AMC Trauma Practice Management Guideline: Blunt Cardiac Injury

Total Page：16

File Type：pdf, Size：1020Kb

AMC Trauma Practice Management Guideline: Blunt Cardiac Injury Created: 4/2108 Revised: 1/2019 AMC Trauma Practice Management Guideline: Blunt Cardiac Injury PURPOSE: Outline an evidence based, protocoled approach to diagnosis and management of blunt cardiac injury (BCI) PROBLEM: Blunt cardiac injury can be difficult to diagnose. It is hard to distinguish cardiovascular collapse from other causes of hypotension in the severally injured trauma patient. There is also no specific injury (i.e.. sternal fracture) associated with a higher risk of BCI. Therefore, anyone with severe blunt trauma to the chest should be considered for screening for BCI to determine disposition status and need for further monitoring Recommendations: Level 1: An admission EKG should be obtained on all patients suspected of having a BCI Level 2: A. Any new abnormality (arrhythmia, ST changes, ischemia, heart block) on EKG should prompt continuous ECG monitoring. For those with preexisting EKG abnormalities, a comparison should be done with previous EKGs to determine need for monitoring. B. In patients with a normal EKG and normal troponin I level, BCI is ruled out. No further monitoring or imaging is indicated. C. Only patients with hemodynamic instability or a persistent new arrhythmia should have an echocardiogram performed. D. The presence of a sternal fracture alone does not predict the presence of BCI and does not require further monitoring or work-up in patients with a normal EKG and troponin I level. E. CPK and isoenzyme analysis should not be performed Level 3: A. Elderly patients with known cardiac disease, unstable patients, and those with abnormal EKG findings can safely undergo surgery with appropriate intraoperative monitoring B. Troponin I should be measured routinely for patients with suspected BCI; If elevated, the patient should be admitted to a monitored setting and the troponin I should be serially measured. Implementation: A. Anyone with severe blunt trauma to the chest should be considered for screening of BCI. B. Those suspected have having BCI should have an EKG and a troponin level drawn. If both are normal, no telemetry monitoring or echocardiogram is warranted C. Any abnormality on EKG or troponin level should prompt monitoring on telemetry and repeat troponin levels D. An echocardiogram is only warranted in hemodynamically unstable patients or in work-up for another underlying issue (syncope, MI, etc.). REFERENCES Screening for Blunt Cardiac Injury: East Clinical Guidelines. J Trauma. 73(5):S301-S306, November 2012 Created: 4/2108 Revised: 1/2019 .

Copy Link

Recommended publications

Practice Management Guidelines for Screening of Blunt Cardiac Injury
PRACTICE MANAGEMENT GUIDELINES FOR SCREENING OF BLUNT CARDIAC INJURY EAST Practice Parameter Workgroup for Screening of Blunt Cardiac Injury Michael D. Pasquale, MD Kimberly Nagy, MD John Clarke, MD © Copyright 1998 Eastern Association for the Surgery of Trauma 1 Practice Management Guidelines for Screening of Blunt Cardiac Injury I. Statement of the problem The reported incidence of blunt cardiac injury (BCI), formerly called myocardial contusion, depends on the modality and criteria used for diagnosis and ranges from 8% to 71% in those patients sustaining blunt chest trauma. The true incidence remains unknown as there is no diagnostic gold standard, i.e. the available data is conflicting with respect to how the diagnosis should be made (EKG, enzyme analysis, echocardiogram, etc.) The lack of such a standard leads to confusion with respect to making a diagnosis and makes the literature difficult to interpret. Key issues involve identifying a patient population at risk for adverse events from BCI and then appropriately monitoring and treating them. Conversely, patients not at risk could potentially be discharged from the hospital with appropriate follow-up. II. Process A Medline search from January 1986 through February 1997 was performed. All English language citations during this time period with the subject words “myocardial contusion”, “blunt cardiac injury”, and “cardiac trauma” were retrieved. Letters to the editor, isolated case reports, series of patients presenting in cardiac arrest, and articles focusing on emergency room thoracotomy were deleted from the review. This left 56 articles which were primarily well-conducted studies or reviews involving the identification of BCI. III. Recommendations A.
