old woman presented to our trauma center with cardiac rupture after a motor vehicle collision. Our patient was the restrained driver in a high-speed collision. She arrived without external evidence of trauma but in obvious distress with tachycardia, tachypnea, and hypotension. Initial FAST was negative and chest x-ray; however, second FAST was equivocal for pericardial fluid. Computed tomography demonstrated a large hemopericardium, suspicious for cardiac injury. She underwent emergent operative exploration with a median sternotomy. A 1 cm right atrial appendage avulsion was identified and repaired primarily. She recovered uneventfully and was discharged home. Survival of blunt cardiac rupture is extremely rare and can occur in the absence of any external signs of trauma. Surgeons should maintain clinical suspicion for blunt cardiac injury in unstable trauma patients with deceleration injuries. Injury to the low-pressure right atrium likely contributed to her ability to survive transport to a trauma center.

Blunt Cardiac Injuries That Require Operative Management: A Single-Center 7-Year Experience

Purpose Blunt cardiac injuries (BCI) have a wide clinical spectrum, ranging from asymptomatic myocardial contusion to cardiac rupture and death. BCIs rarely require surgical intervention, but can be rapidly fatal, requiring prompt evaluation and surgical treatment in some cases. The aim of this study was to identify potential factors associated with in-hospital mortality after surgery in patients with BCI. Methods The medical records of 15 patients who had undergone emergency cardiac surgery for BCI between January 2014 and August 2020 were retrospectively reviewed. We included trauma patients older than 18 years admitted to Regional Trauma Center, Gachon University Gil Medical Center during the study period. Clinical and laboratory variables were compared between survivors and non-survivors. Results Non-survivors showed a significantly higher Injury Severity Score (p=0.001) and Abbreviated Injury Scale in the chest region (p=0.001) than survivors. American Association for the Surgery of Trauma-Organ Injury Scale Grade V injuries were significantly more common in non-survivors than in survivors (p=0.031). Non-survivors had significantly more preoperative packed red blood cell (PRBC) transfusions (p=0.019) and were significantly more likely to experience preoperative cardiac arrest (p=0.001) than survivors. Initial pH (p=0.010), lactate (p=0.026), and base excess (BE; p=0.026) levels showed significant differences between the two groups. Conclusions Initial pH, lactate, BE, ventricular injury, the amount of preoperative PRBC transfusions, and preoperative cardiac arrest were potential predictors of in-hospital mortality.

Sudden death due to cardiac contusion: Forensic implications in a rare pediatric case

Blunt chest trauma (BCT) often results in blunt cardiac injuries of little clinical concern, but cases of severe heart damage with high mortality rates have also been described. In particular, BCT should never be underestimated, especially when it is located in the anterior thoracic region. Among traffic accidents, motorcyclists are the most vulnerable and at the greatest risk. We report the case of a 14-year-old boy who experienced BCT following a motorcycle accident. He was evaluated at the hospital and was found to be in good medical condition, without bruises or rib fractures. Electrocardiography revealed a left bundle branch block. The patient was kept overnight for observation and was discharged the following morning in a good health condition. However, five days later, the patient suddenly died. Autopsy revealed a cardiac contusion associated with a full-thickness myocardial rupture and massive hemopericardium. Histologically, hemorrhagic infiltration foci, fibrin deposits, neutrophilic granulocytes, and well-defined areas of necrosis were detected in the context of recent fibrosis. Coronary thrombosis was not observed. The cause of death was identified as cardiac contusion that caused myocardial necrosis and, ultimately, cardiac rupture. Because the boy suffered a recent BCT and was assessed at the hospital, issues of medical malpractice were raised. This case demonstrates the potential lethality of blunt chest trauma in pediatric patients and demonstrates the importance of not underestimating such events, even in the absence of clinically identified chest injuries.

State of the Art Imaging Review of Blunt and Penetrating Cardiac Trauma

Traumatic cardiovascular injuries are only second to the central nervous system injuries as a cause of death in young adult population. Multidetector computed tomography is the gold standard diagnostic modality in patients with blunt or penetrating chest trauma and clinical suspicion of cardiac injury. The imaging spectrum of cardiac injuries includes but not limits to pericardial rupture, myocardial contusions, valve rupture, coronary artery injuries, cardiac herniations, and cardiac tamponade. In this review article, we discuss clinical presentation, types, and mechanism of cardiac trauma with emphasis on the imaging findings and illustrations in blunt, penetrating traumatic, and iatrogenic cardiac injuries.

