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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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Cardiac contusions in the acute care setting: Historical background, evaluation and management. Am J Emerg Med 2022; 61:152-157. [PMID: 36116330 DOI: 10.1016/j.ajem.2022.09.005] [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: 06/21/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/21/2022] Open
Abstract
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.
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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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Vaz HA, Guimaraes RB, Dutra O. Challenges in high-sensitive troponin assay interpretation for intensive therapy. Rev Bras Ter Intensiva 2019; 31:93-105. [PMID: 30843948 PMCID: PMC6443313 DOI: 10.5935/0103-507x.20190001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/10/2018] [Indexed: 12/28/2022] Open
Abstract
Cardiac troponins T and I are considered highly sensitive and specific markers for the diagnosis of acute myocardial infarction. Currently, a series of nonprimary cardiac abnormalities may manifest as an elevation in high-sensitive assays. The reduction in their detection limits has allowed earlier diagnosis and the use of evidence-based therapeutic measures; however, this characteristic has increased the spectrum of detectable noncoronary heart diseases, which poses challenges for characterizing acute coronary syndromes and creates a new role for these tests in known disorders in intensive care units, especially sepsis. Management of patients through a greater understanding of how these markers behave should be re-evaluated to ensure their correct interpretation.
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Affiliation(s)
- Humberto Andres Vaz
- Unidade de Terapia Intensiva, Instituto de Cardiologia do Rio Grande do Sul, Fundação Universitária de Cardiologia - Porto Alegre (RS), Brasil
| | - Raphael Boesche Guimaraes
- Unidade de Terapia Intensiva, Instituto de Cardiologia do Rio Grande do Sul, Fundação Universitária de Cardiologia - Porto Alegre (RS), Brasil
| | - Oscar Dutra
- Unidade de Terapia Intensiva, Instituto de Cardiologia do Rio Grande do Sul, Fundação Universitária de Cardiologia - Porto Alegre (RS), Brasil
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Valle-Alonso J, Fonseca del Pozo F, Aguayo-López M, Pedraza J, Rosa-Úbeda F, López- Sánchez A. Transitory electrocardiographic abnormalities following blunt cardiac trauma: Case report and literature review. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2018. [DOI: 10.1016/j.hgmx.2016.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Abstract
Patients with traumatic cardiac injuries can present with wide variability in their severity of illness. The most severe will present in cardiac arrest, whereas the most benign may be altogether asymptomatic; most will fall somewhere in between. Management of cardiac injuries largely depends on mechanism of injury and patient physiology. Understanding the spectrum of injuries and their associated manifestations can help providers react more quickly and initiate potentially life-saving therapies more efficiently when time is critical. This article discusses the workup and management of both blunt and penetrating cardiac injuries.
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Affiliation(s)
- Seth A Bellister
- Division of Trauma and Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Bradley M Dennis
- Division of Trauma and Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA.
| | - Oscar D Guillamondegui
- Division of Trauma and Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
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Yun JH, Byun JH, Kim SH, Moon SH, Park HO, Hwang SW, Kim YH. Blunt Traumatic Cardiac Rupture: Single-Institution Experiences over 14 Years. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:435-442. [PMID: 27965920 PMCID: PMC5147468 DOI: 10.5090/kjtcs.2016.49.6.435] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 08/25/2016] [Accepted: 08/26/2016] [Indexed: 11/30/2022]
Abstract
Background Blunt traumatic cardiac rupture is rare. However, such cardiac ruptures carry a high mortality rate. This study reviews our experience treating blunt traumatic cardiac rupture. Methods This retrospective study included 21 patients who experienced blunt traumatic cardiac rupture from 1999 to 2015. Every patient underwent surgery. Several variables were compared between survivors and fatalities. Results Sixteen of the 21 patients survived, and 5 (24%) died. No instances of intraoperative mortality occurred. The most common cause of injury was a traffic accident (81%). The right atrium was the most common location of injury (43%). Ten of the 21 patients were suspected to have cardiac tamponade. Significant differences were found in preoperative creatine kinase–myocardial band (CK-MB) levels (p=0.042) and platelet counts (p= 0.004) between the survivors and fatalities. The patients who died had higher preoperative Glasgow Coma Scale scores (p=0.007), worse Trauma and Injury Severity Scores (p=0.007), and higher Injury Severity Scores (p=0.004) than those who survived. Conclusion We found that elevated CK-MB levels, a low platelet count, and multi-organ traumatic injury were prognostic factors predicting poor outcomes of blunt cardiac rupture. If a patient with blunt traumatic cardiac rupture has these factors, clinicians should be especially attentive and respond promptly in order to save the patient’s life.
