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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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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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Štěchovský C, Hájek P, Cipro Š, Veselka J. Risk of myocardial contusion in cardiac arrest patients resuscitated with mechanical chest compression device. Int J Cardiol 2014; 182:50-1. [PMID: 25590957 DOI: 10.1016/j.ijcard.2014.12.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 12/21/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Cyril Štěchovský
- Department of Cardiology, 2nd Medical School, Charles University, Motol University Hospital, Prague, Czech Republic.
| | - Petr Hájek
- Department of Cardiology, 2nd Medical School, Charles University, Motol University Hospital, Prague, Czech Republic
| | - Šimon Cipro
- Department of Pathology and Molecular Medicine, 2nd Medical School, Charles University, Motol University Hospital, Prague, Czech Republic
| | - Josef Veselka
- Department of Cardiology, 2nd Medical School, Charles University, Motol University Hospital, Prague, Czech Republic
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Restrepo CS, Gutierrez FR, Marmol-Velez JA, Ocazionez D, Martinez-Jimenez S. Imaging Patients with Cardiac Trauma. Radiographics 2012; 32:633-49. [DOI: 10.1148/rg.323115123] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Co SJ, Yong-Hing CJ, Galea-Soler S, Ruzsics B, Schoepf UJ, Ajlan A, Aljan A, Farand P, Nicolaou S. Role of imaging in penetrating and blunt traumatic injury to the heart. Radiographics 2012; 31:E101-15. [PMID: 21768229 DOI: 10.1148/rg.314095177] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiac injury due to blunt or penetrating chest trauma is common and is associated with significant morbidity and mortality. Understanding the mechanisms, types, and complications of cardiac injuries and the roles of various imaging modalities in characterizing them is important for appropriate diagnosis and treatment. These injuries have not been well documented at imaging, but there are now fast and accurate methods for evaluating the heart and associated mediastinal structures. The authors review the broad spectrum of injuries that can result from blunt or penetrating trauma to the chest, as well as the imaging modalities commonly used in the acute trauma setting for evaluation of the heart and mediastinal structures. A pictorial review of both common and, to date, rarely documented cardiac injuries imaged with a variety of modalities is also presented. While many imaging modalities are available, the authors demonstrate the value of multidetector computed tomography (CT) for the initial evaluation of patients with blunt or penetrating chest trauma. With the advent of multidetector CT, imaging of cardiac injury has increased and accurate identification of these rare but potentially lethal injuries has become paramount for improving survival. Selection of the most appropriate modality for evaluation and recognition of the imaging findings in cardiac injuries in the acute trauma setting is important to expedite treatment and improve survival.
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Affiliation(s)
- Steven J Co
- Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
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Du W, Xiong X, Yang W, Wang X, Li T. Dobutamine stress echocardiography assessment of myocardial contusion due to blunt impact in dogs. Cell Biochem Biophys 2011; 62:169-75. [PMID: 21910029 DOI: 10.1007/s12013-011-9278-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
We sought to investigate the role of two-dimensional stress echocardiography in the early assessment of myocardial contusion. For this purpose, 12 dogs, weighing 11.36 ± 1.50 kg, were selected and the myocardial contusion was experimentally induced. Two-dimensional dobutamine stress echocardiography (DSE) was used to detect abnormal myocardial motions segments at time phases of baseline and 0.5, 2, 4, and 8 h post-wounding. Finally, the above results were compared with pathological findings. The data show that after the dogs were induced to have severe myocardial contusion, 122 segments were found with abnormal myocardial wall motions at 0.5 h post-wounding, 133 segments at 2 h post-wounding, and 142 segments, each, at 4 h and 8 h post-wounding. The wall motion score (WMS) and wall motion score index (WMSI) increased (P < 0.001) as compared with the pre-impaction values. Considering the left ventricular axis view as the standard section, in the 60 segments examined by echocardiography, 54 segments were found to have wall motion abnormalities. Comparing with the results of pathological TTC staining, the sensitivity and specificity were found to be 100 and 66.6%, respectively. It was, therefore, concluded that two-dimensional DSE was a valuable technique in the early diagnosis of myocardial contusion due to its better sensitivity and specificity.
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Affiliation(s)
- WenHua Du
- Department of Ultrasound, Daping Hospital & Research Institute of Surgery, The Military Medical University, Chongqing, China
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Agarwal D, Chandra S. Challenges in the diagnosis of blunt cardiac injuries. Indian J Surg 2009; 71:245-53. [PMID: 23133167 DOI: 10.1007/s12262-009-0078-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Accepted: 07/14/2009] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Blunt thoracic injuries (BTIs) are directly responsible for 20-25% of all deaths, worldwide. Involvement of heart in BTIs is largely underestimated and ignored, but reasonable estimate would be around 15%. This study was planned to emphasize on clinical-presentation and diagnosis of blunt cardiac injuries (BCIs). RESULTS Clinical presentation of BCIs, varied from mild chest discomfort to haemodynamic shock secondary to rapid exsanguinations. Non-specific presentation with associated injuries diverts physician's attention and delayed appearance of clinical features makes diagnosis further difficult. Cardiac markers and ECG are not specific, but high sensitivity of 100% could be reached using combination of elevated cardiactroponin levels and alterations in ECG. Transoesophageal or transthoracic echocardiography, angiography, intravascular ultrasound and nuclear scan have proven to detect cardiac injuries in BTIs, but lack specificity. CONCLUSION Patients with suspicious-ECG finding need cardiac-monitoring for at least 24 hours. Haemodynamically stable young (<55 years) subjects, without underlying cardiac diseases and with normal-ECG and cardiac marker, could be discharged safely.
