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Biffl WL, Fawley JA, Mohan RC. Diagnosis and management of blunt cardiac injury: What you need to know. J Trauma Acute Care Surg 2024; 96:685-693. [PMID: 37968802 DOI: 10.1097/ta.0000000000004216] [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: 11/17/2023]
Abstract
ABSTRACT Blunt cardiac injury (BCI) encompasses a wide spectrum, from occult and inconsequential contusion to rapidly fatal cardiac rupture. A small percentage of patients present with abnormal electrocardiogram or shock, but most are initially asymptomatic. The potential for sudden dysrhythmia or cardiac pump failure mandates consideration of the presence of BCI, including appropriate monitoring and management. In this review, we will present what you need to know to diagnose and manage BCI.
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Affiliation(s)
- Walter L Biffl
- From the Division of Trauma/Acute Care Surgery (W.L.B., J.A.F.) and Division of Cardiology (R.C.M.), Scripps Clinic/Scripps Clinic Medical Group, La Jolla, California
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Predictors of Mortality in Blunt Cardiac Injury: A Nationwide Analysis. J Surg Res 2023; 281:22-32. [PMID: 36108535 DOI: 10.1016/j.jss.2022.07.047] [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: 03/13/2022] [Revised: 06/28/2022] [Accepted: 07/29/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Blunt thoracic injury (BTI) is one of the most common causes of trauma admission in the United States and is uncommonly associated with cardiac injuries. Blunt cardiac injury (BCI) after blunt thoracic trauma is infrequent but carries a substantial risk of morbidity and sudden mortality. Our study aims to identify predictors of concomitant cardiac contusion among BTI patients and the predictors of mortality among patients presenting with BCI on a national level. MATERIALS AND METHODS We performed a 1-y (2017) analysis of the American College of Surgeons Trauma Quality Improvement Program. We included all adults (aged ≥ 18 y) with the diagnosis of BTI. We excluded patients who were transferred, had a penetrating mechanism of injury, and who were dead on arrival. Our primary outcomes were the independent predictors of concomitant cardiac contusions among BTI patients and the predictors of mortality among BCI patients. Our secondary outcome measures were in-hospital complications, differences in injury patterns, and injury severity between the survivors and nonsurvivors of BCI. RESULTS A total of 125,696 patients with BTI were identified, of which 2368 patients had BCI. Mean age was 52 ± 20 y, 67% were male, and median injury severity score was 14 [9-21]. The most common type of cardiac injury was cardiac contusion (43%). Age ≥ 65 y, higher 4-h packed red blood cell requirements, motor vehicle collision mechanism of injury, and concomitant thoracic injuries (hemothorax, flail chest, lung contusion, sternal fracture, diaphragmatic injury, and thoracic aortic injuries) were independently associated with concomitant cardiac contusion among BTI patients (P value < 0.05). Age ≥ 65 y, thoracic aortic injury, diaphragmatic injury, hemothorax, and a history of congestive heart failure were independently associated with mortality in BCI patients (P value < 0.05). CONCLUSIONS Predictors of concomitant cardiac contusion among BTI patients and mortality among BCI patients were identified. Guidelines on the management of BCI should incorporate these predictors for timely identification of high-risk patients.
