Echocardiography and Management for Cardiac Trauma.

Trauma is the number one cause of death among Americans between the ages of 1 and 46, costing >$670 billion a year. Blunt and penetrating trauma can lead to cardiac and aortic injuries, with the incidence of death varying upon the location of the damage. Among those who reach the hospital alive, many may survive if the hemorrhage and cardiovascular injuries are diagnosed and treated adequately in a timely fashion. Although echocardiography often is underused in the setting of cardiac trauma, it offers significant diagnosis and treatment potential because it is accessible in most settings, safe, relatively noninvasive, and can provide rapid and accurate trauma assessment in the hands of trained providers. This review article aims to analyze the pathophysiology of cardiac injuries in patients with trauma and the role of echocardiography for the accurate diagnosis of cardiac injury in trauma. This review, additionally, will offer a patient-centered, team-based, early management plan with a treatment algorithm to help improve the quality of care among these patients with cardiac trauma.

State of the Art Imaging Review of Blunt and Penetrating Cardiac Trauma.

Traumatic cardiovascular injuries are only second to the central nervous system injuries as a cause of death in young adult population. Multidetector computed tomography is the gold standard diagnostic modality in patients with blunt or penetrating chest trauma and clinical suspicion of cardiac injury. The imaging spectrum of cardiac injuries includes but not limits to pericardial rupture, myocardial contusions, valve rupture, coronary artery injuries, cardiac herniations, and cardiac tamponade. In this review article, we discuss clinical presentation, types, and mechanism of cardiac trauma with emphasis on the imaging findings and illustrations in blunt, penetrating traumatic, and iatrogenic cardiac injuries.

Imaging limitations in evaluating blunt cardiac trauma: A case report.

A 20-year old male presented with life-threatening polytrauma secondary to a motor vehicle accident. He had sustained injuries to the chest, including blunt cardiac trauma. On a short-term follow-up imaging, it was determined the patient had an injury to the main pulmonary artery and possible pericardial rupture. Given these imaging findings, he was taken to the operating room for emergent surgical intervention. Surgery revealed intracardiac injury; however, the pulmonary artery was intact. This case report is significant for the following two learning points: (a) The potential limitations of computed tomography when assessing intrathoracic injury, and (b) unique constellation of injuries secondary to trauma.

Penetrating cardiac trauma: A retrospective case series from Karachi.

Penetrating cardiac trauma is a medical emergency that commonly affects young men throughout the world. A retrospective review of the records of all patients presenting with cardiac injury was done from January 2000 to December 2015 at our institute. There were 10 cases of such trauma, all of whom were males, 17 to 48 years of age. The most common mechanism of injury was gunshot wounds followed by stab wounds. The Mean Revised Trauma Score was 7.23±0.855. Only 2 out of the total 10 patients died (20% mortality). The Right Ventricle followed by the Left Ventricle was the most common site of injury. Median Sternotomy was the surgical procedure of choice in managing these patients. Pericardial tamponade and Haemothorax were common intra-operative findings. Patients having penetrating cardiac injury presenting with detectable signs of life on arrival to the hospital can be rescued by early surgical intervention.

The Equine Neonatal Cardiovascular System in Health and Disease.

The neonatal foal is in a transitional state from prenatal to postnatal circulation. Healthy newborn foals often have cardiac murmurs and dysrhythmias, which are usually transient and of little clinical significance. The neonatal foal is prone to infection and cardiac trauma. Echocardiography is the main tool used for valuation of the cardiovascular system. With prompt identification and appropriate action, dysrhythmias and other sequel to cardiac trauma can be corrected. With infection, the management and prognosis are driven by concurrent sepsis. Congenital disease represents an interesting diagnostic challenge for the neonatologist, but surgical correction is not appropriate for most equids.

Trends of Hospitalizations and In-Hospital Outcomes for Traumatic Cardiac Injury in United States.

