Incidence, risk factors, and outcomes for atrial arrhythmias in trauma patients

Cardiac Arrhythmias in Trauma Patients Undergoing Pericardiotomy: A Retrospective Analysis

INTRODUCTION

Pericardiotomy is performed in the setting of trauma to diagnose and treat cardiac injury. The frequency of cardiac arrhythmia after pericardiotomy for trauma is poorly described in the literature. We sought to identify the frequency of and risk factors for the development of postpericardiotomy arrhythmia in trauma patients.

MATERIALS AND METHODS

We performed a retrospective single-center cohort study of patients >16 y of age, querying our institutional trauma database (Jan 2011-Dec 2020) for International Classification of Diseases-9 and -10 codes involving pericardiotomy (i.e., pericardial window, sternotomy). Operative details and postoperative course were collected for patients surviving >24 h. Sinus bradycardia and tachycardia were not included as arrhythmias.

RESULTS

We identified 252 trauma patients who underwent pericardiotomy. One hundred fifty-four patients survived >24 h. Of these, 12.3% experienced arrhythmia. Patients developing arrhythmia were older, had higher injury severity score, were more likely to have a blunt mechanism of injury, and had higher in-hospital mortality. On multiple logistic regressions, increasing age, blunt mechanism, and concomitant laparotomy were associated with arrhythmia development, while operative characteristics were not.

CONCLUSIONS

At our institution, trauma patients undergoing pericardiotomy have a risk of arrhythmia of 12.3%, which is associated with multiple nonmodifiable risk factors. Further study is warranted to identify potential mechanisms to reduce arrhythmias in this population.

A dynamic online nomogram predicting post-traumatic arrhythmias: A retrospective cohort study

BACKGROUND

A nomogram is a visualized clinical prediction models, which offer a scientific basis for clinical decision-making. There is a lack of reports on its use in predicting the risk of arrhythmias in trauma patients. This study aims to develop and validate a straightforward nomogram for predicting the risk of arrhythmias in trauma patients.

METHODS

We retrospectively collected clinical data from 1119 acute trauma patients who were admitted to the Advanced Trauma Center of the Affiliated Hospital of Zunyi Medical University between January 2016 and May 2022. Data recorded included intra-hospital arrhythmia, ICU stay, and total hospitalization duration. Patients were classified into arrhythmia and non-arrhythmia groups. Data was summarized according to the occurrence and prognosis of post-traumatic arrhythmias, and randomly allocated into a training and validation sets at a ratio of 7:3. The nomogram was developed according to independent risk factors identified in the training set. Finally, the predictive performance of the nomogram model was validated.

RESULTS

Arrhythmias were observed in 326 (29.1%) of the 1119 patients. Compared to the non-arrhythmia group, patients with arrhythmias had longer ICU and hospital stays and higher in-hospital mortality rates. Significant factors associated with post-traumatic arrhythmias included cardiovascular disease, catecholamine use, glasgow coma scale (GCS) score, abdominal abbreviated injury scale (AIS) score, injury severity score (ISS), blood glucose (GLU) levels, and international normalized ratio (INR). The area under the receiver operating characteristic curve (AUC) values for both the training and validation sets exceeded 0.7, indicating strong discriminatory power. The calibration curve showed good alignment between the predicted and actual probabilities of arrhythmias. Decision curve analysis (DCA) indicated a high net benefit for the model in predicting arrhythmias. The Hosmer-Lemeshow goodness-of-fit test confirmed the model's good fit.

CONCLUSION

The nomogram developed in this study is a valuable tool for accurately predicting the risk of post-traumatic arrhythmias, offering a novel approach for physicians to tailor risk assessments to individual patients.

Diagnosis and management of blunt cardiac injury: What you need to know

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.