Diagnostic approach for myocardial contusion: a retrospective evaluation of patient data and review of the literature

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.

In-Hospital Diagnosis of Tricuspid Papillary Muscle Rupture in an Asymptomatic Patient after Blunt Chest Trauma

Tricuspid papillary muscle rupture after blunt chest trauma is an infrequent injury that often remains undiagnosed until patients become symptomatic months to years after the trauma occurred. It is imperative to diagnose patients early with this condition in order to optimize chances of successful recovery and avoidance of sequelae of long-term tricuspid regurgitation such as atrial fibrillation and right heart failure. Here we describe a case of a 58-year-old man involved in a motocross accident suffering amongst other injuries extensive bilateral rib fractures, hemopneumothoraces, and asymptomatic anterior tricuspid papillary muscle rupture. In addition, a review of the literature and an approach for the workup of trauma patients at risk for blunt cardiac injury are provided.

Isolated right atrial rupture from blunt trauma: a case report with systematic review of a lethal injury

Background

Isolated right atrial rupture (IRAR) from blunt chest trauma is rare. There are no physical exam findings and non-invasive testing specific to the condition, which result in diagnostic delays and poor outcomes. We present a case of IRAR along with a systematic review of similar cases in the literature.

Case report

A 23-year-old male presented following a motor vehicle accident (MVA). He was bradycardic and hypotensive during transportation; and required intubation. There were contusions along the right chest wall with clear breath sounds, and no jugular venous distension, muffled heart sounds. Hemodynamic status progressively worsened, ultimately leading to his death. However, no external sources of bleeding or evidence of cardiac tamponade was found.

Methods

A search of PubMed, Ovid, and the Cochrane Library using: (Blunt OR Blunt trauma) AND (Laceration OR Rupture OR Tear) AND (Right Atrium OR Right Atrial). Articles were included if they were original articles describing cases of IRAR.

Results

Forty-five reports comprising seventy-five (n = 75) cases of IRAR.

Conclusion

IRAR most commonly occurs following MVAs as the result of blunt chest trauma. Rupture occurs at four distinct sites and is most commonly at the right atrial appendage. IRAR is a diagnostic challenge and requires a high index of suspicion, as patients’ hemodynamics can rapidly deteriorate. The presentations vary depending on multiple factors including rupture size, pericardial integrity, and concomitant injuries. Cardiac tamponade may have a protective effect by prompting the search for a bleeding source. A pericardial window can be diagnostic and therapeutic in IRAR. Outcomes are favourable with timely recognition and prompt surgical intervention.

Myocardial infarction following a blunt chest trauma: A case report

RATIONALE

Blunt cardiac injury (BCI) is a common complication after blunt chest trauma, which can lead to mild arrhythmia, severe chamber or valvular rupture, or even death. Myocardial infarction following blunt chest trauma is a rare but fatal condition.

PATIENT CONCERNS

A 38-year-old, previously healthy, man was admitted to our hospital with a complaint of dyspnea. He had a history of being hit in the chest by a high-speed screw while working in a factory 3 months before he was admitted to the hospital.

DIAGNOSIS

After performing coronary angiography and echocardiography, he was finally diagnosed with myocardial infarction.

INTERVENTIONS

He received optimized medications, including diuretics, β-blockers, and cardiac stimulants.

OUTCOMES

At the 4-year follow-up, the patient was diagnosed as having chronic heart failure with a reduced ejection fraction.

LESSONS

Owing to the first doctor's lack of experience and knowledge with this case, the patient was misdiagnosed and treatment was delayed, which subsequently led to heart failure.BCI can lead to myocardial infarction if patients are misdiagnosed and treatment is delayed. Thus, surgeons and physicians should consider cardiac complications in patients with chest trauma to reduce the incidence of its misdiagnosis.

National risk factors for blunt cardiac injury: Hemopneumothorax is the strongest predictor

BACKGROUND

Blunt cardiac injury (BCI) can occur after chest trauma and may be associated with sternal fracture (SF). We hypothesized that injuries demonstrating a higher transmission of force to the thorax, such as thoracic aortic injury (TAI), would have a higher association with BCI.

METHODS

We queried the National Trauma Data Bank (NTDB) from 2007-2015 to identify adult blunt trauma patients.

