Karate kick-induced myocardial contusion.

Myocardial contusion should be suspected in a selected patient group with blunt thoracic trauma, who have elevated troponin, ECG changes and/or haemodynamical instability. Echocardiography is useful for direct visualisation of possible complications. In stable conditions, MRI allows for good visualisation of the heart and can confirm a suspected myocardial contusion as well as demonstrate the extent of myocardial damage. Based on the present literature, the authors developed a diagram for the diagnostic approach of a patient with suspected myocardial contusion.

Solving the impossible: penetrating cardiac injuries, a case series of diagnostic workup and management / Resolviendo lo imposible: heridas penetrantes cardíacas, serie de casos del abordaje diagnóstico y terapéutico

For a long time, any heart-based injury was an off-limits area for surgeons; a patient with a traumatic cardiac injury was doomed to die. Little more than one hundred years have passed since the first surgical correction of a penetrating cardiac injury and there is still a high rate of mortality, despite the medical advances. We present the case of 6 patients with penetrating cardiac injuries that were repaired at a third level hospital of Mexico, alongside relevant findings on the literature about the topic. From 2019 to 2020, an incidence of 6 patients with penetrating cardiac injuries was present; all men aged 30 years or older. The etiology of 4 (67%) patients was stab wounds and 2 (33%) gunshot wounds. Left anterolateral thoracotomy was used on 5 (83%) patients and midline sternotomy on 1 (17%) patient. 2 (33%) injuries on the left ventricle presented along with coronary arteries injuries. Left ventricle and right atrium injuries presented each 50% of mortality. The mortality was of 33%, 1 patient died due to intraoperative complications and another one due to massive cerebral infarction and polyuric syndrome because of diabetes insipidus. There is a long path ahead of the surgical field on this topic and further to be analyzed. An excellent tool for cardiac tamponade diagnosis due to penetrating cardiac injuries is cardiac ultrasound, therefore it should be used on every hemodynamic unstable patient in the context of PCI. Definitively, time is of the essence, and the survival of patients depends on immediate transport to a hospital and an opportune surgical intervention.

Durante mucho tiempo las heridas en el corazón eran un área prohibida para el cirujano. Cualquier persona con herida penetrante cardíaca estaba condenada a morir. Poco más de cien años han transcurrido desde la primera corrección quirúrgica de una herida penetrante cardíaca y sigue habiendo una tasa alta de mortalidad, a pesar de los avances médicos. Se presenta una serie de casos de 6 pacientes con heridas penetrantes cardíacas que fueron reparadas en un hospital de tercer nivel de México, junto con revisión de la literatura. Desde el 2019 al 2020, hubo una incidencia de 6 pacientes con heridas penetrantes cardíacas; todos fueron hombres de 30 años o mayores. La etiología en 4 (67%) casos fueron heridas por arma blanca y 2 (33%) por herida por proyectil de arma de fuego. Se usó el abordaje por toracotomía anterolateral izquierda en 5 (83%) pacientes y esternotomía media en 1 (17%) paciente. Dos (33%) heridas se suscitaron en el ventrículo izquierdo en conjunto con heridas en arterias coronarias. Heridas en el ventrículo izquierdo y atrio derecho presentaron una mortalidad del 50% cada una. La mortalidad total fue de 33%, 1 paciente falleció por complicaciones intraoperatorias y otro más por infarto cerebral masivo y síndrome poliúrico causado por diabetes insípida. Hay un gran camino por recorrer en el ámbito quirúrgico de este tipo de heridas y más por ser analizado. Una herramienta útil para el diagnóstico del taponamiento cardíaco por heridas penetrantes cardíacas es el ultrasonido cardíaco, y, por ende, debe ser usado en todo paciente con inestabilidad hemodinámica en el contexto de una herida penetrante cardíaca. Definitivamente, el tiempo es vida, y la sobrevivencia de estos pacientes depende del transporte inmediato a un hospital y una intervención quirúrgica oportuna.

Management of Seat Belt-type Blunt Abdominal Aortic Trauma and Associated Injuries in Pediatric Patients.