Antioxidants in Arrhythmia Treatment—Still a Controversy? A Review of Selected Clinical and Laboratory Research

Antioxidants are substances that can prevent damage to cells caused by free radicals. Production of reactive oxygen species and the presence of oxidative stress play an important role in cardiac arrhythmias. Currently used antiarrhythmic drugs have many side effects. The research on animals and humans using antioxidants (such as vitamins C and E, resveratrol and synthetic substances) yields many interesting but inconclusive results. Natural antioxidants, such as vitamins C and E, can reduce the recurrence of atrial fibrillation (AF) after successful electrical cardioversion and protect against AF after cardiac surgery, but do not affect the incidence of atrial arrhythmias in critically ill patients with trauma. Vitamins C and E may also effectively treat ventricular tachycardia, ventricular fibrillation and long QT-related arrhythmias. Another natural antioxidant—resveratrol—may effectively treat AF and ventricular arrhythmias caused by ischaemia–reperfusion injury. It reduces the mortality associated with life-threatening ventricular arrhythmias and can be used to prevent myocardial remodelling. Statins also show antioxidant activity. Their action is related to the reduction of oxidative stress and anti-inflammatory effect. Therefore, statins can reduce the post-operative risk of AF and may be useful in lowering its recurrence rate after successful cardioversion. Promising results also apply to polyphenols, nitric oxide synthase inhibitors and MitoTEMPO. Although few clinical trials have been conducted, the use of antioxidants in treating arrhythmias is an interesting prospect.

Blunt Trauma to the Heart: A Review of Pathophysiology and Current Management

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.

Development of atrial fibrillation following trauma increases short term risk of cardiovascular events

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.

Trauma, a Matter of the Heart-Molecular Mechanism of Post-Traumatic Cardiac Dysfunction

Trauma remains a leading global cause of mortality, particularly in the young population. In the United States, approximately 30,000 patients with blunt cardiac trauma were recorded annually. Cardiac damage is a predictor for poor outcome after multiple trauma, with a poor prognosis and prolonged in-hospitalization. Systemic elevation of cardiac troponins was correlated with survival, injury severity score, and catecholamine consumption of patients after multiple trauma. The clinical features of the so-called "commotio cordis" are dysrhythmias, including ventricular fibrillation and sudden cardiac arrest as well as wall motion disorders. In trauma patients with inappropriate hypotension and inadequate response to fluid resuscitation, cardiac injury should be considered. Therefore, a combination of echocardiography (ECG) measurements, echocardiography, and systemic appearance of cardiomyocyte damage markers such as troponin appears to be an appropriate diagnostic approach to detect cardiac dysfunction after trauma. However, the mechanisms of post-traumatic cardiac dysfunction are still actively being investigated. This review aims to discuss cardiac damage following trauma, focusing on mechanisms of post-traumatic cardiac dysfunction associated with inflammation and complement activation. Herein, a causal relationship of cardiac dysfunction to traumatic brain injury, blunt chest trauma, multiple trauma, burn injury, psychosocial stress, fracture, and hemorrhagic shock are illustrated and therapeutic options are discussed.

The Association of Early Electrocardiographic Abnormalities With Brain Injury Severity and Outcome in Severe Traumatic Brain Injury

The aim of this study was to evaluate the frequency of electrocardiographic (ECG) abnormalities in the acute phase of severe traumatic brain injury (TBI) and the association with brain injury severity and outcome. In contrast to neurovascular diseases, sparse information is available on this issue. Data of adult patients with severe TBI admitted to the Intensive Care Unit (ICU) for intracranial pressure monitoring of a level-1 trauma center from 2002 till 2018 were analyzed. Patients with a cardiac history were excluded. An ECG recording was obtained within 24 h after ICU admission. Admission brain computerized tomography (CT)-scans were categorized by Marshall-criteria (diffuse vs. mass lesions) and for location of traumatic lesions. CT-characteristics and maximum Therapy Intensity Level (TILmax) were used as indicators for brain injury severity. We analyzed data of 198 patients, mean (SD) age of 40 ± 19 years, median GCS score 3 [interquartile range (IQR) 3–6], and 105 patients (53%) had thoracic injury. In-hospital mortality was 30%, with sudden death by cardiac arrest in four patients. The incidence of ECG abnormalities was 88% comprising ventricular repolarization disorders (57%) mostly with ST-segment abnormalities, conduction disorders (45%) mostly with QTc-prolongation, and arrhythmias (38%) mostly of supraventricular origin. More cardiac arrhythmias were observed with increased grading of diffuse brain injury (p = 0.042) or in patients treated with hyperosmolar therapy (TILmax) (65%, p = 0.022). No association was found between ECG abnormalities and location of brain lesions nor with thoracic injury. Multivariate analysis with baseline outcome predictors showed that cardiac arrhythmias were not independently associated with in-hospital mortality (p = 0.097). Only hypotension (p = 0.029) and diffuse brain injury (p = 0.017) were associated with in-hospital mortality. In conclusion, a high incidence of ECG abnormalities was observed in patients with severe TBI in the acute phase after injury. No association between ECG abnormalities and location of brain lesions or presence of thoracic injury was present. Cardiac arrhythmias were indicative for brain injury severity but not independently associated with in-hospital mortality. Therefore, our findings likely suggest that ECG abnormalities should be considered as cardiac mimicry representing the secondary effect of traumatic brain injury allowing for a more rationale use of neuroprotective measures.

