Review Article Understanding traumatic blunt cardiac injury

Ayman El-Menyar1,2, Hassan Al Thani1, Ahmad Zarour1, Rifat Latifi1,2 1Department of Surgery, Section of Trauma Surgery, Hamad Medical Corporation, 2Clinical Medicine, Weill Cornell Medical School, Qatar

ABSTRACT Cardiac injuries are classified as blunt and penetrating injuries. In both the injuries, the major issue is missing the diagnosis and high mortality. Blunt cardiac injuries (BCI) are much more common than penetrating injuries. Aiming at a better understanding of BCI, we searched the literature from January 1847 to January 2012 by using MEDLINE and EMBASE search engines. Using the key word “Blunt Cardiac Injury,” we found 1814 articles; out of which 716 articles were relevant. Herein, we review the causes, diagnosis, and management of BCI. In conclusion, traumatic cardiac injury is a major challenge in critical trauma care, but the guidelines are lacking. A high index of suspicion, application of current diagnostic protocols, and prompt and appropriate management is mandatory.

Received: 17-3-2012 Accepted: 29-6-2012 Key words: Blunt trauma, Blunt cardiac injury, Aortic injury

INTRODUCTION echocardiographic analysis, 24 prospective studies, 20 retrospective studies, and 1 Cardiac injuries are classified as blunt meta-analysis. Herein, we review the causes, and penetrating injuries. In both the type diagnosis, and management of BCI. of injuries, the major issue is missing the diagnosis and high mortality. Blunt cardiac BLUNT CARDIAC INJURY injuries (BCIs) are much more common than penetrating injuries. Penetrating trauma is seen BCI ranges from asymptomatic myocardial in urban trauma centers and predominantly bruise to cardiac rupture and death.[2-4] BCIs due to stab wounds, gunshot wounds, or less most often occur during motor vehicle crashes commonly other iatrogenic instrumentation. (MVC). Based on the associated injuries, In penetrating injuries, up to 90% of victims intensity of chest injury, and complexity of die before reaching hospital and resuscitation injuries the incidence of BCI varies from is of limited benefit; therefore, survival 20 to 76%. Falls and crush injuries are less depends on rapid pre-hospital transport.[1] frequently associated with BCI. BCIs are characterized by patchy areas of muscle Access this article online Aiming at better understanding of BCI, we necrosis and hemorrhagic infiltrate(s), rupture Website: www.annals.in reviewed the literature from January 1847 of small vessels, and hemorrhage into the PMID: to January 2012 by utilizing MEDLINE interstitium and around the muscle fibers.[4] *** and EMBASE search engines. Using the Myocardial contusion has been reported in DOI: 10.4103/0971-9784.101875 key word “Blunt Cardiac Injury,” we found 60–100% autopsy series of patients with BCI.[3] Quick Response Code: 1814 articles; out of which 716 articles were relevant. Of the relevant articles, 559 were Commotio Cordis published in English language; there were 100 Commotio Cordis is a rare type of BCI in reviews, 135 case reports (some case reports which low-impact chest trauma causes sudden were followed by review of the literature), 22 cardiac arrest, usually occurs from being struck pediatric-related articles, 35 articles based on by a projectile during sports. Cardiac arrest

Address for correspondence: Dr. Ayman El-Menyar, Weill Cornell Medical School, Clinical Medicine, Cardiologist and Clinical Research, Trauma Surgery, Hamad General Hospital, PO Box 3050, Doha, Qatar. E-mail: [email protected]