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Patel KM, Kumar NS, Desai RG, Mitrev L, Trivedi K, Krishnan S. Blunt Trauma to the Heart: A Review of Pathophysiology and Current Management. J Cardiothorac Vasc Anesth 2021; 36:2707-2718. [PMID: 34840072 DOI: 10.1053/j.jvca.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/09/2021] [Accepted: 10/13/2021] [Indexed: 11/11/2022]
Abstract
Blunt cardiac injury (BCI), defined as an injury to the heart from blunt force trauma, ranges from minor to life-threatening. The majority of BCIs are due to motor vehicle accidents; however, injuries caused by falls, blasts, and sports-related injuries also can be sources of BCI. A significant proportion of patients with BCI do not survive long enough to receive medical care, succumbing to their injuries at the scene of the accident. Additionally, patients with blunt trauma often have coexisting injuries (brain, spine, orthopedic) that can obscure the clinical picture; therefore, a high degree of suspicion often is required to diagnose BCI. Traditionally, hemodynamically stable injuries suspicious for BCI have been evaluated with electrocardiograms and chest radiographs, whereas hemodynamically unstable BCIs have received operative intervention. More recently, computed tomography and echocardiography increasingly have been utilized to identify injuries more rapidly in hemodynamically unstable patients. Transesophageal echocardiography can play an important role in the diagnosis and management of several BCIs that require operative repair. Close communication with the surgical team and access to blood products for potentially massive transfusion also play key roles in maintaining hemodynamic stability. With proper surgical and anesthetic care, survival in cases involving urgent cardiac repair can reach 66%-to-75%. This narrative review focuses on the types of cardiac injuries that are caused by blunt chest trauma, the modalities and techniques currently used to diagnose BCI, and the perioperative management of injuries that require surgical correction.
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Affiliation(s)
- Kinjal M Patel
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ.
| | - Nakul S Kumar
- Cardiothoracic and Critical Care Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Ronak G Desai
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ
| | - Ludmil Mitrev
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ
| | - Keyur Trivedi
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ
| | - Sandeep Krishnan
- Adult Cardiothoracic Anesthesiology, Wayne State University School of Medicine Pontiac, MI
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Nassoiy SP, Blackwell RH, Brown M, Kothari AN, Plackett TP, Kuo PC, Posluszny JA. Development of atrial fibrillation following trauma increases short term risk of cardiovascular events. J Osteopath Med 2021; 121:529-537. [PMID: 33691355 PMCID: PMC8159849 DOI: 10.1515/jom-2020-0260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/11/2021] [Indexed: 11/23/2022]
Abstract
Context: New onset atrial fibrillation (AF) is associated with poor outcomes in several different patient populations. Objectives: To assess the effect of developing AF on cardiovascular events such as myocardial infarction (MI) and cerebrovascular accident (CVA) during the acute index hospitalization for trauma patients. Methods: The Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida were used to identify adult trauma patients (18 years of age or older) who were admitted between 2007 and 2010. After excluding patients with a history of AF and prior history of cardiovascular events, patients were evaluated for MI, CVA, and death during the index hospitalization. A secondary analysis was performed using matched propensity scoring based on age, race, and preexisting comorbidities. Results: During the study period, 1,224,828 trauma patients were admitted. A total of 195,715 patients were excluded for a prior history of AF, MI, or CVA. Of the remaining patients, 15,424 (1.5%) met inclusion criteria and had new onset AF after trauma. There was an associated increase in incidence of MI (2.9 vs. 0.7%; p<0.001), CVA (2.6 vs. 0.4%; p<0.001), and inpatient mortality (8.5 vs. 2.1%; p<0.001) during the index hospitalization in patients who developed new onset AF compared with those who did not. Cox proportional hazards regression demonstrated an increased risk of MI (odds ratio [OR], 2.35 [2.13–2.60]), CVA (OR, 3.90 [3.49–4.35]), and inpatient mortality (OR, 2.83 [2.66–3.00]) for patients with new onset AF after controlling for all other potential risk factors. Conclusions: New onset AF in trauma patients was associated with increased incidence of myocardial infarction (MI), cerebral vascular accident (CVA), and mortality during index hospitalization in this study.