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Affiliation(s)
- Jeong Hee Yun
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Joung Hun Byun
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine
| | - Sung Hwan Kim
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine
| | - Sung Ho Moon
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine
| | - Hyun Oh Park
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine
| | - Sang Won Hwang
- Department of Thoracic and Cardiovascular Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine
| | - Yong Hwan Kim
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine
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8
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Abstract
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.
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Affiliation(s)
- Sucheta Gosavi
- Division of Cardiology, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Alan H. Tyroch
- Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Debabrata Mukherjee
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
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10
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Skinner DL, Laing GL, Rodseth RN, Ryan L, Hardcastle TC, Muckart DJJ. Blunt cardiac injury in critically ill trauma patients: a single centre experience. Injury 2015; 46:66-70. [PMID: 25264354 DOI: 10.1016/j.injury.2014.08.051] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 08/13/2014] [Accepted: 08/31/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE This study describes the incidence and outcomes of blunt cardiac injury (BCI) in a single trauma intensive care unit (TICU), together with the spectrum of thoracic injuries and cardiac abnormalities seen in BCI. METHODS We performed a retrospective observational study of 169 patients with blunt thoracic trauma admitted from January 2010 to April 2013. BCI was diagnosed using an elevated serum troponin in the presence of either clinical, ECG or transthoracic echocardiography (TTE) abnormalities in keeping with BCI. The mechanism of injury, associated thoracic injuries and TTE findings in these patients are reported. RESULTS The incidence of BCI among patients with blunt thoracic trauma was 50% (n=84). BCI patients had higher injury severity scores (ISS) (median 37 [IQR 29-47]; p=0.001) and higher admission serum lactate levels (median 3.55 [IQR 2.4-6.2], p=0.008). In patients with BCI, the median serum TnI level was 2823ng/L (IQR 1353-6833), with the highest measurement of 64950ng/L. TTEs were performed on 38 (45%) patients with BCI, of whom 30 (79%) had abnormalities. Patients with BCI had a higher mortality (32% vs. 16%; p=0.028) and trended towards a longer length of stay (17.0 days [standard deviation (SD) 13.5] vs. 13.6 days [SD 12.0]; p=0.084). CONCLUSIONS BCI was associated with an increased mortality and a trend towards a longer length of stay in this study. It is a clinically relevant diagnosis which requires a high index of suspicion. Screening of high risk patients with significant blunt thoracic trauma for BCI with serum troponins should be routine practise. Patients diagnosed with BCI should undergo more advanced imaging such as TTE or TOE to exclude significant cardiac structural injury.
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Affiliation(s)
- D L Skinner
- Department of Critical Care, King Edward VIII Hospital, P/Bag X02 Congella 4013, Durban, KwaZulu-Natal 4083, South Africa; Perioperative Research Group, Department of Anaesthetics & Critical Care, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - G L Laing
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - R N Rodseth
- Perioperative Research Group, Department of Anaesthetics & Critical Care, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - L Ryan
- Perioperative Research Group, Department of Anaesthetics & Critical Care, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - T C Hardcastle
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Level I Trauma Unit and Trauma Intensive Care, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - D J J Muckart
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Level I Trauma Unit and Trauma Intensive Care, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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Abstract
Blunt cardiac injury has a wide spectrum of clinical presentations, some of them quite severe. Its definition varies throughout the literature. The purpose of this review is to describe the epidemiology, screening, diagnosis and management of blunt cardiac injury. Blunt cardiac injury complicates up to 30% of severe blunt force trauma. It can be classified into electrical and structural abnormalities. Screening modalities include electrocardiogram and cardiac enzymes. Serial negative electrocardiograms and troponins can safely rule out blunt cardiac injury. A transthoracic echocardiogram should be performed if persistent dysrhythmia or hypotension. All dysrhythmias should be treated. Patients with structural abnormalities rarely survive. In conclusion, blunt cardiac injury is prevalent after significant blunt trauma. The appropriate screening modalities should be employed and any abnormality to be treated.