RESULTS

BCI occurred in 15,976 patients (0.3%). SF had a higher association with BCI (OR = 5.52, CI = 5.32-5.73, p < 0.001) compared to TAI (OR = 4.82, CI = 4.50-5.17, p < 0.001). However, the strongest independent predictor was hemopneumothorax (OR = 9.53, CI = 7.80-11.65, p < 0.001) followed by SF and esophageal injury (OR = 5.47, CI = 4.05-7.40, p < 0.001).

CONCLUSION

SF after blunt trauma is more strongly associated with BCI compared to TAI. However, hemopneumothorax is the strongest predictor of BCI. We propose all patients presenting after blunt chest trauma with high-risk features including hemopneumothorax, sternal fracture, esophagus injury, and TAI be screened for BCI.

SUMMARY

Using the National Trauma Data Bank, sternal fracture is more strongly associated with blunt cardiac injury than blunt thoracic aortic injury. However, hemopneumothorax was the strongest predictor.

Cardiac laceration following non-penetrating chest trauma in dog and cat

Cardiac laceration with non-penetrating chest trauma is reported as a common cause of death in human following rapid deceleration in high-speed vehicular accident. In contrast, in veterinary medicine, traumatic rupture of heart and great-vessel structures appears to be an uncommon cause of death. Here we report three cases of cardiac laceration following non-penetrating chest trauma in a one cat and two dogs. In two of these cases, necropsy revealed a rupture of the heart associated with fractures of the ribs and lung contusion; only one case did not exhibit any external chest injury but revealed pericardial tear associated with hemothorax following rupture of the right auricle of the heart. However, in all three presented cases, the thoracic location of the injuries allowed to conclude that the cause of the cardiac rupture was due to a direct impact of the chest wall with a high speed object and consequent transmission of the kinetic force and compression of the heart between left and right thorax. These case reports underline the importance of a systematic and complete macroscopic evaluation of the heart in all cases of death following non-penetrating chest trauma in dog and cat such as in human. They also highlight how, in clinical and forensic practice, the cardiac injury following blunt chest trauma should be ruled out even in the cases of absence of external chest injury.

Cardiac injuries caused by trauma: Review and case reports

Assessment of suspected cardiac injuries in a trauma setting is a challenging and time-critical matter, with clinical and imaging findings having complementary roles in the formation of an accurate diagnosis. In this article, we review the supporting literature for the pathophysiology, classification and evaluation of cardiac injuries caused by trauma. We also describe 4 cardiac trauma patients seen at a tertiary referral hospital.

Role of H-FABP values in determining the etiologic factors of the cardiac injuries

Introduction

Cardiac injury resulting from blunt thoracic trauma is a frequent clinical occurrence which is difficult to diagnose. Our purpose in this study was to research whether H-FABP, which is a new marker for the diagnosis of cardiac injury, can be used in this patient group.

Methods

50 patients with blunt thoracic injury who were admitted to our emergency service within a period of 8 months and 50 cases as controls were included in our study.

Results

Of the 50 patients with blunt thoracic injury in our study, 88% were male while 12% were female. The average age of the patients was 43 ± 15.15. While 27 (54%) of the 50 patients with blunt thoracic injury had cardiac injury, 23 (46%) did not have cardiac injury. The results of the statistical analyses showed a significant association between thorax trauma and cTnI, CPK, CPKMB and H-FABP (p<0.05). While there was a significant association between cardiac injury resulting from thoracic trauma and cTnI, ECG and TTE (p<0.05), there was no significant association between CPK, CPKMB and H-FABP (p>0.05).

Conclusion

In thoracic traumas, cardiac injury diagnosis can be made as a result of the assessment with Troponin-I, ECG and ECHO. For cardiac injury diagnosis, wide scale prospective studies are needed for H-FABP use.

Sudden death due to the atrioventricular node contusion: Three cases report

INTRODUCTION

Atrioventricular node (AVN) contusion usually results in cardiogenic shock and arrhythmia and is a rare but fatal condition. The condition is difficult to diagnose and easily overlooked because it develops rapidly and is asymptomatic. We here report 3 cases that demonstrate blunt chest impact and hemorrhages of the posterior atrioventricular junction, eventually result in death.