Predictors of new-onset atrial fibrillation in geriatric trauma patients

INTRODUCTION

Geriatric patients (age >65) comprise a growing segment of the trauma population. New-onset atrial fibrillation may occur after injury, complicating clinical management and resulting in significant morbidity and mortality. This study was undertaken to identify clinical and demographic factors associated with new-onset atrial fibrillation among geriatric trauma patients.

METHODS

In this case control study, eligible participants included admitted trauma patients age 65 and older who developed new-onset atrial fibrillation during the hospitalization. Controls were admitted trauma patients who were matched for age and injury severity score, who did not develop atrial fibrillation. We evaluated the associations between new-onset atrial fibrillation and clinical characteristics, including patient demographics, health behaviors, chronic medical conditions, and course of care.

RESULTS

Data were available for 63 cases and 25 controls. Patients who developed atrial fibrillation were more likely to be male, compared to controls (49% versus 24%; odds ratio 3.0[1.0, 8.9]). Other demographic and clinical factors were not associated with new-onset atrial fibrillation, including mechanism of injury, co-morbid medical conditions, drug or alcohol use, surgical procedures, and intravenous fluid administration.

CONCLUSIONS

Male geriatric trauma patients were at higher risk for developing new-onset atrial fibrillation. Other demographic and clinical factors were not associated with new-onset atrial fibrillation.

Resumption of oral anticoagulation following traumatic injury and risk of stroke and bleeding in patients with atrial fibrillation: a nationwide cohort study

Aims

We examined the risks of all-cause mortality, stroke, major bleeding, and recurrent traumatic injury associated with resumption of vitamin K antagonists (VKAs) and non-VKAs oral anticoagulants (NOACs) following traumatic injury in atrial fibrillation (AF) patients.

Methods and results

This was a Danish nationwide registry-based study (2005-16), including 4541 oral anticoagulant (OAC)-treated AF patients experiencing traumatic injury (defined as traumatic brain injury, hip fracture, or traumatic torso or abdominal injury). Within 90 days following discharge from traumatic injury, 60.6% resumed VKA (median age = 80, CHA2DS2-VASc = 4, HAS-BLED = 2), 16.7% resumed NOAC (median age = 81, CHA2DS2-VASc = 4, HAS-BLED = 2), and 22.7% did not resume OAC treatment (median age = 81, CHA2DS2-VASc = 4, HAS-BLED = 3). Switch from VKA to NOAC occurred among 9.5%. Since 2009, the trend in OAC resumption increased (P-value <0.0001), in particular with NOACs (P-value <0.0001). Follow-up started 90 days after discharge, and time-varying multiple Cox regression analyses were used for comparisons. Compared with non-resumption, VKA and NOAC resumption were associated with lower hazard [95% confidence interval (CI)] of all-cause mortality [hazard ratio (HR) 0.48 (0.42-0.53) and HR 0.55 (0.47-0.66), respectively] and ischaemic stroke [HR 0.56 (0.43-0.72) and HR 0.54 (0.35-0.82), respectively], increased major bleeding hazard [HR 1.30 (1.03-1.64) and HR 1.15 (0.81-1.63), respectively], and similar hazard of recurrent traumatic injury [HR 0.93 (0.73-1.18) and HR 0.87 (0.60-1.27), respectively].

Conclusion

AF patients resuming VKA and NOAC treatment following traumatic injury have lower hazard of all-cause mortality and ischaemic stroke, increased hazard of major bleeding but without additional hazards of recurrent traumatic injury. Withholding OAC following a traumatic injury in AF patients may not be warranted.