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Affiliation(s)
- Sean P Nassoiy
- Department of Surgery, One: MAP Surgical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Robert H Blackwell
- Department of Surgery, One: MAP Surgical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - McKenzie Brown
- Department of Surgery, One: MAP Surgical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Anai N Kothari
- Department of Surgery, One: MAP Surgical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Timothy P Plackett
- Department of Surgery, One: MAP Surgical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Paul C Kuo
- Department of Surgery, One: MAP Surgical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Joseph A Posluszny
- Department of Surgery, One: MAP Surgical Analytics, Loyola University Medical Center, Maywood, IL, USA
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Kalogerakos PD, Lazopoulos G, Palioudakis S, Drositis I, Chionidou K, Chalkiadakis G. Pneumorachis associated with persistent tachycardia after blunt thoracic trauma. Asian Cardiovasc Thorac Ann 2017; 25:463-465. [PMID: 28610438 DOI: 10.1177/0218492317717421] [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] [Indexed: 11/16/2022]
Abstract
Pneumorachis, or intraspinal air, can be a rare result of blunt thoracic trauma. We report the case of a 40-year-old man with multiple injuries and pneumorachis associated with persistent tachycardia. As factors that increase heart rate were gradually ruled out, intraspinal air was considered the potential culprit. Computed tomography revealed intraspinal air at the thoracic level, which possibly promoted cardiac arrhythmogenesis. Air may transiently compress the preganglionic cardiac sympathetic nerves and increase sympathetic output to the heart.
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Affiliation(s)
| | - George Lazopoulos
- Department of Cardiothoracic Surgery, University General Hospital of Heraklion, Crete, Greece
| | - Stefanos Palioudakis
- Department of Cardiothoracic Surgery, University General Hospital of Heraklion, Crete, Greece
| | - Ioannis Drositis
- Department of Cardiothoracic Surgery, University General Hospital of Heraklion, Crete, Greece
| | - Kiriaki Chionidou
- Department of Cardiothoracic Surgery, University General Hospital of Heraklion, Crete, Greece
| | - George Chalkiadakis
- Department of Cardiothoracic Surgery, University General Hospital of Heraklion, Crete, Greece
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Diez C, Conti B, McCunn M, Aboutanos MB, Varon AJ. CASE 6—2015: Penetrating Biventricular Cardiac Injury in a Trauma Patient: Heart Versus Machete. J Cardiothorac Vasc Anesth 2015; 29:797-805. [PMID: 25863730 DOI: 10.1053/j.jvca.2015.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Christian Diez
- Department of Clinical Anesthesiology, Division of Trauma Anesthesiology, Ryder Trauma Center-Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL.
| | - Bianca Conti
- Department of Clinical Anesthesiology, Division of Trauma Anesthesiology, Ryder Trauma Center-Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL
| | - Maureen McCunn
- Department of Clinical Anesthesiology, Division of Trauma Anesthesiology, Ryder Trauma Center-Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL
| | - Michel B Aboutanos
- Department of Clinical Anesthesiology, Division of Trauma Anesthesiology, Ryder Trauma Center-Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL
| | - Albert J Varon
- Department of Clinical Anesthesiology, Division of Trauma Anesthesiology, Ryder Trauma Center-Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL
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Traumatic Tension Pneumothorax as a Cause of ICD Failure: A Case Report and Review of the Literature. Case Rep Cardiol 2014; 2014:261705. [PMID: 25400953 PMCID: PMC4220567 DOI: 10.1155/2014/261705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 09/18/2014] [Accepted: 09/21/2014] [Indexed: 11/17/2022] Open
Abstract
Background. Tension pneumothorax can infrequently cause ventricular arrhythmias and increase the threshold of defibrillation. It should be suspected whenever there is difficulty in defibrillation for a ventricular arrhythmia. Purpose. To report a case of traumatic tension pneumothorax leading to ventricular tachycardia and causing defibrillator failure. Case. A 65-year-old African-American female was brought in to our emergency department complaining of dyspnea after being forced down by cops. She had history of mitral valve replacement for severe mitral regurgitation and biventricular implantable cardioverter defibrillator inserted for nonischemic cardiomyopathy. Shortly after arrival, she developed sustained ventricular tachycardia, causing repetitive unsuccessful ICD shocks. She was intubated and ventricular tachycardia resolved with amiodarone. Chest radiograph revealed large left sided tension pneumothorax which was promptly drained. The patient was treated for congestive heart failure; she was extubated on the third day of admission, and the chest tube was removed. Conclusion. Prompt recognition of tension pneumothorax is essential, by maintaining a high index of suspicion in patients with an increased defibrillation threshold causing ineffective defibrillations.