Annals of Cardiac Anaesthesia  Vol. 15:4  Oct-Dec-2012 287 El-Menyar, et al.: Traumatic blunt cardiac injury appears to stem from blow during a period of electrical Table 1: Summary of the mechanism of BCI vulnerability (10 to 30 ms before the peak of the T Direct impact Commtio cordis wave). A direct blow to the precordium accounts for a Myocardial contusion sizable number of cases. Patients involved in a MVC Rapid deceleration Aortic tear, Cardiac rupture with sudden deceleration, or who sustains significant Rapid deceleration or Compression Ruptured myocardium chest trauma or severe multiple trauma are at risk of Commotio Cordis.[5] and aortic valve insufficiency, respectively. [4] Other less common pathological findings in patients with Cardiac Rupture BCI include septal tears (Atrial septal defect: 7% Between 1847 and 1952, 13 cases of rupture of Ventricular septal defect : 4%) Coronary artery injury interventricular septum due to BCI were described. [6] and thrombosis (3%).[3] The mechanism of injury and factors necessary to produce rupture of the heart after blunt injury were Indirect cardiac injury reported between 1935 and 1938. A full chamber in early Even if the heart is not directly involved in the trauma, systole is more vulnerable if compressed over its outflow cardiac injury remains a possible concern. The stressful tract; the myocardial fibers may rupture at a point away impact of trauma may result in myocardial infarction from the area of direct contusion.[6] Between 1994 and secondary to acute thrombosis or severe coronary 2009, several other mechanisms of blunt traumatic spasm (with patent coronary arteries). Also, significant cardiac rupture have been reported, and include arrhythmia and stress-induced cardiomyopathy precordial impaction with cardiac squeeze between the (Takotsubo cardiomyopathy) have been reported in many sternum and spine and rapid deceleration resulting in cases secondary to the fear and stress of trauma. [13,14] disruption of the atria from their connections to the vena cava and pulmonary veins.[7,8] Minimal force is required Blunt aortic injury for a deceleration type contusion injury that may occur Blunt aortic injury (BAI) is a common cause of traumatic at a relatively low velocity of 20 miles/h.[9,10] pericardial tamponade. It should be considered in patients with a deceleration or acceleration injury with Cardiac rupture is the most devastating BCI and the signs suggestive of mediastinal injury. [15] BAI is the incidence of the site of injury varies in various autopsy second most common cause of death in blunt trauma series (Cardiac wall: 0.16–2%, Right ventricle: 19–32%, patients.[16] Most patients with BAI die at the place of Right atrium: 10–15%, Left ventricle: 5–44%, and Left injury, and only 13–15% reach alive to hospitals.[16,17] atrium: 1–7%).[3,11] The most common mechanism of BAI is motor vehicle crash, pedestrian injury, and falls.[15,18] Forces involved in BCI Include compression of the heart between the spine and Cardiac herniation sternum, abrupt pressure fluctuations in the chest and It is a potentially fatal complication of BCI and abdomen, shearing from rapid deceleration and blast reported in 0.4% of severe blunt trauma. [19,20] Cardiac injury, and fragments from rib fractures causing injury herniation frequently results in early death, and thus to the heart. Table 1 summarizes the mechanism of BCI. the diagnosis is mainly based on autopsy findings.[20] In a series of BCI, patients who survived to hospital The right heart is most commonly injured.[12] This is probably due to its position closest to the anterior chest admission had favorable outcome with survival rate of [21] wall. High-pressure ventricular injuries appear to be as 36.4-42.9%. The high in-hospital mortality rate (up common as low-pressure atrial injuries, but findings to 64%) is probably a reflection of not only pericardial may vary based on the type of study (i.e. clinical or rupture and cardiac herniation but also of the associated autopsy). In autopsy series, ventricular injuries are the injuries.[19,22] dominant findings. Aortic and mitral valve damage has been reported as a complication of blunt chest injury. [4] Pericardial effusion The incidence of tricuspid or mitral valvular injury is Definite diagnosis of traumatic pericardial effusions is around 5% which include chordal rupture, anterior not easy even with Focused Assessment with Sonography papillary muscle and/ or leaflet tear.[3,4] Ismailov et al. for Trauma (FAST), repeat cardiac echocardiography, reported that BCI is independently associated with and computed tomography (CT). [23] Patients who survive 11 and 3 times increase in the incidences of tricuspid to the hospital usually have minor tears in the low-