CLINICAL FINDINGS

Autopsy and histological examination were performed on all cases. External inspection revealed bruises in the hearts and fractures in the sternum and ribs. However, histological examinations were conclusive and showed cardiac contusion on the surface of the posterior atrioventricular junction of the individuals, and the death was due to the AVN contusion. The position of the AVN on the heart surface is determined by detailed examinations via an autopsy and microscopic, both of which are critical in the certification of cause of death.

CONCLUSION

The report is intended to raise our understanding and make forensic pathologists aware of the surface of the posterior atrioventricular junction.

Cardiac Trauma

Cardiac trauma is a leading cause of death in the United States and occurs mostly due to motor vehicle accidents. Blunt cardiac trauma and penetrating chest injuries are most common, and both can lead to aortic injuries. Timely diagnosis and early management are the key to improve mortality. Cardiac computed tomography and cardiac ultrasound are the 2 most important diagnostic modalities. Mortality related to cardiac trauma remains high despite improvement in diagnosis and management.

Traumatic Cardiac Injury: Ventricular Perforation Caught on CT

Myocardial rupture is a rare imaging diagnosis given its clinical severity and high mortality. Early findings should be promptly communicated to the trauma service to ensure immediate intervention. We present a rare case of blowout perforation of the right ventricle which was prospectively diagnosed on computed tomography (CT) leading to emergent operative repair. The patient subsequently survived and was discharged after a lengthy hospital course.

Restart the heart

Early bystander cardiopulmonary resuscitation and rapid defibrillation are the most important factors for favourable outcomes after out of hospital cardiac arrest (OHCA)-as the new American Heart Association/European Resuscitation Council (AHA/ERC) guidelines emphasise. The patient in our case was a healthy young man who had a witnessed cardiac arrest due to a chest collision with the goalkeeper during a football match. Basic life support was immediately provided by his teammates until an automated external defibrillator was brought to the scene. Blunt cardiac injury (BCI) may result in injured myocardium or arrhythmias. Ventricular fibrillation due to BCI in absence of structural cardiac disease is one of the main causes of OHCA in young healthy athletes with high mortality rates. We demonstrate important aspects of the recently released guidelines on cardiac arrest and the chain of survival by the leading societies.

Cardiac Injuries: A Review of Multidetector Computed Tomography Findings

Trauma is the leading cause of death in United States in the younger population. Cardiac trauma is common following blunt chest injuries and is associated with high morbidity and mortality. This study discusses various multidetector computed tomography (MDCT) findings of cardiac trauma. Cardiac injuries are broadly categorized into the most commonly occurring blunt cardiac injury and the less commonly occurring penetrating injury. Signs and symptoms of cardiac injury can be masked by the associated injuries. Each imaging modality including chest radiographs, echocardiography, magnetic resonance imaging and MDCT has role in evaluating these patients. However, MDCT is noninvasive; universally available and has a high spatial, contrast, and temporal resolution. It is a one stop shop to diagnose and evaluate complications of cardiac injury. MDCT is an imaging modality of choice to evaluate patients with cardiac injuries especially the injuries capable of causing hemodynamic instability.

Complete heart block and asystole following blunt cardiac trauma

Cardiac contusion is a well-recognized complication of blunt chest trauma. Various conduction system disorders have been reported in association with this condition, the most common being right bundle branch block. Complete heart block (CHB) is seen rarely. Most cases of CHB are transient. We present the case of an 80-year-old woman who developed CHB and asystole following blunt cardiac trauma. Malignant cardiac arrhythmias such as CHB can be associated with blunt cardiac trauma. In most cases, CHB is transient resolving in days to weeks. In rare cases, however, CHB leads to asystole. Close monitoring and prompt intervention is thus required.

Identification of Cardiac and Aortic Injuries in Trauma with Multi-detector Computed Tomography

Blunt and penetrating cardiovascular (CV) injuries are associated with a high morbidity and mortality. Rapid detection of these injuries in trauma is critical for patient survival. The advent of multi-detector computed tomography (MDCT) has led to increased detection of CV injuries during rapid comprehensive scanning of stabilized major trauma patients. MDCT has the ability to acquire images with a higher temporal and spatial resolution, as well as the capability to create multiplanar reformats. This pictorial review illustrates several common and life-threatening traumatic CV injuries from a regional trauma center.