[Show full text]
ACR Appropriateness Criteria: Blunt Chest Trauma-Suspected Cardiac Injury
Revised 2020 American College of Radiology ACR Appropriateness Criteria® Blunt Chest Trauma-Suspected Cardiac Injury Variant 1: Suspected cardiac injury following blunt trauma, hemodynamically stable patient. Procedure Appropriateness Category Relative Radiation Level US echocardiography transthoracic resting Usually Appropriate O Radiography chest Usually Appropriate ☢ CT chest with IV contrast Usually Appropriate ☢☢☢ CT chest without and with IV contrast Usually Appropriate ☢☢☢ CTA chest with IV contrast Usually Appropriate ☢☢☢ CTA chest without and with IV contrast Usually Appropriate ☢☢☢ US echocardiography transesophageal May Be Appropriate O CT chest without IV contrast May Be Appropriate ☢☢☢ CT heart function and morphology with May Be Appropriate IV contrast ☢☢☢☢ US echocardiography transthoracic stress Usually Not Appropriate O MRI heart function and morphology without Usually Not Appropriate and with IV contrast O MRI heart function and morphology without Usually Not Appropriate IV contrast O MRI heart with function and inotropic stress Usually Not Appropriate without and with IV contrast O MRI heart with function and inotropic stress Usually Not Appropriate without IV contrast O MRI heart with function and vasodilator stress Usually Not Appropriate perfusion without and with IV contrast O CTA coronary arteries with IV contrast Usually Not Appropriate ☢☢☢ SPECT/CT MPI rest only Usually Not Appropriate ☢☢☢ FDG-PET/CT heart Usually Not Appropriate ☢☢☢☢ SPECT/CT MPI rest and stress Usually Not Appropriate ☢☢☢☢ ACR Appropriateness
[Show full text]
Blunt Cardiac Injury William Fox, MD
Blunt Cardiac Injury William Fox, MD My experience with cardiac injuries prior to my trauma rotation consisted of patients coming to the ED with acute exacerbations of chronic heart conditions, leading to arrhythmias or evidence of ischemia. Further evaluation of these patients consisted of an EKG, but can also include bedside or formal echocardiograms. As I began my trauma rotation, a number of patients suffering blunt chest trauma were admitted for “cardiac monitoring” on telemetry for 24 hours due to their injuries. I was curious as to the reasoning behind this and the clinical significance of cardiac dysfunction that develops after blunt trauma to the heart. A brief literature search on blunt cardiac injuries and arrhythmias initially led me to a review article in Heart that examined a number of diagnostic modalities and their effectiveness in detecting blunt cardiac injury. In considering EKGs, the authors comment on the greater amount of tissue in the left ventricle versus the right, and how the right ventricle may be more commonly injured in blunt cardiac injury due to its positioning in the anterior chest. These factors make detection of right ventricle injury with an EKG more difficult. Transient right bundle branch blocks have been detected with severe right ventricle injury. Left ventricle injuries can cause changes in the ST-T segment or potentially even Q wave development. It is important to recognize that arrhythmias that develop may manifest as a result of secondary issues relating to trauma, such as hemorrhage and/or hypotension. Where the EKG falls short, an echocardiogram can provide a wealth of information relating to cardiac environment and function.
[Show full text]
Blunt Cardiac Injury (BCI) Practice Management Guideline Patients At
Blunt Cardiac Injury (BCI) Practice Management Guideline Patients at high risk for BCI: 1. Blunt chest trauma AND at least one of the following: a. Complaints of chest pain b. Hemodynamically unstable patients unresponsive to resuscitation c. Arrhythmia other than sinus tachycardia Patients not requiring screening: 1. Sternal fractures without the above Patient suspected of BCI Check 12 lead EKG and Troponin **Do not check CK, CK-MB Normal Abnormal May be safely discharged 1. ICU or stepdown admission home in absence of other with telemetry admission criteria 2. Repeat EKG and troponin in 6 hours 3. Notify NP, Chief, Fellow, and/or Staff Hemodynamically stable No Yes Check transthoracic echo, if Continue to monitor until not optimal evaluation proceed EKG is normal and troponin to transesophageal echo is downtrending. Blunt Cardiac Injury 1 Updated 12/19 Brad Dennis, MD Bethany Evans, ACNP-BC **Special Consideration in BCI Underlying cardiac disease 1. In patients with known underlying coronary artery disease and BCI, use of CT or MRI coronary angiography may be able to distinguish between structural injury and acute myocardial infarction Use of Swan Ganz Catheters 1. In setting of unclear etiology of post-traumatic hypotension, use of pulmonary artery catheters may provide useful information, and is considered safe in BCI. Operative Intervention 1. Elderly patients with BCI are safe to proceed with surgery with appropriate monitoring 2. Patients with new arrhythmia are safe to proceed to the operative theater Blunt Cardiac Injury 1 Updated 12/19 Brad Dennis, MD Bethany Evans, ACNP-BC Sources: 1. Biffl WL, Moore FA, Moore EE, et al.