288 Annals of Cardiac Anaesthesia  Vol. 15:4  Oct-Dec-2012 El-Menyar, et al.: Traumatic blunt cardiac injury pressure chamber with a blood clot that temporarily significant BCI are usually present at the time of stops the bleeding or have decompression of blood admission or occasionally within 24 h. [3,34] However, into the pleural cavity because of a pleuropericardial it can be difficult to determine whether the ECG defect.[23] Compared with penetrating chest injuries, abnormality is a primary event (e.g. an acute coronary cardiac injury is more easily neglected in blunt trauma, syndrome (ACS) that preceded trauma), a direct especially when associated with head or abdominal result of cardiac injury, or a problem brought on by injury.[23,24] Huang et al. reported that 87.1% of traumatic the physiologic stress of severe trauma.[2,34] Several pericardial effusions were due to blunt trauma and studies concluded that in hemodynamically stable 51.7% were associated with cardiac injury or rupture.[23] young patients, normal ECG rules out the need for further evaluation to detect BCI. [3,35] Patients with Associated injuries unexplained tachycardia that persists over several In BCI, the most common associated injuries are: hours despite adequate fluid resuscitation and pain rib fractures (18–69%), lung contusion (6–58%), flail control, or with a new bundle branch block, or with chest (3–38%), sternal fracture (0–60%), head injury significant arrhythmia, should be admitted for rhythm (20–73%), and abdominal solid organ injury (5–43%).[3] monitoring and possible echocardiographic study. Life- threatening ventricular arrhythmias were reported in Delayed complications up to 16% of patients with BCI.[4] A 24 h monitoring Pericardial, myocardial or valvular injuries may present with ECG telemetry is required if a patient suspected of late after trauma. Most patients with trauma of the aortic having BCI is hemodynamically stable and has either valve suffer its disruption immediately after the initial an abnormal ECG, or a history of cardiac disease, or is trauma; however, “delayed” rupture may occur. [4,25] ≥55 years old.[3,35] Delayed tricuspid and mitral valvular rupture may be due to papillary muscle contusion with hemorrhage, Sonographic and echocardiographic evaluation inflammation, and late necrosis, leading to disruption FAST provides the preferred initial approach for over time.[26] Cardiac tamponade has been reported after sonographic evaluation.[4,36-38] It enables the trained several days or weeks after minor blunt chest or isolated physician to rapidly and accurately determine the abdominal trauma.[27,28] presence of pericardial effusion and cardiac activity. After excluding pericardial tamponade, an echocardiogram DIAGNOSIS OF BCI is useful in trauma patients with signs of cardiac dysfunction to diagnose the cause of dysfunction, The severity of the trauma does not necessarily correlate estimate the need for volume and/or inotropic support, with the degree of BCI. Moreover, there is no single test and identify other injuries requiring intervention that can be considered a gold standard when diagnosing (Table 2 describes the cardiac injury scale). [38] BCI. Different tests such as electrocardiogram (ECG), sonographic and echocardiographic evaluation, and Echocardiography can provide important information in cardiac biomarkers are currently used. The incidence of a patient who manifests signs consistent with significant BCI may vary due to diagnostic tools; however, all these BCI. However, it has little utility as a screening tool tests and mechanism of injury as well as clinical picture for clinically significant BCI in hemodynamically need to be taken in consideration when diagnosing and stable patients.[29,39] It is recommended to obtain an managing a patient with suspected BCI. Additionally, echocardiogram in any patient with blunt trauma BCI could be identified by using cardiac markers creatine and unexplained persistent shock out of proportion kinase and creatine kinase-MB in 19% of patients, to apparent injuries or shock despite aggressive troponin in 15–24%, transthoracic echocardiography resuscitation, and in any patient with signs consistent (TTE) in 3–26%, transesophageal echocardiogram (TEE) with significant BCI. Echocardiographic signs include in 27–56%, and by ECG in 29–56% of patients.[4,29-31] abnormal cardiac wall motion, decreased cardiac contractility, valvular dysfunction or rupture, septal ECG defects, intracardiac thrombus, and pericardial effusion or rupture of the myocardium. However, findings may Although there is no single ECG sign pathognomonic be misleading in patients with prior chronic heart for BCI, the guidelines (level 1 evidence) recommends disease and studies may be limited by the presence of performing 12-lead ECG on admission to all suspected chest tubes, chest wall trauma, morbid obesity, pain, BCI patients.[32,33] ECG changes that indicate clinically and suboptimal views.[3,10]

