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Usefulness of Transthoracic and Transoesophageal Echocardiography in Recognition and Management of Cardiovascular Injuries After Blunt Chest Trauma

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Heart 1996;75:301-306 301 Usefulness of transthoracic and transoesophageal echocardiography in recognition and management of cardiovascular injuries after blunt chest trauma Fabio Chirillo, Oscar Totis, Antonio Cavarzerani, Andrea Bruni, Antonio Famia, Mario Sarpellon, Paolo Ius, Carlo Valfre, Paolo Stritoni Abstract About 10% of victims of major trauma sustain Objective-To assess the diagnostic poten- cardiac or aortic lesions.' Although the vast tial of transthoracic and transoesophageal majority of these individuals die at the scene,2 echocardiography for the detection of an increasing number of patients with previ- traumatic cardiovascular injuries in ously lethal injuries arrive at a treatment facility patients suffering from severe blunt chest because of improvements in prehospital care, trauma. more aggressive resuscitation in the field, and Design-Prospective study over a three rapid transportation to appropriate units.3 The year period. identification of cardiovascular injury in these Setting-A regional cardiothoracic centre. patients is often difficult because of severe Patients-134 consecutive patients (94 associated lesions which are more apparent M/40 F; mean age 38 (SD 14) years) suffer- and require prompt treatment.4 The diagnos- ing from severe blunt chest trauma (injury tic value of routine techniques for the detec- severity score 33 5 (18.2)). Most patients tion of traumatic cardiovascular injuries is (89%) were victims of motor vehicle acci- limited56 and the accuracy of more refined dents. techniques, such as computed tomography Evaluation-All patients underwent trans- and magnetic resonance imaging, has been thoracic and transoesophageal echocar- questioned.7 9 diography within 8 h of admission. Aortography is still considered to be the Aortography was performed in the first 20 gold standard technique for the detection of patients and in a further five equivocal traumatic aortic rupture,'01' but it cannot be cases. always performed on an emergency basis, has Results-Transthoracic echocardiography the complications involved in an invasive tech- provided suboptimal images in 83 patients, nique,'2 does not identify myocardial or valvar detecting three aortic ruptures, 28 pericar- lesions, and has a low diagnostic yield and very dial effusions (one cardiac tamponade), 35 high cost when performed on all trauma left pleural effusions, and 15 myocardial patients. contusions. Transoesophageal echocardio- Transthoracic echocardiography has been graphy was feasible in 131 patients and used in previous studies'3-'5 on patients suffer- detected 14 aortic ruptures (13 at the ing from chest trauma: it proved helpful in isthmus), 40 pericardial effusions, 51 detecting myocardial contusion, whereas no left pleural effusions, 34 periaortic data have been reported on identification of haematomas, 45 myocardial contusions, aortic rupture. right atrial laceration in one patient with Transoesophageal echocardiography over- cardiac tamponade, one tricuspid valve comes most of the technical limitations of rupture, and one severe mitral regurgita- transthoracic echocardiography and provides heart and almost Department of tion caused by annular disruption. For the excellent visualisation of the Cardiology, Regional detection of aortic rupture trans- the entire thoracic aorta in nearly all patients.'6 17 Hospital, Treviso, Italy oesophageal echocardiography showed The aim of this study was to assess the diagnos- F Chirillo and 98% tic potential of transthoracic and trans- O Totis 93% sensitivity, 98% specificity, A Cavarzerani accuracy. Time to surgery was signifi- oesophageal echocardiography for the detection A Bruni candy shorter (30 (12) v 71 (21) min; P < oftraumatic cardiovascular lesions and to evalu- P Stritoni 0.05) for patients operated on only on the ate the impact of transoesophageal echocardio- Department of basis of transoesophageal echocardio- graphic findings on the management of patients Anaesthesiology and Intensive Care, graphic findings. following severe blunt chest trauma. Regional Hospital, Conclusions-Transthoracic echocardiog- Treviso, Italy raphy has low diagnostic yield in severe A Famia blunt chest trauma, while trans- Methods M Sarpellon oesophageal echocardiography provides Between September 1991 and September Department of Cardiovascular accurate diagnosis in a short time at the 1994 134 consecutive patients (94 men, 40 Surgery, Regional bedside, is inexpensive, mimally inva- women) aged 15-78 years (mean 38 (SD 14) Hospital, Treviso, Italy sive, and does not interfere with other years) admitted to our hospital following P Ius diagnostic or therapeutic procedures. severe blunt chest trauma