[Show full text]
Chapter : Chest Trauma 5 Contact Hours
Chapter : Chest Trauma 5 Contact Hours Author: Jassin M. Jouri Jr., MD Learning objectives Describe the common etiology of chest trauma. Describe diagnosis strategies for blunt chest injuries. Explain the pathophysiology of chest trauma. Identify common treatments for blunt chest injuries. List common injuries to the chest wall. Explain common treatment strategies for penetrating chest injuries. Identify common types of pulmonary and pleural space injuries. Describe recovery procedures for chest injuries. Recognize the impact of chest trauma on the tracheobronchial Identify the most common cause of penetrating chest injuries. region. Explain pain management strategies for chest injuries. Define common types of cardiac injury. Describe the purpose of intubation and ventilation in patients with Identify the two categories of chest injury. cardiac injury. Recognize the visual signs of a blunt chest injury. Introduction Chest trauma is ranked 3rd highest cause of morbidity and mortality positive pressure imposed on the chest wall. [13] These are typically in the USA after head and extremity trauma. [2] An accident or caused by accidents and fall injury. Blunt injury can affect all the areas premeditated penetration of a foreign object into the chest is the usual of the chest wall, thoracic cage and its contents. These components cause of chest trauma or injury. This type of injury may further result may range from the bony structures like ribs, clavicles, scapulae, and in bruises, fracture of ribs or severe injury to the chest wall such as sternum and viscera like lungs and pleurae, trachea-bronchial tree, lung or heart contusions. Furthermore, major chest trauma may occur esophagus, heart, great vascular structures, and the diaphragm.
[Show full text]
Blunt Cardiac Injury (BCI) Is Uncommon and Varies in Clinical Significance
Surgical BLUNT CARDIAC TRAUMA Evidence Based Medicine Guideline Critical Care.net Primary Author: Joseph Lewis, DO Editor: Michael L. Cheatham, MD Approved: 9/28/2016 Last revision date: 3/23/2021 SUMMARY Blunt cardiac injury (BCI) is uncommon and varies in clinical significance. When clinically significant, it carries substantial morbidity and mortality. Screening includes electrocardiography (ECG) and troponin I levels in those patients with blunt thoracic trauma. Patients with negative screening can be safely discharged home in the absence of other injuries. Echocardiography plays a role in the evaluation of new onset arrhythmias, hypotension, or heart failure. A troponin I greater than 1 ng/mL is associated with BCI. RECOMMENDATIONS • Level 1 ➢ All patients with blunt thoracic trauma should receive an ECG and troponin I level to screen for BCI. • Level 2 ➢ Patients with normal ECG and troponin I after 8 hours can safely be discharged in the absence of other injuries requiring admission. ➢ An echocardiogram should be obtained in patients with a troponin I > 1 ng/ml. • Level 3 ➢ Patients with an abnormal ECG or troponin I should undergo echocardiogram only in the presence of hypotension, new arrhythmia, or heart failure. ➢ Patients with known BCI should be monitored for at least 24 hours in an intensive care unit or on a telemetry floor. ➢ Patients with BCI should undergo heart failure screening 3-6 months post-injury. INTRODUCTION Blunt cardiac injury (BCI) occurs in 2.3-4.6% of trauma patients (1,2) with an overall mortality of 11.4-24.5%. An autopsy-based review by Turan et al.