Introduction: Traumatic cardiac injury (TCI) poses a significant risk of morbidity and mortality, yet there is a lack of population-based outcomes data for these patients. Methods: The authors examined national yearly trends, demographics, and in-hospital outcomes of TCI using the National Inpatient Sample from 2007 to 2014. We focused on adult patients with a primary discharge diagnosis of TCI, categorizing them into blunt (BTCI) and penetrating (PTCI) cardiac injury. Results: A total of 11,510 cases of TCI were identified, with 7,155 (62.2%) classified as BTCI and 4,355 (37.8%) as PTCI. BTCI was predominantly caused by motor vehicle collisions (66.7%), while PTCI was mostly caused by piercing injuries (67.4%). The overall mortality rate was 11.3%, significantly higher in PTCI compared to BTCI (20.3% vs. 5.9%, χ2(1, N = 11,185) = 94.9, p <0.001). Additionally, 21.5% required blood transfusion, 19.6% developed hemopericardium, and 15.9% suffered from respiratory failure. Procedures such as heart and pericardial repair were more common in PTCI patients. Length of hospitalization and cost of care were also significantly higher for PTCI patients, W(1, N = 11,015) = 88.9, p <0.001). Conclusions: Patients with PTCI experienced higher mortality rates than those with BTCI. Within the PTCI group, young men from minority racial groups and low-income households had poorer outcomes. This highlights the need for early and specialized attention from emergency and cardiothoracic providers for patients in these demographic groups.

Surgical treatment for a child with traumatic ventricular septal rupture and ventricular aneurysm.

A five-year-old boy was diagnosed with the ventricular septal rupture and ventricular aneurysm after blunt chest trauma in child abuse. Because of the intractable heart failure, he underwent operation in subacute period. Postoperative course was uneventful. The blunt cardiac injury in children can be caused by mild trauma and can be lethal. Surgical intervention should be considered when the clinical condition is unstable.

From Blunt Cardiac Injury to Heart Transplant Following Motorcycle Collision.

Traumatic coronary artery occlusion and dissection is an exceedingly rare complication of blunt cardiac injury (BCI), though it has been previously noted in a number of case reports. However, it can also lead to heart transplant, which to our knowledge has not been previously described in the literature. We present a case of a healthy 24-year-old man without significant past medical history who was in a motorcycle accident, resulting in sternal fracture and BCI. He was ultimately found to have thrombotic occlusion and dissection of his left anterior descending artery (LAD), requiring mechanical thrombectomy and drug-eluting stent, as well as subsequent hospitalizations and operations due to various complications. It was suspected that he went into ventricular fibrillation and had a second motorcycle collision, resulting in cardiogenic shock. Ultimately, his progression of ischemic cardiomyopathy and mitral regurgitation led to the need for heart transplant. Blunt cardiac injury with myocardial contusion has such a broad range of pathologies. It is essential that patients with these injury patterns raise a high level of suspicion for BCI and are followed closely with appropriate diagnostic testing and rapid intervention for best possible outcomes.

Successful management of a delayed presentation of traumatic descending thoracic aorta pseudoaneurysm: a literature review based on a case report.

BACKGROUND: Blunt traumatic aortic injury (BTAI) is the second leading cause of death due to traumas in young patients. The primary presentation might be chest or interscapular pain, difficulty in breathing, and, in severe cases, hypotension. Considering the rapid deterioration of these patients' clinical conditions, prompt diagnosis and treatment initiation are crucial. In these injuries, the most involved parts of the aorta are the isthmus (distal to the left subclavian artery) and the descending part in the thorax. Therefore, the main diagnostic strategies include transthoracic echocardiography, CT angiography, and endovascular diagnostic approaches. Case presentation The patient was a 19-year-old male presenting with the symptoms of chest pain, dyspnea, and extremities excruciating pain after a car turnover. The initial evaluation showed no abnormal cardiovascular finding except bilateral hemothorax, addressed with chest tubes. Twelve hours later, when the patient was under observation for orthopedic surgeries, his chest pain and dyspnea started, and TTE and CTA showed a grade three descending aneurysm of the aorta. The patient was treated immediately with an endovascular procedure of stent implantation. A delayed debranching surgery was also performed, which resulted in desirable outcomes and uneventful follow-up. CONCLUSION: Although open thoracic surgery is the main and almost the only option for treating aneurysms of the aorta in hemodynamically unstable patients, the endovascular procedure has shown superior outcomes in selected patients with appropriate anatomy. Debranching surgery, which can be done simultaneously or with delay after the initial procedure, has proven protective against thromboembolic cerebral events. CLINICAL KEY POINT: Patients with an aneurysm of the aorta should be transported to a medical center with a multidisciplinary team for an urgent evaluation and treatment. The initial resuscitation and diagnosis are challenging, considering the fatal nature of these injuries, and the selection of the treatment is based on the patient's clinical condition and evaluated anatomy in cardiovascular imaging.