BACKGROUND: "Seat belt-type" pediatric abdominal aortic trauma is uncommon but potentially lethal. During high speed motor vehicle collisions (MVCs), seat or lap belt restraints may concentrate forces in a band-like pattern across the abdomen, resulting in the triad of hollow viscus perforation, spine fracture, and aortoiliac injury. We report 4 cases of pediatric seat belt-type aortic trauma and review management strategies for the aortic disruption and the associated constellation of injuries. METHODS: -approved, retrospective review of all pediatric patients requiring surgical intervention for seat belt-type constellation of abdominal aortic/iliac and associated injuries over a 5-year period. Blunt thoracic aortic injuries were excluded. RESULTS: We identified 4 patients, ranging from 2 to 17 years of age, who required surgical correction of seat belt-type aortoiliac trauma and associated injuries: 3 abdominal aortas and 1 left common iliac artery. The majority (3/4 patients) were hemodynamically unstable at emergency room presentation, and all underwent computed tomography angiography of the chest/abdomen/pelvis during initial resuscitation. Injuries of the suprarenal and proximal infrarenal aorta were accompanied by unilateral renal artery avulsion requiring nephrectomy. Presumed or proven spinal instability mandated supine positioning and midline laparotomy, with medial visceral rotation utilized for proximal injuries. Aortoiliac injuries requiring repair were accompanied by significant distal intraluminal prolapse of dissected intima, with varying degrees of obstruction. Conduit selection was dictated by the presence of enteric contamination and the rapid availability of an autologous conduit. The sole neurologic deficit was irreparable at presentation. CONCLUSIONS: Seat belt aortoiliac injuries in pediatric patients require prompt multidisciplinary evaluation. Evidence of contained aortoiliac transection, major branch vessel avulsion, and bowel perforation mandates immediate exploration, which generally precedes spinal interventions. Lesser degrees of aortoiliac injuries have been managed with surveillance, but long-term follow-up is needed to fully validate this approach.

Early cardiac magnetic resonance imaging in troponin-positive acute chest pain and non-obstructed coronary arteries.

OBJECTIVE: We assessed the diagnostic and prognostic implications of early cardiac magnetic resonance (CMR), CMR-based deformation imaging and conventional risk factors in patients with troponin-positive acute chest pain and non-obstructed coronary arteries. METHODS: In total, 255 patients presenting between 2009 and 2019 with troponin-positive acute chest pain and non-obstructed coronary arteries who underwent CMR in ≤7 days were followed for a clinical endpoint of all-cause mortality. Cine movies, T2-weighted and late gadolinium-enhanced images were evaluated to establish a diagnosis of the underlying heart disease. Further CMR analysis, including left ventricular strain, was carried out. RESULTS: CMR (performed at a mean of 2.7 days) provided the diagnosis in 86% of patients (54% myocarditis, 22% myocardial infarction (MI) and 10% Takotsubo syndrome and myocardial contusion (n=1)). The 4-year mortality for a diagnosis of MI, myocarditis, Takotsubo and normal CMR patients was 10.2%, 1.6%, 27.3% and 0%, respectively. We found a strong association between CMR diagnosis and mortality (log-rank: 24, p<0.0001). Takotsubo and MI as the diagnosis, age, hypertension, diabetes, female sex, ejection fraction, stroke volume index and most of the investigated strain parameters were univariate predictors of mortality; however, in the multivariate analysis, only hypertension and circumferential mechanical dispersion measured by strain analysis were independent predictors of mortality. CONCLUSIONS: CMR performed in the early phase establishes the proper diagnosis in patients with troponin-positive acute chest pain and non-obstructed coronary arteries and provides additional prognostic factors. This may indicate that CMR could play an additional role in risk stratification in this patient population.

Alteraciones electrofisiológicas y/o bioquímicas del trauma cardíaco / Electrophysiological and/or biochemical alterations of cardiac trauma

Resumen El trauma cardíaco constituye una de las primeras causas de mortalidad en la población general. La gran mayoría son causados por accidentes automovilísticos. Su diagnóstico es difícil y requiere alto índice de sospecha en trauma cerrado. Posee un índice de mortalidad muy elevado, cercano al 76%. Existen varios métodos diagnósticos disponibles para facilitar su detección pero ninguno logra alcanzar una sensibilidad cercana al 100%. El trauma cardíaco contuso puede variar desde lesión cardíaca asintomática hasta ruptura cardíaca y muerte. Actualmente se utilizan marcadores bioquímicos como enzimas cardíacas, siendo la Troponina I la más específica; y electrofisiológicos como hallazgos en el electrocardiograma sugestivos de bloqueo de rama y taquicardia sinusal, siendo estos los más frecuentemente encontrados.

Abstract Heart trauma is one of the leading causes of mortality in the general population. The vast majority are caused by automobile accidents. Its diagnosis is difficult and requires a high index of suspicion in closed trauma. It has a very high mortality rate, close to 76%. There are several diagnostic methods available to facilitate its detection, but none can reach a sensitivity close to 100%. Contusive heart trauma can range from asymptomatic cardiac injury to cardiac rupture and death. Currently, biochemical markers are used as cardiac enzymes, with Troponin I being the most specific; and electrophysiological findings in the electrocardiogram suggestive of branch block and sinus tachycardia, these being the most frequently found.

Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture.

Extracorporeal cardiopulmonary resuscitation (ECPR) followed by operating room sternotomy, rather than resuscitative thoracotomy, might be life-saving for patients with blunt cardiac rupture and cardiac arrest who do not have multiple severe traumatic injuries. A 49-year-old man was injured in a vehicle crash and transferred to the emergency department. On admission, he was hemodynamically stable, but a plain chest radiograph revealed a widened mediastinum, and echocardiography revealed hemopericardium. A computed tomography scan revealed hemopericardium and mediastinal hematoma, without other severe traumatic injuries. However, the patient's pulse was lost soon after he was transferred to the intensive care unit, and cardiopulmonary resuscitation was initiated. We initiated ECPR using femorofemoral veno-arterial extracorporeal membrane oxygenation (ECMO) with heparin administration, which achieved hemodynamic stability. He was transferred to the operating room for sternotomy and cardiac repair. Right ventricular rupture and pericardial sac laceration were identified intraoperatively, and cardiac repair was performed. After repairing the cardiac rupture, the cardiac output recovered spontaneously, and ECMO was discontinued intraoperatively. The patient recovered fully and was discharged from the hospital on postoperative day 7. In this patient, ECPR rapidly restored brain perfusion and provided enough time to perform operating room sternotomy, allowing for good surgical exposure of the heart. Moreover, open cardiac massage was unnecessary. ECPR with sternotomy and cardiac repair is advisable for patients with blunt cardiac rupture and cardiac arrest who do not have severe multiple traumatic injuries.

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.

Blunt cardiac injury due to trauma associated with snowboarding: a case report.

BACKGROUND: Cardiac trauma is associated with a much higher mortality rate than injuries to other organ systems, even though cardiac trauma is identified in less than 10% of all trauma admissions. Here we report blunt trauma of the left atrium due to snowboarding trauma. CASE PRESENTATION: A 45-year-old Asian man collided with a tree while he was snowboarding and drinking. He lost consciousness temporarily. An air ambulance was requested and he was transported to an advanced critical care center. On arrival, a pericardial effusion was detected by a focused assessment with sonography for trauma. His presenting electrocardiogram revealed normal sinus rhythm and complete right bundle branch block. Laboratory findings included a white blood cell count of 13.5 × 103/µl, serum creatine kinase level of 459 IU/l, and creatine kinase-myocardial band level of 185 IU/l. Enhanced computed tomography showed a large pericardial effusion and bleeding from his left adrenal gland. There were no pelvic fractures. A diagnosis of cardiac tamponade due to blunt cardiac injury and left adrenal injury due to blunt trauma was made. Subsequently, emergency thoracic surgery and transcatheter arterial embolization of his left adrenal artery were performed simultaneously. A laceration of the left atrial appendage in the lateral wall of his left ventricle was detected intraoperatively and repaired. His postoperative course progressed favorably, although a pericardial effusion was still detected on chest computed tomography on hospital day 35. His electrocardiogram showed normal sinus rhythm and the complete right bundle branch block pattern changed to a narrow QRS wave pattern. He was discharged on hospital day 40. CONCLUSIONS: The present case report illustrates two points: (1) severe injuries resulted from snowboarding, and (2) complete right bundle branch block was caused by blunt cardiac injury. The present report showed blunt trauma of the left atrium with complete right bundle branch block as an electrocardiogram change due to snowboarding trauma. To detect cardiac trauma in snowboarding accidents, an examination of an electrocardiogram is required in all patients who might have a bruised chest.

Cardiac magnetic resonance imaging in suspected blunt cardiac injury: A prospective, pilot, cohort study.

INTRODUCTION: The aim of this study was to evaluate the incidence and severity of blunt cardiac injury (BCI) as determined by cardiac magnetic resonance imaging (CMR), and to compare this to currently used diagnostic methods in severely injured patients. MATERIALS AND METHODS: We conducted a prospective, pilot cohort study of 42 major trauma patients from July 2013 to Jan 2015. The cohort underwent CMR within 7 days, enrolling 21 patients with evidence of chest injury and an elevated Troponin I compared to 21 patients without chest injury who acted as controls. Major adverse cardiac events (MACE) including ventricular arrhythmia, unexplained hypotension requiring inotropes, or a requirement for cardiac surgery were recorded. RESULTS: 6/21 (28%) patients with chest injuries had abnormal CMR scans, while all 21 control patients had normal scans. CMR abnormalities included myocardial oedema, regional wall motion abnormalities, and myocardial haemorrhage. The left ventricle was the commonest site of injury (5/6), followed by the right ventricle (2/6) and tricuspid valve (1/6). MACE occurred in 5 patients. Sensitivity and specificity values for CMR at predicting MACE were 60% (15-95) and 81% (54-96), which compared favourably with other tests. CONCLUSION: In this pilot trial, CMR was found to give detailed anatomic information of myocardial injury in patients with suspected BCI, and may have a role in the diagnosis and management of patients with suspected BCI.