Serum Cardiac Troponin I in the Evaluation of Nonaccidental Trauma

OBJECTIVE

To determine if troponin I is more often elevated in children with suspected nonaccidental trauma (NAT) compared with uninjured children of similar age, and describe associations between troponin I elevation and NAT injuries.

STUDY DESIGN

Prospective 2-group study of children less than 2 years of age presenting to the emergency department with nonaccidental abdominal, thoracic, or intracranial injuries, and similarly aged uninjured children. Primary outcome was serum troponin I (≥ 0.04 ng/mL) using frozen blood samples from the 2 groups. Secondary outcomes included descriptive analyses of age, injury characteristics, and clinical appearance.

RESULTS

There were 129 subjects; 60 injured patients and 69 uninjured patients. Groups had similar age and sex. Troponin I was elevated in 38% of injured children compared with 17% of uninjured children (P = .008). No uninjured patient over 3 months of age had elevated troponin I. Abdominal trauma, acute rib fractures, or the child's ill-appearance in the emergency department were associated with having elevated troponin I.

CONCLUSIONS

Troponin I is more often elevated in children with suspected NAT than uninjured children. Elevation of troponin I in children greater than 3 months of age with suspected NAT is concerning for trauma. Occult cardiac injury is more likely to occur in children with inflicted abdominal trauma, acute rib fractures, or ill appearance.

Blunt Cardiac Injury in the Severely Injured - A Retrospective Multicentre Study

Background

Blunt cardiac injury is a rare trauma entity. Here, we sought to evaluate the relevance and prognostic significance of blunt cardiac injury in severely injured patients.

Methods

In a retrospective multicentre study, using data collected from 47,580 patients enrolled to TraumaRegister DGU (1993-2009), characteristics of trauma, prehospital / hospital trauma management, and outcome analysis were correlated to the severity of blunt cardiac injury. The severity of cardiac injury was assessed according to the abbreviated injury score (AIS score 1-6), the revised injury severity score (RISC) allowed comparison of expected outcome with injury severity-dependent outcome. N = 1.090 had blunt cardiac trauma (AIS 1-6) (2.3% of patients).

Results

Predictors of blunt cardiac injury could be identified. Sternal fractures indicate a high risk of the presence of blunt cardiac injury (AIS 0 [control]: 3.0%; AIS 1: 19.3%; AIS 2-6: 19.1%). The overall mortality rate was 13.9%, minor cardiac injury (AIS 1) and severe cardiac injury (AIS 2-6) are associated with higher rates. Severe blunt cardiac injury (AIS 4 and AIS 5-6) is associated with a higher mortality (OR 2.79 and 4.89, respectively) as compared to the predicted average mortality (OR 2.49) of the study collective.

Conclusion

Multiple injured patients with blunt cardiac trauma are at high risk to be underestimated. Careful evaluation of trauma patients is able to predict the presence of blunt cardiac injury. The severity of blunt cardiac injury needs to be stratified according to the AIS score, as the patients’ outcome is dependent on the severity of cardiac injury.

Efficacy of cardiac magnetic resonance for the qualitative diagnosis of blunt cardiac injury

Case

A 47-year-old man was admitted after a car collision in shock with cardiac tamponade. After his circulation was stabilized by pericardial drainage, we treated him conservatively. Abnormal laboratory data and initial electrocardiogram (ECG) were suggestive of myocardial injury. However, echocardiography and cardiac computed tomography could not reveal the cause of the tamponade or the site of cardiac injury. ECG-gated cardiac magnetic resonance images were acquired.

Outcome

The cardiac magnetic resonance black-blood T2-weighted images showed hyperintense signals in the interventricular septum, whereas the late gadolinium enhancement images showed no enhancement in this region. We could accurately diagnose cardiac contusion of the anteroseptal area, which would explain the initial ECG abnormality seen in this patient.

Conclusion

Cardiac magnetic resonance imaging may be especially useful in the evaluation of non-operative management of blunt cardiac injury and could explain the initial ECG abnormality seen in our patient.