Management of penetrating cardiac injury and tricuspid regurgitation with extracorporeal-membrane oxygenation (ECMO): a case report.

BACKGROUND: Gunshot wounds (GSW) to the heart are lethal, and most patients die before they arrive to the hospital. Survival decreases with number of cardiac chambers involved. We report a case of a 17-year-old male who survived a GSW injury involving two cardiac chambers with acute severe tricuspid regurgitation (TR) who subsequently developed cardiogenic shock requiring extracorporeal membrane oxygenation (ECMO) support. CASE PRESENTATION: A 17-year-old male sustained a single gunshot wound to the left chest, resulting in pericardial tamponade and right hemothorax. Emergency sternotomy revealed injury to the right ventricle and inferior cavoatrial junction with the adjacent pericardium contributing to a right hemothorax. The cardiac injuries were repaired primarily. Tricuspid regurgitation was confirmed immediately postoperatively. Five days after presentation, the patient developed cardiogenic shock secondary to TR requiring emergent stabilization with ECMO. He subsequently underwent successful tricuspid valve replacement. CONCLUSIONS: This is the first report to our knowledge of successful ECMO support of severe TR due to gunshot injury to the heart.

Unveiling a Unique Presentation of Superior Vena Cava Syndrome Succeeding a Traumatic Motor Vehicle Crash and Implantable Cardioverter-Defibrillator Lead Placement.

Superior vena cava (SVC) syndrome, once a rarity, has seen an uptick in cases with diverse origins. While this disease process is clinically diagnosable, imaging modalities and tissue biopsies further refine interventions. The clinical presentation includes but is not limited to edema of the arms, neck, and head, facial plethora, cyanosis, and or distention of subcutaneous vessels. SVC syndrome can be attributed to extrinsic compression or thrombosis in many cases. If symptoms are not life-threatening, the overall morbidity is based on the underlying root cause. Few cases have been reported with associated death due to epistaxis. However, the obstruction itself can be initially asymptomatic and then slowly progress over months to years. This case report highlights a distinct instance of SVC syndrome with notable risk factors: implantable cardioverter defibrillator placement and prior cardiac trauma status post-intervention.

Penetrating cardiac trauma: 20-y experience from a university teaching hospital.

BACKGROUND: Penetrating traumas, including gunshot and stab wounds, are the major causes of cardiac trauma. Our aim was to describe and compare the variables between patients with penetrating cardiac trauma in the past 20 y in a university hospital, identifying risk factors for morbidity and death. METHODS: Review of trauma registry data followed by descriptive statistical analysis comparing the periods 1990-1999 (group 1, 54 cases) and 2000-2009 (group 2, 39 cases). Clinical data at hospital admission, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and Revised Trauma Score (RTS) were recorded. RESULTS: The incidences of penetrating cardiac injuries were steady within the period of study in the chosen metropolitan area. The two groups were similar regarding age, mechanism of trauma (gunshot × stab), and ISS. Group 1 showed lower systolic blood pressure at admission (mean 87 versus 109 mm Hg), lower GCS (12.9 versus 14.1), lower RTS (6.4 versus 7.3), higher incidence of grade IV-V cardiac lesions (74% versus 48.7%), and were less likely to survive (0.83 versus 0.93). The major risk factor for death was gunshot wound (13 times higher than stab wound), systolic blood pressure < 90 mm Hg, GCS < 8, RTS < 7.84, associated injuries, grade IV-V injury, and ISS > 25. We observed a tendency in mortality reduction from 20.3% to 10.3% within the period of observation. CONCLUSIONS: Several associated factors for mortality and morbidity were identified. In the last decade, patients were admitted in better physiological condition, perhaps reflecting an improvement on prehospital treatment. We observed a trend toward a lower mortality rate.