The Feasibility of Dual-Energy Computed Tomography in Cardiac Contusion Imaging for Mildest Blunt Cardiac Injury.

PURPOSE: The purpose of this study was to evaluate the efficiency and feasibility of dual-energy computed tomography (DECT) used in the diagnosis of cardiac contusion with the mildest blunt cardiac injury. MATERIAL AND METHODS: This study was performed between February 2014 and September 2015; a total of 17 consecutive patients (10 men and 7 women; median age, 51 years [range: 20-78]) were enrolled in the study. The DECT was performed within 48 hours of the trauma and a subsequent follow-up DECT was performed a little less than 1 year after the first examination. All examinations were analyzed on iodine map images by 2 experienced radiologists. Interobserver and intraobserver agreement was calculated. The correlation of initial troponin level, age, and sex with number of contusion areas in the left ventricle and complete recovery of contusion were measured. RESULTS: The contusion areas were amorphous, with considerable variation in their size, shape, and density. Contusions were primarily located in the left free wall of the ventricle, the ventricular septum, and the apex, respectively. In 10 patients, contusion areas disappeared on follow-up examination. In 4 patients, the contusion areas decreased but were still present in the follow-up examination. The interobserver agreements were almost perfect with respect to the presence of cardiac contusion, the anatomic location of contusions, and the contusion areas (kappa values of 1.0, 1.0, and 0.9 for intraobserver agreement and 1.0, 1.0, and 1.0 for intraobserver agreement, respectively). Correlations were found between age of patients and complete recovery of contusion (P = 0.01). CONCLUSIONS: Dual-energy computed tomography can show cardiac contusion and could be useful and feasible for the diagnosis and follow-up of blunt cardiac injuries. Dual-energy computed tomography is a new, user-independent, and valuable imaging technique.

Cardiac Trauma.

Cardiac trauma is a leading cause of death in the United States and occurs mostly due to motor vehicle accidents. Blunt cardiac trauma and penetrating chest injuries are most common, and both can lead to aortic injuries. Timely diagnosis and early management are the key to improve mortality. Cardiac computed tomography and cardiac ultrasound are the 2 most important diagnostic modalities. Mortality related to cardiac trauma remains high despite improvement in diagnosis and management.

Imaging in blunt cardiac injury: Computed tomographic findings in cardiac contusion and associated injuries.

BACKGROUND: Blunt cardiac injury (BCI) may manifest as cardiac contusion or, more rarely, as pericardial or myocardial rupture. Computed tomography (CT) is performed in the vast majority of blunt trauma patients, but the imaging features of cardiac contusion are not well described. PURPOSE: To evaluate CT findings and associated injuries in patients with clinically diagnosed BCI. MATERIALS AND METHODS: We identified 42 patients with blunt cardiac injury from our institution's electronic medical record. Clinical parameters, echocardiography results, and laboratory tests were recorded. Two blinded reviewers analyzed chest CTs performed in these patients for myocardial hypoenhancement and associated injuries. RESULTS: CT findings of severe thoracic trauma are commonly present in patients with severe BCI; 82% of patients with ECG, cardiac enzyme, and echocardiographic evidence of BCI had abnormalities of the heart or pericardium on CT; 73% had anterior rib fractures, and 64% had pulmonary contusions. Sternal fractures were only seen in 36% of such patients. However, myocardial hypoenhancement on CT is poorly sensitive for those patients with cardiac contusion: 0% of right ventricular contusions and 22% of left ventricular contusions seen on echocardiography were identified on CT. CONCLUSION: CT signs of severe thoracic trauma are frequently present in patients with severe BCI and should be regarded as indirect evidence of potential BCI. Direct CT findings of myocardial contusion, i.e. myocardial hypoenhancement, are poorly sensitive and should not be used as a screening tool. However, some left ventricular contusions can be seen on CT, and these patients could undergo echocardiography or cardiac MRI to evaluate for wall motion abnormalities.