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Table 2: Cardiac injury scale Grade Injury description I Blunt cardiac injury with minor ECG abnormality (nonspecific ST or T wave changes, premature atrial or ventricular contraction, or persistent sinus tachycardia) Blunt or penetrating pericardial wound without cardiac injury, cardiac tamponade, or cardiac herniation II Blunt cardiac injury with heart block or ischemic changes without cardiac failure Penetrating tangential cardiac wound up to but not extending through endocardium without tamponade III Blunt cardiac injury with sustained or multifocal ventricular contractions Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid incompetence, papillary muscle dysfunction, or distal coronary artery occlusion without cardiac failure Blunt pericardial laceration with cardiac herniation Blunt cardiac injury with cardiac failure Penetrating tangential myocardial wound up to but not through endocardium with tamponade IV Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid incompetence, papillary muscle dysfunction, or distal coronary artery occlusion producing cardiac failure Blunt or penetrating cardiac injury with aortic or mitral incompetence Blunt or penetrating cardiac injury of the right ventricle, right or left atrium V Blunt or penetrating cardiac injury with proximal coronary artery occlusion Blunt or penetrating left ventricular perforation Stellate injuries <50% tissue loss of the right ventricle, right or left atrium VI Blunt avulsion of the heart Penetrating wound producing >50% tissue loss of a chamber Adapted from Ref. 38 with permission: Lippincott Williams and Wilkins, Inc.: Moore EE et al. Organ injury scaling. IV: Thoracic vascular, lung, cardiac, and diaphragm. J Trauma 1994;36:299.

TEE is superior for investigating the cause of persistent during a brief course of observation (4–6 h) is more hemodynamic instability or other problems thought valuable for screening for BCI, if doubt exists. The to be related to BCI. It provides a clear view of wall patients with normal ECG and troponin can be safely motion abnormalities and valvular and septal injuries. discharged if there are no other associated injuries.[34] Nowadays, TEE can be performed safely by anesthetists, intensivists, and even accident and emergency Diagnosis of BAI physicians. It improves sensitivity for injuries that Chest X-ray is a valuable screening test.[42] A widened require intervention.[3] TEE is not only able to detect mediastinum is the most frequent indication for myocardial injury missed by TTE but also superior to further investigations.[43] Angiography is the gold TTE in visualizing thoracic aorta.[10] standard diagnostic test for BAI.[15,44] CT of the chest is a very useful diagnostic tool.[45] TEE is a very sensitive Cardiac biomarkers screening test, but is usually followed by angiography.[46] The utility of cardiac biomarkers in the setting of CT may be a first tool for the diagnosis of these multi- BCI remains unclear because of the lack of a gold traumatized patients. Multislice CT may be more useful standard for diagnosis; moreover, there are several tool for identifying minor leaks and adjacent structural biomarkers with different sources and cutoff values. injuries. The need for aortography would decrease by However, following blunt chest trauma, the diagnostic 56% if chest CT is used in the screening for BAI.[47-49] In value of troponin increases when it is combined with a previous study, chest CT was performed to evaluate the admission ECG; moreover, the use of troponin BAI in 677 patients with positive or equivocal findings as a screening test becomes more appreciated when at chest radiography, the investigators concluded that performed prior to echocardiography.[3,10,34,40] Collin reliance on findings at admission CT before angiography et al.[41] concluded, “measuring troponin with a normal could save more than $365,000.[49] Helical CT is more ECG is not necessary and if the admission ECG has sensitive tool for BAI diagnosis; it has a sensitivity of minor abnormalities and the troponin at 4 to 6 hours 100%, as compared with 92% for angiography.[50] In after injury is normal then the risk of BCI-related patients with blunt chest trauma in whom BAI was complications is low.” However, in the presence of ruled out by helical CT, none required procedures significant ECG abnormalities, a normal troponin value for or died of injuries to the aorta or great vessels.[51] may carry little benefit for risk stratification for cardiac However, some studies reported a 28% rate of missed complications.[3] Instead of biomarkers, use of repeat diagnoses of BAI in patients who did not have a chest examinations, serial ECGs, and cardiac monitoring CT scan on admission and therefore, helical CT has been