[Show full text]
Management of Blunt Cardiac Injury
Medical Reports and Case Studies 2020, Vol. 5 Issue 1, 1-3 Mini Review Management of Blunt Cardiac Injury Lawrence Nair1, Brendan Winkle2*and Eshan Senanayake1 1Department of Cardiothoracic Surgery, The Prince Charles Hospital, Brisbane, Queensland, Australia 2Department of Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia Corresponding Author* be. As the vena cava is a fixed structure, as compared to the right atrium, the difference in deceleration creates a large shearing force, resulting in Brendan Winkle injury [6]. Right atrial ruptures are likely more common due to weakness of Department of Surgery, the right atrial appendage [7). Parmely et al. demonstrated that 43% of Royal Darwin Hospital, Darwin, Northern Territory, Australia ruptures from BCI were in the right atrium, compared to 13% in the left E-mail: [email protected] atrium and 13% in the intraventricular septum [8]. Tel: 61406300393 The lower rates of ventricular rupture are thought to be due to a Copyright:2020 Nair L, et al. This is an open-access article distributed difference in mechanism. Rather than deceleration, ventricular rupture is under the terms of the Creative Commons Attribution License, which more likely to occur following direct trauma to the precordium. This results permits unrestricted use, distribution, and reproduction in any medium, in compression of the heart between the sternum and the vertebral column. provided the original author and source are credited. The incidence of ventricular rupture is also related to the stage of the cardiac cycle at time of injury. If the heart is maximally distended, as at end-diastole, the force required for compression is less and thus the risk is Received: 13 Mar 2020; Accepted: 03 Apr 2020; Published: 10 Apr 2020 increased [9].
[Show full text]
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).
[Show full text]
Traumatic Heart and Great Vessels Injuries
195 Editorial Traumatic heart and great vessels injuries Cristina Barbero, Davide Ricci, Massimo Boffini, Mauro Rinaldi Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, San Giovanni Battista Hospital “Molinette”, Turin, Italy Correspondence to: Davide Ricci, MD, PhD. Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, San Giovanni Battista Hospital “Molinette”, C.so Bramante 88-90, 10126 Turin, Italy. Email: [email protected]. Submitted May 29, 2018. Accepted for publication Oct 22, 2018. doi: 10.21037/jtd.2018.10.73 View this article at: http://dx.doi.org/10.21037/jtd.2018.10.73 Introduction Cardiac trauma Noteworthy steps forward in diagnosis and management In the case of penetrating cardiac trauma, the right ventricle of cardiac and great vessels injuries have been made since alone is involved in the 35% of the patients reaching the Hippocrates stated that all wounds of the heart were hospital, the left ventricle alone in the 25% of the cases, while deadly (1). the right atrium alone is infrequently involved; in nearly During the last century, major trauma approach 30% of the cases more than one chamber is injured (8,9). A had shifted from simple clinical observation to surgical meta-analysis by Rhee et al. regarding penetrating trauma intervention, and pioneers such as Francis Stewart, John showed that survival rate was higher for isolated cardiac Bingham Roberts, and Rehn Ludwig have led surgeons injuries versus non-cardiac thoracic injuries or abdominal to believe that cardiac and great vessels injuries can be injuries (respectively 19% versus 11% and 4%) (10).
[Show full text]
Traumatic Right Ventricular Rupture After Blunt Cardiac Injury: CT Diagnosis After False Negative Pericardial Window on FAST Due to Concomitant Pericardial Rupture
IMAGES IN EMERGENCY MEDICINE Traumatic Right Ventricular Rupture after Blunt Cardiac Injury: CT Diagnosis after False Negative Pericardial Window on FAST Due to Concomitant Pericardial Rupture C. Eric McCoy, MD, MPH University of California, Irvine, Department of Emergency Medicine, Irvine, California Mark I. Langdorf, MD, MHPE Section Editor: Rick A. McPheeters, DO Submission history: Submitted October 10, 2016; Accepted November 8, 2016 Electronically published January 23, 2017 Full text available through open access at http://escholarship.org/uc/uciem_cpcem DOI: 10.5811/cpcem.2016.11.32821 [Clin Pract Cases Emerg Med. 2017;1(1):65–66.] CASE A 93-year-old male presented to a Level I trauma center in hemorrhagic shock after a head-on motor vehicle collision in which he was a restrained driver. Initial vitals were temperature 35oC, BP 100/50 mmHg, HR 63 beats/minute, respirations 28/minute, and oxygen saturation of 93% on 10L. Physical exam was significant for Glasgow Coma Scale 14 (-1 for confusion), decreased breath sounds bilaterally with diffuse chest wall tenderness, a seatbelt sign in the driver-side chest and hip distribution. Cardiac exam was without murmur. Bedside focused assessment with sonography for trauma (FAST) was negative, and chest radiograph revealed multiple bilateral rib fractures and large right hemothorax. The patient developed worsening hypotension after a chest tube yielded Computed tomography of chest revealing rupture of right >1L of gross blood despite blood product resuscitation. Image. ventricle with leak of contrast and associated hemopericardium Computed tomography of the chest revealed multiple thoracic (white arrow). injuries including but not limited to several rib fractures, sternum fracture, large right-sided hemothorax and right ventricular rupture with leak of contrast and associated decompression of the cardiac hemorrhage into the ipsilateral hemopericardium (Image).