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Affiliation(s)
- Emilie Joos
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Matthew D Tadloc
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
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Pfortmueller CA, Lindner G, Leichtle AB, Fiedler GM, Exadaktylos AK. Diagnostic significance of high sensitivity troponin in diagnosis of blunt cardiac injury. Intensive Care Med 2014; 40:623-4. [PMID: 24464357 DOI: 10.1007/s00134-013-3204-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Carmen Andrea Pfortmueller
- Department of General Internal Medicine, University Hospital and University of Bern, 3010, Bern, Switzerland,
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Khoriati AA, Rajakulasingam R, Shah R. Sternal fractures and their management. J Emerg Trauma Shock 2013; 6:113-6. [PMID: 23723620 PMCID: PMC3665058 DOI: 10.4103/0974-2700.110763] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 08/07/2012] [Indexed: 11/13/2022] Open
Abstract
Sternal fractures are predominantly associated with deceleration injuries and blunt anterior chest trauma. Sternal trauma must be carefully evaluated by monitoring of vital parameters and it is of paramount importance that concomitant injuries are excluded. Nevertheless, routine admission of patients with isolated sternal fractures for observation is still common in today's practice, which is often unnecessary. This article aims to describe the prognosis, the recommended assessment and management of patients with sternal fractures, to help clinicians make an evidence-based judgment regarding the need for hospitalization.
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Affiliation(s)
- Al-Achraf Khoriati
- Department of Trauma and Orthopaedics, Lister Hospital, Stevenage SG1 4AB, Hertfordshire, England
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Sangha GS, Pepelassis D, Buffo-Sequeira I, Seabrook JA, Fraser DD. Serum troponin-I as an indicator of clinically significant myocardial injury in paediatric trauma patients. Injury 2012; 43:2046-50. [PMID: 22119453 DOI: 10.1016/j.injury.2011.10.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 10/05/2011] [Accepted: 10/28/2011] [Indexed: 02/02/2023]
Abstract
Myocardial injury is a cause of mortality in paediatric trauma, but it is often difficult to diagnose. The objectives of this pilot study were to (1) determine the prevalence of elevated cardiac troponin I (TnI) in paediatric trauma patients and (2) to determine whether elevated TnI correlates with clinically significant myocardial injury, defined as abnormalities on echocardiogram (ECHO) and/or electrocardiograms (ECG). To this end, we investigated a convenient sample size of 59 paediatric trauma patients with an Injury Severity Score (ISS)>12. TnI and creatine kinase-MB (CK-MB) were measured on admission, at then at regular intervals until TnI had normalized. Patients with elevated TnI levels had an ECHO performed within 24h of admission and underwent daily ECGs until TnI normalized. Elevated serum TnI was found in n=16/59 (27%; 95% CI: 18-40%) patients and was associated with elevated CK-MB in all cases. Abnormal ECHOs were seen in 4/16 patients with elevated TnI, but peak TnI values did not correlate with abnormalities on ECHO (p=0.23). Only 1 patient had a clinically significant, albeit mild, decrease in cardiac function. All ECGs were normal. Patients with elevated TnI were more likely to be intubated (p=0.04), to have higher Injury Severity Scores (p=0.02), required more resuscitation fluid (p=0.001), and to have thoracic injuries (p<0.001). Our data indicates that the prevalence of elevated TnI in paediatric trauma patients is 27%; and whilst elevated TnI reflects overall trauma severity, it is frequently elevated without a clinically significance myocardial injury. Hence, large scale studies are required to determine if an elevated threshold TnI value can be identified to accurately diagnose severe myocardial injury in paediatric trauma.