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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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Peters ST, Hopkins A, Stewart S, Slack J, de Solis CN. Myocardial contusion and rib fracture repair in an adult horse. J Vet Emerg Crit Care (San Antonio) 2013; 23:663-9. [DOI: 10.1111/vec.12096] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 08/02/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Sarah T. Peters
- Department of Clinical Studies, New Bolton Center; University of Pennsylvania; Kennett Square PA 19348
| | - Amber Hopkins
- Department of Clinical Studies, New Bolton Center; University of Pennsylvania; Kennett Square PA 19348
| | - Suzanne Stewart
- Department of Clinical Studies, New Bolton Center; University of Pennsylvania; Kennett Square PA 19348
| | - Joanne Slack
- Department of Clinical Studies, New Bolton Center; University of Pennsylvania; Kennett Square PA 19348
| | - Cristobal Navas de Solis
- Department of Clinical Studies, New Bolton Center; University of Pennsylvania; Kennett Square PA 19348
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De'Ath HD, Rourke C, Davenport R, Manson J, Renfrew I, Uppal R, Davies LC, Brohi K. Clinical and biomarker profile of trauma-induced secondary cardiac injury. Br J Surg 2012; 99:789-97. [PMID: 22437496 DOI: 10.1002/bjs.8728] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND Secondary cardiac injury has been demonstrated in critical illness and is associated with worse outcomes. The aim of this study was to establish the existence of trauma-induced secondary cardiac injury, and investigate its impact on outcomes in injured patients. METHODS Injured adult patients eligible for enrolment in the Activation of Coagulation and Inflammation in Trauma 2 study, and admitted to the intensive care unit between January 2008 and January 2010, were selected retrospectively for the study. Markers of cardiac injury (brain natriuretic peptide (BNP), heart-type fatty acid binding protein (H-FABP) and troponin I) were measured on admission, and after 24 and 72 h in blood samples from injured patients. Individual records were reviewed for adverse cardiac events and death. RESULTS During the study period, 135 patients were enrolled (106 male, 78·5 per cent) with a median age of 40 (range 16-89) years. Eighteen patients (13·3 per cent) had an adverse cardiac event during admission and these events were not associated with direct thoracic injury. The in-hospital mortality rate was higher among the adverse cardiac event cohort: 44 per cent (8 of 18) versus 17·1 per cent (20 of 117) (P = 0·008). Raised levels of H-FABP and BNP at 0, 24 and 72 h, and troponin I at 24 and 72 h, were associated with increased adverse cardiac events. BNP levels were higher in non-survivors on admission (median 550 versus 403 fmol/ml; P = 0·022), after 24 h (794 versus 567 fmol/ml; P = 0·033) and after 72 h (1043 versus 753 fmol/ml; P = 0·036), as were admission troponin I levels. CONCLUSION Clinical and cardiac biomarker characteristics support the existence of trauma-induced secondary cardiac injury, which is associated with death, and unrelated to direct thoracic injury.
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Affiliation(s)
- H D De'Ath
- Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK.