[Show full text]
Atrial Fibrillation Due to Blunt Cardiac Injury: Case Report
Journal of Emergency Medicine J Emerg Med Case Rep 2018; 9(4): 77-9 DOI: 10.5152/ jemcr.2018.2323 Case Reports Atrial Fibrillation due to Blunt Cardiac Injury: Case Report Kasım Turgut1 , Neslihan Yücel2 , Hakan Oğuztürk2 , Zeynep Ulutaş3 , Abdulmecit Afşin3 1Clinic of Emergency Medicine, Adıyaman Training and Research Hospital, Adıyaman, Turkey 2Department of Emergency Medicine, İnönü University, Malatya, Turkey 3Department of Cardiology, İnönü University, Malatya, Turkey Cite this article as: Turgut K, Yücel N, Oğuztürk H, Ulutaş Z, Afşin A. Atrial Fibrillation due to Blunt Cardiac Injury: Case Report. J Emerg Med Case Rep 2018; 9(4): 77-9. ABSTRACT Introduction: Blunt cardiac injury secondary to chest trauma is an important cause of emergency department admissions. It can range from asymptomatic myocardial contusion to significant dysrhythmia, acute heart failure, valvular injury, or cardiac rupture. Case Report: A 38-years-old patient was admitted to the emergency department with atrial fibrillation (AF) that occurred after a car accident. The patient had chest trauma caused by striking the steering wheel during the accident. The AF rhythm of the patient reverted to the normal sinus rhythm at the 3rd hour after trauma. Conclusion: Emergency medicine professionals should keep in mind arrhythmias due to blunt chest trauma and take electrocardiograms of patients to be able to provide treatment in time. Keywords: Atrial fibrillation, cardiac injury, chest trauma Received: 08.03.2018 Accepted: 12.09.2018 Introduction Blunt cardiac injury (BCI) encompasses different clinical circumstances, such as gradual myocardial injuries, great artery injuries, cardiac tamponade, septum or wall ruptures, pump failure, conduction disturbances, and cardiac arrhythmias (1).
[Show full text]
A Case Report: Hemothorax Caused by Rupture of the Left Atrial Appendage
Oizumi et al. Surgical Case Reports (2016) 2:142 DOI 10.1186/s40792-016-0270-2 CASE REPORT Open Access A case report: hemothorax caused by rupture of the left atrial appendage Hiroaki Oizumi1*, Kenji Suzuki2, Hironobu Hoshino1, Takahiro Tatsumori1 and Hideomi Ichinokawa1 Abstract Cardiac rupture is defined as a full-thickness myocardial tear; this injury after blunt chest trauma is rare, and is associated with high mortality. Blunt cardiac rupture typically presents with either cardiac tamponade or massive hemothorax, and is often unrecognized in the context of blunt chest trauma. It is a little known fact that pericardial effusions can decrease due to pericardial lacerations. Hence, cardiac rupture with pericardial lacerations may be easily overlooked especially by chest surgeons. We herein report a case of hemothorax caused by rupture of the left atrial appendage. An 80-year-old male was involved in a motor vehicle crash. We made the diagnosis of hemothorax on the basis of bloody thoracic effusion and left pleural effusion on computed tomography (CT). CT also showed small pericardial effusion in amount and non-displaced rib fractures. We made a tentative diagnosis of intercostal artery injury with rib fractures, we performed left thoracotomy. However, in the operating room, we recognized that cardiac rupture led to massive hemothorax, and that hemothorax was not associated with intercostal artery injury. We repaired left atrial appendage rupture, and his postoperative course was uneventful. Cardiac rupture can present as slight pericardial effusion with hemothorax. On the basis of this case, we propose that cardiac rupture should be considered at the time of hemothorax examination with careful attention to pericardial effusions.
[Show full text]