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Affiliation(s)
- Gurinder S Sangha
- Emergency Medicine and Paediatrics, University of Western Ontario, London, ON, Canada
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ACCF 2012 expert consensus document on practical clinical considerations in the interpretation of troponin elevations: a report of the American College of Cardiology Foundation task force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2012; 60:2427-63. [PMID: 23154053 DOI: 10.1016/j.jacc.2012.08.969] [Citation(s) in RCA: 263] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Reiter T, Ritter O, Beer M, Petritsch B. An unusual finding after resuscitation: contusio cordis. Clin Res Cardiol 2012; 101:767-70. [PMID: 22476822 DOI: 10.1007/s00392-012-0449-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 03/22/2012] [Indexed: 11/28/2022]
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Kamdar G, Santucci K, Emerson BL. Management of Pediatric Cardiac Trauma in the ED. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2011. [DOI: 10.1016/j.cpem.2011.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Al-Otaiby MA, Al-Amri HS, Al-Moghairi AM. The clinical significance of cardiac troponins in medical practice. J Saudi Heart Assoc 2010; 23:3-11. [PMID: 23960628 DOI: 10.1016/j.jsha.2010.10.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 10/09/2010] [Indexed: 12/16/2022] Open
Abstract
Troponins are regulatory proteins that form the cornerstone of muscle contraction. The amino acid sequences of cardiac troponins differentiate them from that of skeletal muscles, allowing for the development of monoclonal antibody-based assay of troponin I (TnI) and troponin T (TnT). Along with the patient history, physical examination and electrocardiography, the measurement of highly sensitive and specific cardiac troponin has supplanted the former gold standard biomarker (creatine kinase-MB) to detect myocardial damage and estimate the prognosis of patients with ischemic heart disease. The current guidelines for the diagnosis of non-ST segment elevation myocardial infarction are largely based on an elevated troponin level. The implementation of these new guidelines in clinical practice has led to a substantial increase in the frequency of myocardial infarction diagnosis. Automated assays using cardiac-specific monoclonal antibodies to cardiac TnI and TnT are commercially available. They play a major role in the evaluation of myocardial injury and prediction of cardiovascular outcome in cardiac and non-cardiac causes. In this review we discuss the clinical applications of cardiac troponins and the interpretation of elevated levels in the context of various clinical settings.
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Mavinkurve-Groothuis AMC, Kapusta L, Nir A, Groot-Loonen J. The role of biomarkers in the early detection of anthracycline-induced cardiotoxicity in children: a review of the literature. Pediatr Hematol Oncol 2008; 25:655-64. [PMID: 18850478 DOI: 10.1080/08880010802244001] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Anthracycline-induced cardiotoxicity can cause serious health problems for an increasing number of children surviving childhood malignancies. Early detection of cardiac failure is critically important for the prevention and management of anthracycline-induced cardiotoxicity. The aim of this research was to determine the role of biomarkers in the early detection of anthracycline-induced cardiotoxicity in children. A literature review is presented of studies regarding the use of the biomarkers B-type natriuretic peptide (BNP), N-terminal pro-BNP (NT-pro-BNP), cardiac troponin T (cTnT), and cardiac troponin I (cTnI) in relation with anthracycline-induced cardiotoxicity in children. Six of 14 studies in children showed a significant relation between elevated biomarkers BNP, NT-pro-BNP, and cTnT and cardiac dysfunction. Six studies, although small, suggest that BNP, NT-pro-BNP, and cTnT might be useful markers in the early detection of anthracycline-induced cardiotoxicity.
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Carreras González E, Carreras González G, Álvarez Pérez R. Traumatismos torácicos graves. Revisión de 39 casos. An Pediatr (Barc) 2007; 67:553-8. [DOI: 10.1016/s1695-4033(07)70803-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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22
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Klaase JM, Swaanenburg JCJM, Schouwink H, Sosef MN, Bonfrer JMG, Zoetmulder FAN, Rutgers EJT, Baas P. Monitoring of Impending Myocardial Damage After Pleuropneumonectomy and Intraoperative Photodynamic Therapy for Malignant Pleural Mesothelioma Using Biochemical Markers. Photochem Photobiol 2007. [DOI: 10.1562/0031-8655(2000)0710351moimda2.0.co2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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23
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Diniz P, Schwartz D, Collicchio-Zuanaze R. Cardiac trauma confirmed by cardiac markers in dogs: two case reports. ARQ BRAS MED VET ZOO 2007. [DOI: 10.1590/s0102-09352007000100015] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Two clinical cases of cardiac contusion in dogs were studied Radiographic evaluation showed pneumothorax and alveolar pattern on diaphragmatic pulmonary lobe in one dog, and arrhythmias in both dogs. Cardiac troponin I and CK-MB serum analysis associated with clinical history and eletrocardiographic findings indicated accurately the extension of myocardial injury secondary to trauma.