Diagnostic implications of an elevated troponin in the emergency department

Objective. To determine the proportion of initial troponin (cTn) elevations associated with Type I MI versus other cardiovascular and noncardiovascular diagnoses in an emergency department (ED) and whether or not a relationship exists between the cTn level and the likelihood of Type I MI. Background. In the ED, cTn is used as a screening test for myocardial injury. However, the differential diagnosis for an initial positive cTn result is not clear. Methods. Hospital medical records were retrospectively reviewed for visits associated with an initial positive troponin I-ultra (cTnI), ≥0.05 μg/L. Elevated cTnI levels were stratified into low (0.05–0.09), medium (0.1–0.99), or high (≥1.0). Discharge diagnoses were classified into 3 diagnostic groups (Type I MI, other cardiovascular, or noncardiovascular). Results. Of 23,731 ED visits, 4,928 (21%) had cTnI testing. Of those tested, 16.3% had initial cTnI ≥0.05. Among those with elevated cTn, 11% were classified as Type I MI, 34% had other cardiovascular diagnoses, and 55% had a noncardiovascular diagnosis. Type I MI was more common with high cTnI levels (41% incidence) than among subjects with medium (9%) or low (6%). Conclusion. A positive cTn is most likely a noncardiovascular diagnosis, but Type I MI is far more common with cTnI levels ≥1.0.

Dual-source computed tomography may define cardiac contusion in patients with blunt chest trauma in ED

We report a 20-year-old woman with blunt chest trauma because of a motor vehicle injury who has traumatic asphyxia and hypotension. The diagnosis of blunt cardiac injury was put by using dual-energy computed tomography in the emergency department because other laboratory and imaging modalities were useless. After hospitalization in intensive care unit, she was treated with supportive and antiedema therapy. The patient was extubated on the fifth day and discharged on the ninth day without any sequel. Coexistence of traumatic asphyxia with blunt cardiac injury is rare. Several imaging techniques such as transthoracic and transesophageal echocardiography, contrast-enhanced multislice thorax computed tomography or initial electrocardiogram, and troponin I levels are used to detect the myocardial damage, but diagnostic capability is low. Dual-energy computed tomography is a promising new technology with the ability of defining blunt cardiac injuries and may have an indication in the emergency setting in patients with hemodynamic instability to rule in traumatic cardiac complications especially when electrocardiogram and transthoracic echocardiography are useless in the emergency department.

Mechanical Chest Compressions in Prolonged Cardiac Arrest due to ST Elevation Myocardial Infarction Can Cause Myocardial Contusion

Acute coronary syndrome is a common cause of sudden cardiac death. We present a case report of a 60-year-old man without a history of coronary artery disease who presented with ST-elevation myocardial infarction. During transportation to the hospital, he developed ventricular fibrillation (VF) and later pulseless electrical activity. Chest compressions with LUCAS 2 (Medtronic, Minneapolis, MN) automated mechanical compression-decompression device were initiated. Coronary angiography showed total occlusion of the left main coronary artery and primary percutaneous coronary intervention (PCI) was performed. After the PCI, his heart started to generate effective contractions and LUCAS could be discontinued. Return of spontaneous circulation was achieved after 90 minutes of cardiac arrest. The patient died of cardiogenic shock 11 hours later. An autopsy revealed a transmural anterolateral myocardial infarction but also massive subepicardial hemorrhage and interstitial edema and hemorrhages on histologic samples from regions of the myocardium outside the infarction itself and also from the right ventricle. These lesions were concluded to be a myocardial contusion. The true incidence of myocardial contusion as a consequence of mechanical chest compressions is not known. We speculate that severe myocardial contusion might have influenced outcome of our patient.

A combination of methylprednisolone and quercetin is effective for the treatment of cardiac contusion following blunt chest trauma in rats

Cardiac contusion is a potentially fatal complication of blunt chest trauma. The effects of a combination of quercetin and methylprednisolone against trauma-induced cardiac contusion were studied. Thirty-five female Sprague-Dawley rats were divided into five groups (n=7) as follows: sham, cardiac contusion with no therapy, treated with methylprednisolone (30 mg/kg on the first day, and 3 mg/kg on the following days), treated with quercetin (50 mg·kg⁻¹·day⁻¹), and treated with a combination of methylprednisolone and quercetin. Serum troponin I (Tn-I) and tumor necrosis factor-alpha (TNF-α) levels and cardiac histopathological findings were evaluated. Tn-I and TNF-α levels were elevated after contusion (P=0.001 and P=0.001). Seven days later, Tn-I and TNF-α levels decreased in the rats treated with methylprednisolone, quercetin, and the combination of methylprednisolone and quercetin compared to the rats without therapy, but a statistical significance was found only with the combination therapy (P=0.001 and P=0.011, respectively). Histopathological degeneration and necrosis scores were statistically lower in the methylprednisolone and quercetin combination group compared to the group treated only with methylprednisolone (P=0.017 and P=0.007, respectively). However, only degeneration scores were lower in the combination therapy group compared to the group treated only with quercetin (P=0.017). Inducible nitric oxide synthase positivity scores were decreased in all treatment groups compared to the untreated groups (P=0.097, P=0.026, and P=0.004, respectively). We conclude that a combination of quercetin and methylprednisolone can be used for the specific treatment of cardiac contusion.

