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The Heart in Blunt Trauma Gilles Orliaguet, M.D.,* Mustapha Ferjani, M.D.,† Bruno Riou, M.D., Ph.D.‡

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The Heart in Blunt Trauma Gilles Orliaguet, M.D.,* Mustapha Ferjani, M.D.,† Bruno Riou, M.D., Ph.D.‡ Ⅵ CLINICAL CONCEPTS AND COMMENTARY Richard B. Weiskopf, M.D., Editor Anesthesiology 2001; 95:544–8 © 2001 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. The Heart in Blunt Trauma Gilles Orliaguet, M.D.,* Mustapha Ferjani, M.D.,† Bruno Riou, M.D., Ph.D.‡ DIAGNOSIS of lesions of the heart related to blunt be used when no lesion can be evidenced by any imag- trauma is a challenge, mainly because of confusion about ing method, including histology. Myocardial commotion Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/95/2/544/331722/0000542-200108000-00041.pdf by guest on 25 September 2021 the terms used and the absence of recognized standards. results from low-energy impact to the precordium lead- It has been recommended that the term myocardial con- ing to cardiac arrest, with most events observed during tusion be avoided and that the term blunt cardiac trauma athletic activity (baseball, golf, hockey). Cardiac arrest be used only in the presence of pump failure or malig- may result either from an impact 30–15 ms before the nant cardiac rhythms.1 These uncertainties make the peak of the T wave, leading to ventricular fibrillation, or literature difficult to analyze and compare. The clinician from an impact during the QRS complex, leading to is left knowing that “myocardial contusion” occurs in complete heart block.2 In contrast, myocardial contu- blunt trauma and may be responsible for significant clin- sion results from high energy impact and is associated ical events (arrhythmias and perioperative hemodynamic with myocardial lesions (hemorrhage, increase in edema instability, including cardiogenic shock and death). formation, necrosis, polymorphonuclear infiltrates) that Moreover, assessment of the heart in blunt trauma also increase extravascular resistance and may result in de- includes assessment of intracardiac volume, the pericar- creased coronary blood flow and cardiac function.3–5 dium, and rare surgical lesions, such as valve rupture, Injury most frequently involves the right ventricle and septal defect, and coronary artery lesions. The aim of this the septum.3 Clinical Concepts and Commentary article is to provide Myocardial contusion may induce severe complica- the clinician with a brief review of the literature and tions, the most frequent being arrhythmias. Arrhythmias some recommendations that could be useful in clinical may occur after even minor myocardial contusion, ex- practice. plaining why most of the literature in emergency medi- cine proposes algorithms to exclude myocardial contu- Pathophysiology sion and thus the need for cardiac monitoring after thoracic trauma. Robert et al.6 recently provided con- Blunt trauma can induce myocardial lesions by several vincing evidence that myocardial contusion is responsi- mechanisms: (1) direct transfer of energy during the ble for the reentry mechanism potentially leading to impact on the thorax; (2) rapid deceleration of the heart; severe arrhythmias. Hemopericardium can be caused by and (3) compression of the heart between the sternum myocardial contusion but is rarely responsible for car- and the spine. Although there is a continuum between diac tamponade. Severe myocardial contusion may in- these two entities, myocardial lesions may be divided duce a decrease in cardiac function, but frank cardio- into “myocardial commotion” and myocardial contusion. genic shock is rarely observed.7 Nevertheless, because Theoretically, the term myocardial commotion should the right ventricle is more often involved than the left ventricle in myocardial contusion and because an in- crease in pulmonary artery resistance is often observed *Assistant Professor of Anesthesiology, Department of Anesthesiology and Critical Care, Centre Hospitalier Universitaire (CHU) Necker-Enfants Malades, when adult respiratory distress syndrome occurs, a mod- Paris. †Associate Professor of Anesthesiology, Department of Anesthesiology, erate decrease in right ventricular function may be a Critical Care and Hemodialysis, Military Hospital, Tunis. ‡Professor of Anesthe- siology, Department of Anesthesiology, and Chairman, Department of Emer- clinically relevant problem in severely traumatized pa- gency Medicine and Surgery, CHU Pitié-Salpêtrière, Paris. tients. The hemodynamic consequences of mechanical Received from the Department of Anesthesiology and Critical Care, CHU ventilation (peak inspiratory pressure, positive end-expi- Necker-Enfants Malades, Paris, France; the Department of Anesthesiology, Criti- cal Care and Hemodialysis, Military Hospital, Tunis, Tunisia; and the Department ratory pressure, arterial carbon