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24
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Stahel PF, Schneider P, Buhr HJ, Kruschewski M. [Emergency management of thoracic trauma]. DER ORTHOPADE 2005; 34:865-79. [PMID: 16044335 DOI: 10.1007/s00132-005-0845-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Thoracic injuries are a major cause of mortality during the "golden hour" of trauma. Many patients with chest trauma die after reaching the hospital. Less than 10% of all blunt thoracic injuries require a thoracotomy, and many potentially life-threatening conditions can be relieved by simple procedures, such as chest tube insertion.Thus, many cases of traumatic deaths due to chest injury may be prevented by prompt diagnosis and a standardized therapeutic approach in the emergency room. A high index of suspicion for lethal injury patterns, based on the mechanism of trauma and the clinical presentation, is a crucial prerequisite for an adequate initial assessment and management of patients with chest trauma. The worldwide implementation of standardized diagnostic and therapeutic guidelines, such as the "Advanced Trauma Life Support" (ATLS) protocol, has led to a significant reduction of early deaths attributed to thoracic injuries.
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Affiliation(s)
- P F Stahel
- Klinik für Unfall- und Wiederherstellungschirurgie, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany.
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25
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Rajan GP, Zellweger R. Cardiac Troponin I as a Predictor of Arrhythmia and Ventricular Dysfunction in Trauma Patients With Myocardial Contusion. ACTA ACUST UNITED AC 2004; 57:801-8; discussion 808. [PMID: 15514534 DOI: 10.1097/01.ta.0000135157.93649.72] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Myocardial contusion during blunt chest trauma is common and may lead to potentially fatal cardiac complications. Therefore, it is useful to identify a serum marker reflecting the myocardial damage that can predict risk for cardiac complications. In this study, the authors determined the strength of the association between cardiac troponin I (cTnI) levels and the risk of arrhythmia or the development of left ventricular dysfunction in a cohort of patients with blunt chest trauma. METHODS AND RESULTS In 187 multiply injured patients with blunt chest trauma, serial measurements of cTnI, total creatine kinase (CK), and isoenzyme of creatine kinase with muscle and brain subunits (CK-MB) were combined with sequential electrocardigraphic and echocardiographic recordings. The results showed that 63 patients (34%) had myocardial contusion, as defined by positive cTnI levels, of which 47 (25%) were symptomatic and 16 (9%) showed no abnormalities. The remaining 124 patients (66%) displaying negative CTnI levels were asymptomatic during the entire study. Severity of arrhythmia correlated directly with increase in cTnI levels. The levels of cTnI in the symptomatic group remained elevated significantly longer than the levels in the asymptomatic group. The depression of left ventricular ejection fraction was inversely correlated with the increase in cTn levels. The patients whose cTnI levels were below 1.05 microg/L at admission and during the first 6 hours afterward showed no cardiac abnormalities throughout the entire study period CONCLUSIONS Levels of cTnI below 1.05 microg/L in asymptomatic patients at admission and within the first 6 hours after admission rule out myocardial injury, whereas positive cTn levels above 1.05 microg/L mandate further cardiologic workup for the detection and management of myocardial injury. Furthermore, the dynamics and peak levels of pathologic cTnI levels allow estimation of arrhythmia risk and left ventricular dysfunction in trauma patients with myocardial contusion.
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Affiliation(s)
- Gunesh P Rajan
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland.
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Bernardis V, Kette F, Blarasin L, Pegoraro C, Coassin R. Isolated myocardial contusion in blunt chest trauma. Eur J Emerg Med 2004; 11:287-90. [PMID: 15359204 DOI: 10.1097/00063110-200410000-00010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of this case report was to document a rare case of isolated myocardial contusion in the setting of blunt thoracic trauma. Although demonstrated by electrocardiogram and myocardium-specific enzymes, the trauma had no clinical relevance and the patient was discharged uneventfully from the intensive care unit. The clinical significance of blunt myocardial contusion is then discussed.