Multidetector-row computed tomography of thoracic trauma

Imaging in trauma patients has dramatically evolved since the advent of computed tomography (CT), particularly multidetector CT (MDCT) technology. Axial MDCT images of the body can be acquired in seconds and shown any plane, allowing immediate viewing and interpreting. These factors make CT an invaluable means to detect many injuries not previously visible by any other noninvasive imaging techniques. Potentially subtle, but significant, thoracic injuries such as pneumothorax, haemothorax, aortic injury, sternal and spinal fractures can be detected on MDCT easily. In this article, the author will discuss the use of MDCT in the diagnosis of various thoracic injuries.

Cardiac changes after simulated behind armor blunt trauma or impact of nonlethal kinetic projectile ammunition

BACKGROUND

Cardiac-related injuries caused by blunt chest trauma remain a severe problem. The aim of this study was to investigate pathophysiological changes in the heart that might arise after behind armor blunt trauma or impacts of nonlethal projectiles.

METHODS

Sixteen pigs were shot directly at the sternum with "Sponge Round eXact I Mpact" (nonlethal ammunition; diameter 40 mm and weight 28 g) or hard-plastic ammunition (diameter 65 mm and weight 58 g) to simulate behind armor blunt trauma. To evaluate the influence of the shot location, seven additional pigs where exposed to an oblique heart shot. Physiologic parameters, electrocardiography, echocardiogram, the biochemical marker troponin I (TnI), and myocardial injuries were analyzed.

RESULTS

Nonlethal kinetic projectiles (101-108 m/s; 143-163 J) did not cause significant pathophysiological changes. Five of 18 pigs shot with 65-mm plastic projectiles (99-133 m/s; 284-513 J) to the front or side of the thorax died directly after the shot. No major physiologic changes could be observed in surviving animals. Animals shot with an oblique heart shot (99-106 m/s; 284-326 J) demonstrated a small, but significant decrease in saturation. Energy levels over 300 J caused increased TnI and myocardial damages in most of the pigs.

CONCLUSION

This study indicates that nonlethal kinetic projectiles "eXact iMpact" does not cause heart-related damage under the examined conditions. On impact, sudden heart arrest may occur independently from the cardiac's electrical cycle. The cardiac enzyme, TnI, can be used as a reliable diagnostic marker to detect heart tissue damages after blunt chest trauma.

Elevated cardiac troponin I level in cases of thoracic nonaccidental trauma

BACKGROUND

Injury patterns in nonaccidental trauma (NAT) often include injury to the chest. However, signs and symptoms of cardiac insult are often nonspecific and may be missed. Evaluation with serum cardiac troponin I (CTnI), a specific indicator of myocardial injury, could improve the comprehensive evaluation of patients with suspected NAT.

OBJECTIVE

The objective of this study was to describe the patient characteristics and results of CTnI testing in children with thoracic NAT.

METHODS

Children presenting to the emergency department were included if CTnI was obtained and they had at least one of the following: history of blunt trauma to the chest, bruising or abrasions to the chest, or fractures of the ribs, sternum, or clavicles. A serum CTnI level above 0.04 ng/mL was considered elevated.

RESULTS

Ten patients (6 males) with an age range from 2 months to 4 years (mean [SD], 20 [20] months) were identified during the 17-month study period. All patients were evaluated with NAT. Cardiac troponin I level was elevated in 7 (70%) of 10 patients with levels between 2 and 50 times the upper limit of normal.

CONCLUSIONS

This report is the first to document elevation of CTnI levels in cases of thoracic NAT. The elevation of the level of this specific biomarker may be indicative of sufficient chest trauma to result in the heart being injured, independent of the presence of cardiac decompensation or shock from other causes. Prospective evaluation of the forensic and clinical use of CTnI in this population is warranted.