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Hadjizacharia P, O'Keeffe T, Brown CVR, Inaba K, Salim A, Chan LS, Demetriades D, Rhee P. Incidence, risk factors, and outcomes for atrial arrhythmias in trauma patients. Am Surg 2011; 77:634-9. [PMID: 21679600 DOI: 10.1177/000313481107700526] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study is to determine the incidence, risk factors, and outcomes after the development of an atrial arrhythmia (AA) in trauma patients admitted to the intensive care unit (ICU). We performed a retrospective study of more than 7 years of trauma patients admitted to the ICU at an urban, academic Level I trauma center. Patients with AA, defined as atrial fibrillation, atrial flutter, or paroxysmal supraventricular tachycardia, were compared with patients without AA. Groups were compared by univariate and multivariate analysis. Three thousand, four hundred and ninety-nine trauma patients were admitted to the ICU during the study period and 210 (6%) developed an AA. AA patients were more likely to sustain blunt trauma, were older, more often female, more severely injured, and sustained more head injuries. The only independent risk factor for developing an AA was age > 55 years (odds ratio = 4.6, P < 0.01). Mortality was higher in the AA group (33% vs. 14%, P < 0.01) and AA was an independent risk factor for mortality (odds ratio = 1.7, P = 0.01). Twenty-eight per cent (n = 59) of AA patients received beta-blockers in the postinjury period, and these patients had lower mortality (22% vs. 37%, P = 0.04). AA occurs in 6 per cent of trauma patients admitted to the ICU. Developing an AA is an independent risk factor for mortality after trauma. Beta-blocker therapy was associated with decreased mortality in trauma patients with AA.
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Affiliation(s)
- Michael F Cocchiaro
- William R. Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California-Davis, Davis, CA 95616, USA.
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Ismailov RM. Trauma Associated with Cardiac Conduction Abnormalities: Population-Based Perspective, Mechanism and Review of Literature. Eur J Trauma Emerg Surg 2010; 36:227-32. [PMID: 26815865 DOI: 10.1007/s00068-009-9096-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Accepted: 09/13/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Various cardiac conduction abnormalities have been described as being a result of trauma in many case reports. The aim of this research was to look at the association between trauma (thoracic and cardiac) and conduction abnormalities in a large hospitalized population. METHODS Cases diagnosed with trauma and various cardiac conduction disorders were identified based on ICD-9-CM discharge diagnoses from 986 acute general hospitals across 33 states in 2001. RESULTS Independent of potential confounding factors, discharge for blunt cardiac injury (BCI) was associated with a threefold increased risk for cardiac conduction abnormalities (95% confidence interval 2.45-4.51) during hospitalization in 2001. Both BCI and thoracic trauma had a significant association with right bundle branch block (RBBB) in this study (OR 6.04; 95% confidence interval (CI) 3.77-9.67 and OR 1.75; 95% CI 1.38-2.23 respectively). CONCLUSIONS The results of this study demonstrate the impact of trauma on cardiac conduction abnormalities. This study represents an attempt to consider a mechanism of a complex traumatic cardiac event from a population-based perspective, and may improve the prognosis for patients diagnosed with cardiac or thoracic injuries.
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Affiliation(s)
- Rovshan M Ismailov
- Department of Population Health, Cancer Care Ontario, Toronto, ON, Canada.
- Department of Population Health, Cancer Care Ontario, 157 Adelaide Street West #275, Toronto, ON, Canada, M5H 4E7.
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Abstract
PURPOSE OF REVIEW This article reviews new aspects about the significance, diagnosis and treatment of different chest injuries. RECENT FINDINGS Age and Injury Severity Score were risk factors for pneumonia and mortality in patients with rib fractures or flail chest. Occult pneumothoraces were detected in 14.5% and occult hemothoraces in 21.4% using computed tomography, whereas lung contusions were detected two times more frequently with computed tomography compared with chest X-ray. The current treatment of acute respiratory distress syndrome has been ameliorated by extracorporeal membrane oxygenation and pumpless extracorporeal lung assist system. Endovascular repair of thoracic aortic injuries has reduced mortality and morbidity compared with open repairs. Increased serum levels of troponin are related to the degree of overall injury severity and physiologic parameters but not to mechanical chest impact. The mortality of penetrating cardiac injuries is still very high (15.6% for stab wounds, 81% for gunshot wounds). SUMMARY Faster and more detailed diagnosis of thoracic injuries has been achieved by multislice computed tomography. The modern management of thoracic injuries is complex. Minimally invasive techniques (thoracoscopic surgery, endovascular repair) and recent developments in lung supportive therapies reduce mortality and morbidity. However, emergency thoracotomy is still an important and valuable approach for life-saving or damage-control procedures.
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