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Affiliation(s)
- Valentina Bernardis
- Department of Emergency Medicine, San Vito al Tagliamento Hospital, San Vito al Tagliamento (PN), Italy
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28
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Lehrke S, Steen H, Sievers HH, Peters H, Opitz A, Müller-Bardorff M, Wiegand UKH, Katus HA, Giannitsis E. Cardiac troponin T for prediction of short- and long-term morbidity and mortality after elective open heart surgery. Clin Chem 2004; 50:1560-7. [PMID: 15217992 DOI: 10.1373/clinchem.2004.031468] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Increased cardiac troponins in blood are observed after virtually every open heart surgery, indicating perioperative myocardial cell injury. We sought to determine the optimum time point for blood sampling and the respective cutoff value of cardiac troponin T (cTnT) for risk assessment in patients undergoing cardiac surgery. METHODS In a series of 204 patients undergoing scheduled open heart surgery, mainly for coronary artery bypass grafting (n = 132) or valve repair (n = 27), cTnT concentrations were measured before and 4 and 8 h after cross-clamping and then daily for 7 days. Individual risk was assessed by use of the Cleveland Clinic Foundation Risk score and intraoperative risk indicators such as duration of cardiopulmonary bypass, cross-clamping, and perioperative release of cardiac markers. Patients were followed for 28 months. RESULTS Cardiac mortality, all-cause mortality rates, and rates of nonfatal acute myocardial infarction (AMI) at 28 months were 6.9%, 8.8%, and 6.8%, respectively. cTnT was higher in patients with Q-wave AMI or postoperative heart failure requiring inotropic support, and in nonsurvivors. The ROC curve revealed a cTnT > or = 0.46 microg/L at 48 h as the optimum discriminator for long-term cardiac mortality. Stepwise logistic regression identified higher Cleveland Clinic Risk Score [odds ratio (OR) = 2.6 per point], cross-clamp time >65 min (OR = 6.6), and cTnT (OR = 4.9) as significant and independent predictors of long-term cardiac mortality. CONCLUSIONS A single postoperative cTnT measurement can be used to estimate myocardial cell injury that impacts long-term survival after open heart surgery. It adds independently to established risk indicators.
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Affiliation(s)
- Stephanie Lehrke
- Johns Hopkins University, Department of Cardiology, Baltimore, MD, USA
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29
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Abstract
Cardiac contusion is usually caused by blunt chest trauma and therefore is frequently suspected in patients involved in car or motorcycle accidents. The diagnosis of a myocardial contusion is difficult because of non-specific symptoms and the lack of an ideal test to detect myocardial damage. Cardiac contusion can cause life threatening arrhythmias and cardiac failure. Many diagnostic methods, such as ECG, biochemical cardiac markers, transthoracic and transoesophageal echocardiography, and radionuclide imaging studies, have been investigated to determine their use in predicting such complications. Recently, cardiac troponin I and T were found to be highly sensitive for myocardial injury. Troponin I and T have also proved to be useful in the stratification of patients at risk for complications. Nevertheless, diagnosis of a cardiac contusion and identification of patients at risk remain a challenge. In this review the current diagnostic tests will be discussed. Also, based on these diagnostic tests, a screening strategy containing data from the latest studies is presented, with the intention of detecting patients at risk.
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Affiliation(s)
- K C Sybrandy
- Heart Lung Centre Utrecht, Department of Cardiology, University Medical Centre, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
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30
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Bock JL. Test strategies for the detection of myocardial damage. Clin Lab Med 2002; 22:357-75. [PMID: 12134465 DOI: 10.1016/s0272-2712(01)00006-3] [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: 11/23/2022]
Abstract
In the space of half a century, cardiac marker testing has advanced incrementally from enzymes present in nearly all tissues to proteins having remarkable specificity for myocardium. Markers with other desirable properties, such as earlier release, have also been introduced and others may be anticipated, although a single perfect marker is not on the horizon. Optimum application of these new markers still requires improved robustness and harmonization of commercial assays, and continuing insights in the pathophysiology of acute coronary syndromes. As these advances occur, future testing will likely focus more on therapeutic decisions than on arbitrary diagnostic classifications.