dioxide tension [PaCO2]) of Anesthesiology and Critical Care and the Department of Emergency Medicine can be more pronounced in the case of right ventricular and Surgery, CHU Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris, France. Submitted for publication April 14, 2000. Accepted for publication February 6, dysfunction induced by myocardial contusion. Conse- 2001. Support was provided solely from institutional and/or departmental quently, ventilatory management decreasing airway sources. pressure (low tidal volume, high-frequency ventilation) Address correspondence to Dr. Riou: Département d’Anesthésie-Réanimation et Service d’Accueil des Urgences, CHU Pitié-Salpêtrière, 47-81 Boulevard de may be beneficial. Cardiac rupture is a rarely observed l’Hôpital, 75651 Paris Cedex 13, France. Address electronic mail to: complication. [email protected]. The illustration for this section is prepared by Dmitri Karetnikov, 7 Tennyson Recent experimental studies have shown that troponin Drive, Plainsboro, New Jersey 08536. T and I are released after myocardial contusion and that Anesthesiology, V 95, No 2, Aug 2001 544 THE HEART IN BLUNT TRAUMA 545 Table 1. Comparison of Diagnostic Performance of Transthoracic (TTE) and Transesophageal (TEE) (134 ؍ Echocardiography Performed in the Same Blunt Chest Trauma Patients (n Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/95/2/544/331722/0000542-200108000-00041.pdf by guest on 25 September 2021 From Chirillo et al.8 this release correlates with the energy of trauma.4,5 over, the use of catecholamines during resuscitation of Moreover, there is an early peak probably related to severe hemorrhagic shock may also be responsible for membrane damage and release of unbound troponins the myocardial lesions observed in severely traumatized followed by a continuous release from disintegrated patients.10 These may be involved in the decreased left myofibers. ventricular function observed in severely traumatized Many other cardiac lesions may occur during blunt patients. trauma, but they are rare (table 1).8 Valvar lesions occur in less than 1% of the cases and are predominantly of the Assessment of the Heart aortic and mitral valves. Ventricular and atrial septal In the modern era, electrocardiography, troponin I defects occur even more rarely in thoracic blunt trauma. concentration measurement, and echocardiography Lesions of the coronary arteries (laceration, thrombosis, should be used routinely to assess the heart in trauma. dissection of the ostium) have been found in less than Nevertheless, these evaluations share some limitations. 2% of cases in autopsy series. Clear suspicion of myocar- Invasive diagnostic procedures (coronary angiography, dial infarction (electrocardiography, troponin I concen- ventriculography) should be performed in few cases tration measurement, echocardiography) in a young (Ͻ 0.1%), when a coronary lesion or a cardiac rupture is trauma patient should lead to emergency coronary an- suspected. giography and surgery. Pericardial trauma may lead to Electrocardiographic abnormalities frequently occur in hemopericardium with or without myocardial lesions, myocardial contusion, but a normal electrocardiogram and pericardial rupture with possible herniation of does not exclude the diagnosis. The more frequent ar- the heart. rhythmias observed are sinus tachycardia and extrasys- Apart from the direct lesions related to trauma, the toles. Right bundle branch block and atrioventricular heart may have indirect lesions, mainly due to head blocks are the most frequently observed conduction trauma and shock. It is now well-established that head abnormalities. Repolarization abnormalities (ST segment trauma, subarachnoid hemorrhage, and increases in in- and T waves) are frequent, whereas Q waves are rarely tracranial pressure may lead to myocardial lesions. Most observed. Severe arrhythmias (ventricular tachycardia of the knowledge regarding these lesions has been ob- and fibrillation) are rarely noted but are life-threatening tained from brain-dead patients.9 Increase in sympa- complications of myocardial contusion, explaining the thetic activity, with catecholamine storm, is responsible need for cardiac monitoring. for prolonged norepinephrine and neuropeptide Y re- Because a standard electrocardiogram mainly explores lease within the myocardium, leading to ␤-adrenergic the left ventricle, it is not surprising that it can miss right receptor desensitization, coronary vasoconstriction, and ventricular contusion. However, addition of right pre- cardiomyocyte lesions. This phenomenon is associated cordial electrocardiographic leads do not add sensitivity with electrocardiographic abnormalities, troponin re- for the diagnosis. Electrocardiographic abnormalities lease, and decrease in cardiac function and has been may be related to other factors in trauma patients (hy-
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