were prospectively C Valfre and Correspondence to: evaluated for presence of cardiac injury Dr F Chirillo, Cardiologia, (Heart 1996;75:301-306) aortic rupture (table 1). Patients were entered Ospedale Regionale, 31 100 into the study who were found to have Treviso, Italy. con- Accepted for publication Keywords: blunt chest trauma; traumatic cardiovascu- haemothorax, pneumothorax, pulmonary 22 August 1995 lar injuries; echocardiography tusion, fracture of the first two or multiple 302 Chirillo, Totis, Cavarzerani, Bruni, Farnia, Sarpellon, et al Table 1 Clinical characteristics of 134 patients with a 100 cm gastroscope and attached to a Sonos blunt chest trauma evaluatedfor cardiovascular injury 1000 Hewlett-Packard ultrasound system. Sex M/F 94/40 Introduction of the probe was accomplished Age (years) 38 (SD 14) Mechanism of injury, n (%) after the administration of intravenous Drivers 54 (40) droperidole or morphine, when necessary, for Occupants 33 (25) sedation. Pedestrians struck by car 14 (10-5) (Motor)cyclists 18 (13-5) Cross sectional echocardiography identified Fall from height 12 (9) Animal kicks 3 (2) myocardial contusion in presence of hypokine- Injury severity score 33-5 (SD 18-2) sis, akinesis, or dyskinesis of any segment of Associated injuries, n (%) 86 (64) Cranial 38 (28) the left ventricle or right ventricular free wall.20 Abdominal 41 (30 5) Patients with myocardial contusion underwent a Pelvic 16 (2) Major extremity fractures 78 (58) control transthoracic echocardiogram before Emergency surgical procedures, n 145 discharge. Pericardial and pleural effusion were Neurosurgical 15 (11) Abdominal 35 (26) diagnosed when an echo-free space was seen Urological 7 (5) between the visceral and parietal pericardial Orthopaedic 55 (41) Thoracic (non-cardiovascular) 19 (14) and pleural echoes in all imaging planes. Cardiovascular 15 (11) Periaortic haematoma was diagnosed when a Chest film suggestive for aortic rupture, n (%) 65 (48 5) bright echo density was seen around the aorta. Death, n (%) 19 (14) Colour Doppler interrogation of the septa and valves identified intracardiac shunts or valvar regurgitation according to standard criteria.2' 22 Aortic rupture was diagnosed when two or ribs, or to have had a significant field evidence more of the following echographic criteria were of high energy transfer such as falls of more met: (1) abrupt and discrete change in aortic than 4 metres and automobile accidents with diameter (that is, normal diameter proximal structural intrusion, extrication difficulties, and distal to the site of rupture which exhibited passenger ejection, or death at the scene. widened lumen); (2) presence of one or more Motor vehicle accidents were the cause of consistent linear echoes indicative of transec- injury in most patients. The injury severity tion flaps dividing the aortic lumen into two or score'8 19 for the entire group was 33-5 (SD more lumina; (3) focal but complete intimal 18-2). Most patients (64%) experienced asso- and medial disruption with formation of a ciated cranial, abdominal and pelvic injury, pseudoaneurysmatic cavity; (4) colour Doppler often requiring emergency surgery. Ninety identification of a pseudocoarctation pattern seven patients arrived at our institution (that is, flow acceleration through the injured directly from the accident scene, and 37 were aortic segment); (5) periaortic haematoma. transferred from other hospitals. There were Findings on echocardiography were com- 19 deaths: five from head trauma, six from pared with aortography in 25 patients, surgery haemorragic shock, five from multisystem in 15 patients, and necropsy in 19 cases. organ failure, and three from aortic rupture. In Patients with transoesophageal echocardiogra- all but the latter three patients necropsy ruled phy negative for aortic rupture and repeat out major cardiac injury and aortic rupture. chest x ray negative for widened mediastinum Eighty patients were evaluated while endo- were considered free from aortic injury. tracheally intubated; 35 had chest tubes, 21 abdominal tubes, and five had subcutaneous STATISTICAL ANALYSIS emphysema. Continuous values are expressed as means Supine anteroposterior chest plain x ray film (SD). The sensitivity (true positives divided by was obtained in all patients at admission: true positives plus false negatives), specificity mediastinal widening, a blurred aortic knob, (true negatives divided by true negatives plus apical capping of the lung, rightward displace- false positives), positive predictive value (true ment of the trachea, and depression of the left positives divided by true positives plus false main bronchus were considered findings sug- positives), negative predictive value (true nega- gestive of aortic rupture. Chest x ray was tives divided by true negatives plus false nega- repeated in the erect position before discharge tives)
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