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Affiliation(s)
- Jay L Bock
- Department of Pathology, University Hospital and Medical Center, Stony Brook University, Stony Brook, NY 11794-7300, USA.
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Karpas A, Yen K, Sell LL, Frommelt PC. Severe blunt cardiac injury in an infant: a case of child abuse. THE JOURNAL OF TRAUMA 2002; 52:759-64. [PMID: 11956397 DOI: 10.1097/00005373-200204000-00026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Anna Karpas
- Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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Affiliation(s)
- Charlotte Pooler
- Charlotte Pooler is an instructor of advanced studies in critical care nursing and Anna Barkman is an instructor in undergraduate nursing at Mount Royal College in Calgary, Alberta, Canada
| | - Anna Barkman
- Charlotte Pooler is an instructor of advanced studies in critical care nursing and Anna Barkman is an instructor in undergraduate nursing at Mount Royal College in Calgary, Alberta, Canada
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Abstract
Cardiac contusion is an infrequent but occasionally serious complication of deceleration injury. According to ATLS teaching, the true diagnosis of contusion can only be established by direct inspection of the myocardium. The clinically important sequelae of myocardial contusion are hypotension and arrhythmia. Despite recent advances in investigative techniques, myocardial trauma remains an important diagnostic and management challenge. This paper presents an evidence-based review of the topic.
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Affiliation(s)
- P Kaye
- Emergency Department, Bristol Royal Infirmary, Bristol, UK
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Swaanenburg JCJM, Loef BG, Volmer M, Boonstra PW, Grandjean JG, Mariani MA, Epema AH. Creatine Kinase MB, Troponin I, and Troponin T Release Patterns after Coronary Artery Bypass Grafting with or without Cardiopulmonary Bypass and after Aortic and Mitral Valve Surgery. Clin Chem 2001. [DOI: 10.1093/clinchem/47.3.584] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | | | | | | | | | - Anne H Epema
- Department of Anesthesiology, University Hospital Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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Parekh N, Venkatesh B, Cross D, Leditschke A, Atherton J, Miles W, Winning A, Clague A, Rickard C. Cardiac troponin I predicts myocardial dysfunction in aneurysmal subarachnoid hemorrhage. J Am Coll Cardiol 2000; 36:1328-35. [PMID: 11028491 DOI: 10.1016/s0735-1097(00)00857-3] [Citation(s) in RCA: 174] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We studied the incidence of myocardial injury in aneurysmal subarachnoid hemorrhage (SAH) using the more sensitive cardiac troponin I (cTnI) assay, correlated changes in cTnI with creatine kinase, MB fraction (CK-MB), myoglobin, and catecholamine metabolite assays, and examined the predictive value of changes in cTnI for myocardial dysfunction. BACKGROUND Myocardial injury in aneurysmal SAH as evidenced by elevated CK-MB fraction has been reported. Little published data exist on the value of cTnI measurements in aneurysmal SAH. METHODS Thirty-nine patients were studied for seven days. Clinical cardiovascular assessment, electrocardiographic (ECG), echocardiography, cTnI, CK, CK-MB and CK-MB index, myoglobin and 24-h urinary catecholamine assays were performed in all patients. The ECG abnormalities were defined by the presence of ST-T changes, prolonged QT intervals, and arrhythmias. An abnormal echocardiogram was defined by the presence of wall-motion abnormalities and a reduced ejection fraction. The severity of SAH was graded clinically and radiologically. RESULTS Eight patients demonstrated elevations in cTnI (upper limit of normal is 0.1 microg/liter with the immunoenzymatic assay and 0.4 microg/liter with the sandwich immunoassay), while five had abnormal CK-MB levels (upper limit of normal is 8 microg/liter). Patients with more severe grades of SAH were more likely to develop a cTnI leak (p < 0.05). Patients with cTnI elevations were more likely to demonstrate ECG abnormalities (p < 0.01) and manifest clinical myocardial dysfunction (p < 0.01) as evidenced by the presence of a gallop rhythm on auscultation and clinical or radiological evidence of pulmonary edema as compared to those with CK-MB elevations. The sensitivity and specificity of cTnI to predict myocardial dysfunction were 100% and 91%, respectively, whereas the corresponding figures for CK-MB were 60% and 94%, respectively. Elevations in myoglobin levels (upper limit of normal <70 microg/liter) and urinary catecholamine metabolites (urinary vanilmandelate/creatinine ratio upper limit of normal, 2.6) are a nonspecific finding. CONCLUSIONS Measurements of cTnI reveal a higher incidence of myocardial injury than predicted by CK-MB in aneurysmal SAH, and elevations of cTnI are associated with a higher incidence of myocardial dysfunction. Thus, cTnI is a highly sensitive and specific indicator of myocardial dysfunction in aneurysmal SAH.