Penetrating cardiac trauma.

This chapter summarizes approaches to hemorrhage control in penetrating cardiac trauma, an injury that is a true test of trauma systems integration, trauma center readiness, teamwork, decision-making, technical excellence, and multidisciplinary trauma care.

Case report: Eighteen nails gun shots in the head, thorax and abdomen but still conscious at admission: A challenging patient for the cardiac surgeon!

We report an unusual case of multiple penetrating cerebral, cardiac and abdominal injuries following a suicidal attempt using a nail gun. Successful treatment required several emergency procedures and resulted from a wise interdisciplinary management and timing of surgery.

Penetrating cardiac injury: a narrative review.

Background and Objective: Penetrating cardiac trauma is rare but can cause life-threatening complications. Survival is dependent on prompt diagnosis and treatment. Given the low incidence and life-threatening implications, it is difficult to study in large prospective studies. The current literature regarding penetrating cardiac trauma comes primarily from large, experienced trauma centers and military sources. Understanding the history, current literature and even expert opinion can help with effectively treating injury promptly to maximize survival after penetrating cardiac trauma. We aimed to review the etiology and history of penetrating cardiac trauma. We review the prehospital treatment and initial diagnostic modalities. We review the incisional approaches to treatment including anterolateral thoracotomy, median sternotomy and subxiphoid window. The repair of atrial, ventricular and coronary injuries are also addressed in our review. The purpose of this paper is to perform a narrative review to better describe the history, etiology, presentation, and management of penetrating cardiac trauma. Methods: A narrative review was preformed synthesizing literature from MEDLINE and bibliographic review from identified publications. Studies were included based on relevance without exclusion to time of publication or original publication language. Key Content and Findings: Sonographic identification of pericardial fluid can aid in diagnosis of patients too unstable for CT. Anterolateral thoracotomy should be used for emergent repairs and initial stabilization. A median sternotomy can be used for more stable patients with known injuries. Carefully placed mattress sutures can be useful for repair of injuries surrounding coronary vessels to avoid devascularization. Conclusions: Penetrating cardiac trauma is life threatening and requires prompt workup and treatment. Trauma algorithms should continue to refine and be clear on which patients should undergo an emergency department (ED) thoracotomy, median sternotomy and further imaging.

Persistent Hypoxia After Blunt Thoracic Trauma due to Flail Tricuspid Valve Leaflet and Patent Foramen Ovale.

Structural cardiac injury after blunt trauma is uncommon but usually life-threatening. While tricuspid injury is very rare and potentially lethal, the right heart can accommodate larger volumes and higher pressures in acute tricuspid insufficiency and facilitate initial stabilization prior to definitive valvular repair. ECMO may be used to ameliorate resulting right heart failure. The traumatic force required to cause cardiac structural injury is also associated with pulmonary complications related to pneumothorax, hemothorax, effusion, acute pain secondary to rib fractures, and pulmonary contusions causing hypoxia. We present an unusual case of hypoxia in a trauma patient caused by acute tricuspid regurgitation with pre-existing patent foramen ovale.

Acute limb ischemia secondary to bullet embolism following a cardiac gunshot wound in a pediatric patient.

Bullet embolism following a gunshot wound to the heart is a very unusual cause of acute limb ischemia. We report the case of a 3-year-old boy who sustained a penetrating cardiac trauma secondary to an accidental self-inflicted gunshot wound with a BB (ball bearing) gun. The BB pellet entered the left ventricle and embolized into the peripheral circulation, lodging at the bifurcation of the left common femoral artery. This resulted in acute left lower extremity ischemia. The patient was successfully treated by open common femoral artery exploration and foreign body removal.