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Huguet M, Tobon-Gomez C, Bijnens BH, Frangi AF, Petit M. Cardiac injuries in blunt chest trauma. J Cardiovasc Magn Reson 2009; 11:35. [PMID: 19761581 PMCID: PMC2762967 DOI: 10.1186/1532-429x-11-35] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 09/17/2009] [Indexed: 11/10/2022] Open
Abstract
Blunt chest traumas are a clinical challenge, both for diagnosis and treatment. The use of cardiovascular magnetic resonance can play a major role in this setting. We present two cases: a 12-year-old boy and 45-year-old man. Late gadolinium enhancement imaging enabled visualization of myocardial damage resulting from the trauma.
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Affiliation(s)
- Marina Huguet
- Department of Magnetic Resonance Imaging of Cetir Sant Jordi, Barcelona, Spain
- Networking Research Center on Bioengineering, Biomaterials and Nanomedicine, Barcelona, Spain
| | - Catalina Tobon-Gomez
- Department of Magnetic Resonance Imaging of Cetir Sant Jordi, Barcelona, Spain
- Networking Research Center on Bioengineering, Biomaterials and Nanomedicine, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Bart H Bijnens
- Networking Research Center on Bioengineering, Biomaterials and Nanomedicine, Barcelona, Spain
- Center for Computational Imaging and Simulation Technologies in Biomedicine, Universitat Pompeu Fabra, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Alejandro F Frangi
- Center for Computational Imaging and Simulation Technologies in Biomedicine, Universitat Pompeu Fabra, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Marius Petit
- Centro Cardiovascular Sant Jordi, Barcelona, Spain
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Barker S, Ghaemmaghami C. Myocardial contusion–induced right bundle-branch block with ST elevation and troponin elevation. Am J Emerg Med 2009; 27:375.e5-375.e7. [DOI: 10.1016/j.ajem.2008.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Accepted: 08/09/2008] [Indexed: 11/16/2022] Open
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El-Chami MF, Nicholson W, Helmy T. Blunt Cardiac Trauma. J Emerg Med 2008; 35:127-33. [DOI: 10.1016/j.jemermed.2007.03.018] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2005] [Revised: 05/16/2006] [Accepted: 10/02/2006] [Indexed: 10/23/2022]
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Velmahos GC, Butt MU. Cardiac and Pulmonary Injury. Eur J Trauma Emerg Surg 2008; 34:327. [PMID: 26815810 DOI: 10.1007/s00068-008-8099-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 07/02/2008] [Indexed: 11/28/2022]
Abstract
Cardiac and pulmonary injuries present major challenges in diagnosis and treatment. Distinct differences between penetrating and blunt trauma of these organs exist. Outcomes for severe injuries are still grave. Organized trauma systems can provide optimal care by minimizing prehospital time, allowing easy access to imaging modalities, and offering state-of-the-art treatment strategies. A multidisciplinary approach, including surgeons, intensivists, and others, is absolutely necessary.
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Affiliation(s)
- George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
| | - Muhammad U Butt
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, MA, Boston, USA
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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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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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Welch RD. Management of traumatically injured patients in the emergency department observation unit. Emerg Med Clin North Am 2001; 19:137-54. [PMID: 11214395 DOI: 10.1016/s0733-8627(05)70172-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An EDOU may be an ideal setting for the short-term monitoring and treatment of certain acutely injured patients. The patients choosen for observation, and the diagnostic studies used, will be specific to a particular institution's availability and expertise. Pathways should be developed in conjunction with all services caring for these patients.
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Affiliation(s)
- R D Welch
- Department of Emergency Medicine, Wayne State University School of Medicine, Detriot, Michigan, USA.
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Swaanenburg JC, Klaase JM, DeJongste MJ, Zimmerman KW, ten Duis HJ. Troponin I, troponin T, CKMB-activity and CKMB-mass as markers for the detection of myocardial contusion in patients who experienced blunt trauma. Clin Chim Acta 1998; 272:171-81. [PMID: 9641358 DOI: 10.1016/s0009-8981(98)00014-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Myocardial contusion is an infrequent, but sometimes serious complication in patients who experienced deceleration (blunt) trauma. We investigated the assessment of the new cardiac markers troponin I (cTnI) and troponin T (cTnT) in relation to the conventional CKMB-activity, the CKMB-activity/CK-total ratio, CKMB-mass and the CKMB-mass/CK-total ratio for the detection of myocardial contusion in 89 patients with blunt trauma (38 patients with thoracic injuries and 51 patients without thoracic injuries). All parameters were analysed at admission (t1) and 24 h after admission (t2). For the patients with thoracic injuries, at t1 cTnI was elevated in three, and cTnT in four patients; at t2 both cTnI and cTnT were elevated in nine patients. At t1, eighteen to thirty patients had increased levels of the conventional parameters; at t2 this was true for six to thirty-five patients. For the patients without thoracic injuries all cTnI and cTnT levels were within the reference ranges at t1. At t2 one patient, who experienced an acute myocardial infarction, had elevated cTnI and cTnT levels. At t1, five to thirty-five patients had increased levels of the conventional parameters; at t2 this was true for four to forty-two patients. From this study we conclude that the conventional parameters are not useful for the detection of myocardial contusion in patients experiencing blunt trauma. The parameters cTnI and cTnT are equally accurate and more reliable for the selection of patients who require intensive cardiac monitoring. If at admission the cTnI or the cTnT levels are within the reference ranges, a second analysis after admission is necessary to reach a reliable conclusion concerning myocardial contusion as a result of trauma on basis of the troponin levels.
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Affiliation(s)
- J C Swaanenburg
- Central Clinical Chemical Laboratory, University Hospital Groningen, The Netherlands.
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