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Affiliation(s)
- N Parekh
- Royal Brisbane Hospital, Herston, Australia
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Bertinchant JP, Polge A, Mohty D, Nguyen-Ngoc-Lam R, Estorc J, Cohendy R, Joubert P, Poupard P, Fabbro-Peray P, Monpeyroux F, Poirey S, Ledermann B, Raczka F, Brunet J, Nigond J, de la Coussaye JE. Evaluation of incidence, clinical significance, and prognostic value of circulating cardiac troponin I and T elevation in hemodynamically stable patients with suspected myocardial contusion after blunt chest trauma. THE JOURNAL OF TRAUMA 2000; 48:924-31. [PMID: 10823538 DOI: 10.1097/00005373-200005000-00018] [Citation(s) in RCA: 116] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The frequency and prognostic influence of myocardial injury in patients with blunt chest trauma is controversial. We investigated the value of cardiac troponin I (cTn-I) and cardiac troponin T (cTn-T), highly specific markers of myocardial injury, to determine whether their measurement would improve the ability to detect myocardial contusion in stable patients with blunt chest trauma in comparison with conventional markers and whether they were associated with significantly worse late clinical outcome. METHODS AND RESULTS Over an 18-month period, myocardial contusion was diagnosed in 26 of 94 patients (27.6%) with acute blunt chest trauma (motor vehicle crash; 81%), because of echocardiographic abnormalities (n = 12), electrocardiographic abnormalities (n = 29), or both. Patients with myocardial contusion had a significantly higher Injury Severity Score at the time of admission (p = 0.001) and a significantly longer hospital stay (p = 0.0008). All patients survived admission to hospital and were hemodynamically stable. None of the patients died or had severe in-hospital cardiac complications. The percentage of patients with elevated CK, (CK-MB/total CK) ratio, or CK-MB mass concentration was not significantly different between patients with or without myocardial contusion. However, there were significant differences between the two groups when we applied the commonly used threshold levels of CK-MB activity and myoglobin. The percentage of patients with elevated circulating cTn-I and cTn-T (> or = 0.1 microg/L) was significantly higher in patients with myocardial contusion (23% vs. 3%; p = 0.01 and 12% vs. 0%; p = 0.03, respectively). Complete changes in cTn-I and cTn-T correlated well (r = 0.91, p = 0.0001). Sensitivity, specificity, and negative and positive predictive values of cTn-I and cTn-T in predicting a myocardial contusion in blunt trauma patients were 23%, 97%, and 77%, 75%, and 12%, 100%, and 74%, 100%, respectively. Clinical follow-up was available in 83 patients (88%) (mean, 16 +/- 7.5 months). There were no deaths in either group directly attributed to cardiac complications. None of the patients had any long-term cardiac complications or myocardial failure related to blunt chest trauma. CONCLUSION Although improved specificity of cTn-I and cTn-T compared with conventional markers, it should be emphasized that the main problem with cTn-I and cTn-T is low sensitivity as well as low predictive values in diagnosing myocardial contusion. cTn-I and cTn-T measurement is currently not an improved method in diagnosing blunt cardiac injury in hemodynamically stable patients. Moreover, there was no association of postmyocardial contusion cell injury and late outcome in these patients when cTn-I and cTn-T and other conventional markers were considered.
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Affiliation(s)
- J P Bertinchant
- Department of Cardiology, University Hospital, Nîmes, France.
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