Neuroprotective Agents in the Intensive Care Unit: -Neuroprotective Agents in ICU

Neuroprotection or prevention of neuronal loss is a complicated molecular process that is mediated by various cellular pathways. Use of different pharmacological agents as neuroprotectants has been reported especially in the last decades. These neuroprotective agents act through inhibition of inflammatory processes and apoptosis, attenuation of oxidative stress and reduction of free radicals. Control of this injurious molecular process is essential to the reduction of neuronal injuries and is associated with improved functional outcomes and recovery of the patients admitted to the intensive care unit. This study reviews neuroprotective agents and their mechanisms of action against central nervous system damages.

Risk of thromboembolism in patients developing critical illness-associated atrial fibrillation

Although common, the long-term significance of -developing atrial fibrillation (AF) during a period of critical illness is unclear. We undertook a retrospective cohort analysis to -assess the rate of thromboembolism (TE) in patients -developing atrial fibrillation de novo during admission to our intensive care unit. In total, 1,955 patients were followed up (-maximum follow-up 1,276 days) for the occurrence of TE, of which 220 (11.3%) had developed AF or atrial flutter during their critical care admission. There were 11 TE events among the patients with new AF (0.053 events per patient-year), compared with 18 in the non-AF group (0.0059 events per patient-year). The unadjusted hazard ratio for TE in patients developing new AF compared with those not developing AF was 8.09 (95% CI 3.08-17.19, p<0.001). In patients admitted to critical care, the development of AF appears to be associated with a significantly increased risk of subsequent thromboembolism.

Brain-Heart Interactions in Traumatic Brain Injury

The cardiovascular manifestations associated with nontraumatic head disorders are commonly known. Similar manifestations have been reported in patients with traumatic brain injury (TBI); however, the underlying mechanisms and impact on the patient's clinical outcomes are not well explored. The neurocardiac axis theory and neurogenic stunned myocardium phenomenon could partly explain the brain-heart link and interactions and can thus pave the way to a better understanding and management of TBI. Several observational retrospective studies have shown a promising role for beta-adrenergic blockers in patients with TBI in reducing the overall TBI-related mortality. However, several questions remain to be answered in clinical randomized-controlled trials, including population selection, beta blocker type, dosage, timing, and duration of therapy, while maintaining the optimal mean arterial pressure and cerebral perfusion pressure in patients with TBI.

Beta-blockers and Traumatic Brain Injury: A Systematic Review, Meta-analysis, and Eastern Association for the Surgery of Trauma Guideline

OBJECTIVE

To determine if beta-(β)-blockers improve outcomes after acute traumatic brain injury (TBI).

BACKGROUND

There have been no new inpatient pharmacologic therapies to improve TBI outcomes in a half-century. Treatment of TBI patients with β-blockers offers a potentially beneficial approach.

METHODS

Using MEDLINE, EMBASE, and CENTRAL databases, eligible articles for our systematic review and meta-analysis (PROSPERO CRD42016048547) included adult (age ≥ 16 years) blunt trauma patients admitted with TBI. The exposure of interest was β-blocker administration initiated during the hospitalization. Outcomes were mortality, functional measures, quality of life, cardiopulmonary morbidity (e.g., hypotension, bradycardia, bronchospasm, and/or congestive heart failure). Data were analyzed using a random-effects model, and represented by pooled odds ratio (OR) with 95% confidence intervals (CI) and statistical heterogeneity (I).

RESULTS

Data were extracted from 9 included studies encompassing 2005 unique TBI patients with β-blocker treatment and 6240 unique controls. Exposure to β-blockers after TBI was associated with a reduction of in-hospital mortality (pooled OR 0.39, 95% CI: 0.27-0.56; I = 65%, P < 0.00001). None of the included studies examined functional outcome or quality of life measures, and cardiopulmonary adverse events were rarely reported. No clear evidence of reporting bias was identified.

CONCLUSIONS

In adults with acute TBI, observational studies reveal a significant mortality advantage with β-blockers; however, quality of evidence is very low. We conditionally recommend the use of in-hospital β-blockers. However, we recommend further high-quality trials to answer questions about the mechanisms of action, effectiveness on subgroups, dose-response, length of therapy, functional outcome, and quality of life after β-blocker use for TBI.

Antioxidant supplementation and atrial arrhythmias in critically ill trauma patients

BACKGROUND

The purpose of this study is to determine if antioxidant supplementation influences the incidence of atrial arrhythmias in trauma intensive care unit (ICU) patients.