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BLUNT CARDIAC INJURY PROTOCOL

Suspicion of BCI

Abnormal ECG e.g. arrhythmia, Obtain Admission ST changes, ischemia, heart Normal ECG 12 Lead ECG block, unexplained ST

Patient: Hemodynamically stable, <55 years old, and has no history of cardiac disease

Patient: Hemodynamically unstable, and ≥55 years old, OR has a history of cardiac disease No further evaluation for BCI Initiate cardiac monitoring (24-48 hours)

Patient remains hemodynamically stable

Patient is hemodynamically unstable

Discontinue monitoring

Obtains Trans-thoracic OR Trans- esophageal echocardiography to evaluate cardiac function (TEE preferred)

Figure 1: Evaluation of suspected blunt cardiac injury (with permission : Elsevier Limited: Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin 2004;20:57-70) recommended in all patients with a history of MVC at a cardiac dysfunction, until proven otherwise. With speed of 10 mph or faster for unrestrained drivers and hypotension in the setting of isolated thoracic trauma, 30 mph or faster for restrained drivers.[52,53] clinicians should look for pericardial tamponade or a tension pneumothorax in addition to hemorrhage. MANAGEMENT Valve, septum, or ventricular wall injury Cardiac injury evaluation and management protocols Patients with clinical or echocardiographic evidence based on the hemodynamic status and the electrical of severe cardiac injury (e.g. ruptured valve, septum, cardiac activity are shown in Figures 1–3.[3,7,10] We believe ventricular wall or tamponade) require emergent in the simultaneous assessment; however, priority should surgical consultation. In case of penetrating cardiac be given to the immediate clinical evaluation.[3,7,10,54] injury, immediate surgical intervention is a priority [Figure 4]. If possible, anesthesia and intubation Initial stabilization should be delayed in patients who require operative BCI is often associated with thoracic trauma, but can intervention until just before sternotomy because occur in any patient with multiple trauma. Initial anesthesia induction may cause hemodynamic collapse. evaluation proceeds according to standard Advanced Any patient suspected to have BCI with cardiac free- Trauma Life Support protocols, beginning with wall rupture, septal rupture, coronary artery injury, or stabilization of the patient’s airway, breathing, and valve injury should be seen by a cardiothoracic surgeon circulation. Clinicians should assume that hypotension without delay.[55] Figure 3 summarizes the management in the trauma patient results from hemorrhage, not of suspected blunt cardiac rupture.

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BLUNT CHEST TRAUMA

Patient transported to emergency/trauma centre

Mechanism of injury: blunt chest trauma or cardiac trauma

Patients haemodynamically unstable

YES NO

Admit to monitored bed

Cardiac ECHO troponin Serial Chest Physical ECGs X- ray exam TEE TTE

TEE can be performed pre-op or Abnormal study Normal study intra-op with follow-up imaging

post Discharge operatively

Observation monitored bed Consider holter

monitor as outpatient

Figure 2: Algorithm for blunt chest trauma and cardiac trauma injury (with permission : BMJ Publishing Group Ltd.: Bansal MK et al. Myocardial contusion injury: Redefining the diagnostic algorithm. Emerg Med J 2005;22:465-9)