MATERIALS AND METHODS

In this retrospective pre-post study, critically ill injured patients aged ≥18 years, admitted to a single-center trauma ICU for ≥48 hours were eligible for inclusion. The control group consists of patients admitted from January 2000 to September 2005, before routine antioxidant supplementation in our ICU. The antioxidant group consists of patients admitted from October 2005 to June 2011 who received an antioxidant protocol for ≥48 hours. The primary outcome is the incidence of atrial arrhythmias in the first 2 weeks of hospitalization or before discharge.

RESULTS

Of the 4699 patients, 1622 patients were in the antioxidant group and 2414 patients were in the control group. Adjusted for age, sex, year, injury severity, past medical history, and medication administration, the unadjusted incidence of atrial arrhythmias was 3.02% in the antioxidant group versus 3.31% in the control group, with no adjusted difference in atrial arrhythmias among those exposed to antioxidants (odds ratio: 1.31 [95% confidence interval: 0.46, 3.75], P = 0.62). Although there was no change in overall mortality, the expected adjusted survival of patients in those without antioxidant therapy was lower (odds ratio: 0.65 [95% confidence interval: 0.43, 0.97], P = 0.04).

CONCLUSIONS

ICU antioxidant supplementation did not decrease the incidence of atrial arrhythmias, nor alter the time from admission to development of arrhythmia. A longer expected survival time was observed in the antioxidant group compared with the control group but without a change in overall mortality between groups.

Cardiac injuries caused by trauma: Review and case reports

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

Prognostic impact of restored sinus rhythm in patients with sepsis and new-onset atrial fibrillation

BACKGROUND

New-onset atrial fibrillation (NeOAF) is a common type of tachyarrhythmia in critically ill patients and is associated with increased mortality in patients with sepsis. However, the prognostic impact of restored sinus rhythm (SR) in septic patients with NeOAF remains unclear.

METHODS

A total of 791 patients with sepsis, who were admitted to a medical intensive care unit from January 2011 to January 2014, were screened. NeOAF was detected by continuous electrocardiographic monitoring. Patients were categorized into three groups: no NeOAF, NeOAF with restored SR (NeOAF to SR), and NeOAF with failure to restore SR (NeOAF to atrial fibrillation (AF)). The endpoint of this study was in-hospital mortality. Patients with pre-existing AF were excluded.

RESULTS

We reviewed the data of 503 eligible patients, including 263 patients with no NeOAF and 240 patients with NeOAF. Of these 240 patients, SR was restored in 165 patients, and SR could not be restored in 75 patients. The NeOAF to AF group had the highest in-hospital mortality rate of 61.3% compared with the NeOAF to SR and no NeOAF groups (26.1% and 17.5%, respectively). Moreover, multivariate logistic regression analysis revealed that failure of restored SR was independently associated with increased in-hospital mortality in patients with sepsis and NeOAF.

CONCLUSIONS

Failure to restore a sinus rhythm in patients with new-onset atrial fibrillation may be associated with increased in-hospital mortality in patients with sepsis. Further prospective studies are needed to clarify the effects of restoration of sinus rhythm on survival in patients with sepsis and new-onset atrial fibrillation.

Prevalence and Course of Atrial Fibrillation in Critically Ill Trauma Patients

Atrial fibrillation (AF) is the most common cardiac dysrhythmia. Its prevalence, risk factors, course, and complications are not well described in critically ill trauma patients. This was a retrospective, single-center, cohort study at an academic, level 1 trauma center. Trauma patients >18 years, identified from the trauma registry and admitted to the intensive care unit (ICU), were sequentially screened for AF. A matched cohort was created by selecting patients consecutively admitted before and after the patients who experienced AF. Of 2591 patients screened, 191 experienced AF, resulting in a prevalence of 7.4%. There was no difference in injury severity score (ISS) between those with and without AF, but patients with AF had higher observed mortality (15.5% vs 6.7%, P < .001). Patients with a history of AF (n = 75) differed from new-onset AF (n = 106) in their mean age, 78.9 ± 8.4 versus 69.2 ± 17.9 years; mean time to AF onset, 1.1 ± 2.3 versus 5.2 ± 10.2 days; median duration of AF, 29.8 (1-745.2) versus 5.9 (0-757) hours; and rate of AF resolution, 28% versus 82.1%, respectively. Despite a higher ISS, Sequential Organ Failure Assessment and length of stay, the new-onset AF group experienced a similar rate of mortality compared to the history of AF group (14.7% vs 16.0%). Patients with AF had a higher mortality when compared to those in sinus rhythm. The course of AF in the new-onset AF group occurred later was shorter and was more likely to convert; however, these patients had a longer ICU stay when compared to those who had a history of AF.