Unstable patients in persons ≥46 years of age. Moreover, in younger In patients who may not survive to an operating room, patients who underwent coronary angiography after emergency resuscitative thoracotomy is the best option. trauma, BCI was associated with a 31-fold increased Pericardiocentesis can be an effective temporizing risk for AMI. Sudden elevation of intra-aortic pressure measure and may be attempted. However, in the caused by sudden external impact to the abdomen setting of blunt trauma, thoracotomy rarely results in possibly result in rupture of the coronary vessel, successful resuscitation. If cardiac injury is suspected particularly if the aortic valve was closed during the in a hypotensive patient and FAST is unavailable, the traumatic impact.[56] Catheterization with stenting may cardiothoracic surgery and cardiology services should be be the best approach for treatment, although some consulted immediately. Such patients should be admitted advocate bypass graft surgery. Thrombolytic agents to a surgical service with cardiology consultation unless are best avoided, especially in patients who sustained operative management is clearly unnecessary. multiple injuries, unless both bypass surgery and angiography are unavailable, and patients do not have Acute coronary syndrome any contraindications to the use of thrombolytic agents. Acute coronary syndrome (ACS) may occur due to Management should be determined in consultation coronary dissection or stress-induced thrombosis or with cardiologist. Cardiothoracic surgery consultation spasm. Ismailov and his colleagues[56] reported that is needed in the rare event when a coronary artery direct trauma to the heart is associated with a 2.6-fold laceration or dissection is identified. For patients increased risk for acute myocardial infarction (AMI) with features suggestive of BCI and in whom cardiac

292 Annals of Cardiac Anaesthesia  Vol. 15:4  Oct-Dec-2012 El-Menyar, et al.: Traumatic blunt cardiac injury

Blunt Chest Trauma

No recordable BP Recordable BP

FAST (+) FAST or CT (+) FAST/CT (-)

Subxiphoid Drainage at ER

Repeat Echo by No response cardiac Response consultation (+)

To OR for Go to suspicions of To OR for non- resuscitation at cardiac lesions cardiac surgery ER

Intra-operative TEE (+) Cardiac lesions as Pericardial decompression an Intra-operative ± Exploratory sternotomy finding ± Cardiac repair ± Cardiopulmonary bypass ± Extracorporal life support

Heart lesion with Heart lesion with poor exposure from good exposure from original incision original incision

Cardiac repair via original incision (eg. Thoracotomy)

Figure 3: Protocol for management of suspected blunt cardiac rupture (with permission: Elsevier Limited : Nan YY et al. Blunt traumatic cardiac rupture: Therapeutic options and outcomes. Injury 2009;40:938-45) FAST - Focused assessment with sonography for trauma; ER - Emergency room; OR - Operating room

a b Figure 4: (a) Intraoperative picture of a right ventricular stab wound that was repaired by using pledgets in a young male who presented with cardiac tamponade (courtesy Dr. Latifi R). (b) Postmortem image of rupture of interventricular septum after blunt injury (with permission: Elsevier Limited) Pollock Be et al: Isolated traumatic rupture of the interventricular septum due to blunt force. Am Heart J 1952;43:273-85)

Annals of Cardiac Anaesthesia  Vol. 15:4  Oct-Dec-2012 293 El-Menyar, et al.: Traumatic blunt cardiac injury biomarkers are found to be elevated, cardiology more in the multi-traumatized patients. Therefore, close consultation is obtained and the patient is admitted for communication between the surgical and anesthesia cardiac monitoring and further evaluation. A screening teams is the key for successful management.[12,62] echocardiogram and cardiac biomarkers do not appear to add to the management of the hemodynamically CONCLUSION stable patient without clinical features suggestive of significant BCI.[3,4] Although traumatic cardiac injury is a challenge in critical trauma care, guidelines are lacking. A high Cardiac dysfunction and arrhythmia index of suspicion, application of current diagnostic Echocardiography is warranted in patients with BCI protocols, and prompt and appropriate management is for clinical findings of hypotension, heart failure, or important for a successful outcome. arrhythmia.[3] Patients without identifiable injury but with persistent cardiac dysfunction (e.g. hypotension) REFERENCES are admitted for cardiac monitoring. Cardiology 1. Kang N, Hsee L, Rizoli S, Alison P. Penetrating cardiac injury: Overcoming consultation is needed for patients with hemodynamic the limits set by Nature. Injury 2009;40:919-27. instability likely due to cardiac injury. In the presence 2. Elie MC. Blunt cardiac injury. Mt Sinai J Med 2006;73:542. of arrhythmia, most physicians initiate standard 3. Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin 2004;20:57-70. 4. Ismailov RM, Weiss HB, Ness RB, Lawrence BA, Miller TR. 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