Arrhythmias in the paediatric intensive care unit: a prospective study of the rates and predictors of arrhythmias in children without underlying cardiac disease

OBJECTIVE

Arrhythmias are common in patients admitted to the paediatric intensive care unit. We sought to identify the rates of occurrence and types of arrhythmias, and determine whether an arrhythmia was associated with illness severity and paediatric intensive care unit length of stay.

DESIGN

This is a prospective, observational study of all patients admitted to the paediatric intensive care unit at the Children's Hospital at Montefiore from March to June 2012. Patients with cardiac disease or admitted for the treatment of primary arrhythmias were excluded. Clinical and laboratory data were collected and telemetry was reviewed daily. Tachyarrhythmias were identified as supraventricular tachycardia, ventricular tachycardia, and arrhythmias causing haemodynamic compromise or for which an intervention was performed.

RESULTS

A total of 278 patients met the inclusion criteria and were analysed. There were 97 incidences of arrhythmia in 53 patients (19%) and six tachyarrhythmias (2%). The most common types of arrhythmias were junctional rhythm (38%), premature atrial contractions (24%), and premature ventricular contractions (22%). Tachyarrhythmias included three supraventricular tachycardia (50%) and three ventricular tachycardia (50%). Of the six tachyarrhythmias, four were related to placement or migration of central venous lines and two occurred during aminophylline infusion. Patients with an arrhythmia had longer duration of mechanical ventilation and paediatric intensive care unit stay (p<0.001). In multivariate analysis, central venous lines (odds ratio 3.1; 95% confidence interval 1.3-7.2, p=0.009) and aminophylline use (odds ratio 5.1; 95% confidence interval 1.7-14.9, p=0.003) were independent predictors for arrhythmias.

CONCLUSIONS

Arrhythmias were common in paediatric intensive care unit patients (19%), although tachyarrhythmias occurred rarely (2%). Central venous lines and use of aminophylline were identified as two clinical factors that may be associated with development of an arrhythmia.

Diagnosis, work-up and management of blunt cardiac injuries

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.

Ultrasound-based imaging in neurocritical care patients: a review of clinical applications

OBJECTIVE

To analyze the diagnostic, monitoring, and procedural applications of ultrasound (US) imaging in neurocritical care (NCC) patients.

METHOD

US imaging has been extensively validated in various subset of critically ill patients, but not specifically in the NCC population. We reviewed the clinical applications of US imaging for heart, vascular, brain, and lung evaluation and for possible procedural uses in NCC patients. Major neurosurgical books, journals, testimonials, authors' personal experience, and scientific databases were analyzed.

RESULTS

Cardiac US imaging provides accurate information at NCC arrival to stratify risk factors, including presence of atrial septal defect/patent formen ovale, abnormal ventricular function, or pericardial effusion, and to monitor cardiac anatomy and function during the NCC stay for guiding goal-directed therapy. Vascular US in NCC patients has three especially relevant indications: to screen anatomy and flow in extracranial supra-aortic arteries, to diagnose deep vein thrombosis, and to optimize the safety of central venous catheterization. Brain US has important clinical applications in the NCC, including transcranial Doppler and emerging techniques for cerebral blood flow evaluation with contrast-enhanced US imaging. Lung US, as demonstrated in other intensive care unit patients, provides accurate diagnosis of anatomical and functional abnormalities and enables diagnosis of pleural effusion, pneumothorax, lung consolidation, pulmonary abscess and interstitial-alveolar syndrome, and lung recruitment/derecruitment. US imaging can effectively guide percutaneous tracheostomy.

CONCLUSION

In conclusion, US imaging is an important diagnostic tool that provides real-time information at the bedside to stratify risk, monitor for complications, and guide invasive procedures in NCC patients.