Traumatic Heart Disease

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Traumatic Heart Disease

• Nagender Reddy, MD
• Nassau County Medical Center

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Traumatic Heart Disease

• Introduction
• Non Penetrating Cardiac Injury
• Pericardium
• Myocardium
• Complications of Cardiac Resuscitation
• Penetrating Cardiac Injuries
• Injuries to valves, papillary muscles, Chordae
• Injuries to coronaries and great vessels
• Conclusion

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Introduction

• In US violent injury account of majority of
  deaths under 40 yrs age
• Cardiac trauma is the leading cause of death in
  these patients
• Chest injuries account to 25 of 50,000-60,000
  deaths annually
• Effective treatments have resulted in increasing
  immediate survivors and late sequel

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5766 Cardiovascular Injuries in 4459 patients.
Epidemiological evolution 1958 to 1987

• 86 males with average 30 yrs
• 90 had penetrating trauma as the etiology
• 66 had truncal injuries (incl.. Neck)
• 27 patients/yr. average increased to 213
  patients/yr.

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Non Penetrating Cardiac Injuries

• Commonly vehicular impact directly or indirectly
• Others are direct blows to chest ( clenched fist,
  sporting equipment, falls, kicks and cardiac
  resuscitation measures)
• Absence of obvious chest injuries following
  trauma should by no means exclude the possibility
  of non penetrating injury to the heart
• Pathological findings
• - Pericarditis and pericardial constriction
• - Ecchymotic areas in subepicardium/subendocardi
  um,
• transmural contusions
• - Healing by scar formation and may
  develop Post
• traumatic aneurysms

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Non - Penetrating Trauma of the Heart
1. Pericardial injury a. Hemopericardium b.
Rupture or laceration c. Serofibrinous
pericarditis d. Constrictive pericarditis 2.
Myocardial injury a. Contusion b. Rupture of
free cardiac wall, early or delayed c.
Rupture of septum d. Aneurysm e. Laceration 3.
Disturbances of rhythm or conduction
4. Valve injury a. Rupture of valve leaflets,
cusp, or chordae tendinea b. Contusion of
papillary muscle 5. Coronary artery injury a.
Thrombosis with or without myocardial
infarction b. Arteriovenous fistula .
c. Laceration with or without myocardial
infarction 6. Great vessel injury a. Rupture b.
Aneurysm formation c. Aorta cardiac chamber
fistula d. Thrombotic occlusion
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Pericardium

• Range from contusion to laceration or rupture
• Parmley et al. Pericardial laceration or rupture
  in 249 of 546 autopsy cases of Non-Penetrating
  Injury (Circ 1958)
• DeMuth et al. Experiments on canines 14/18 dogs
  developed pericardial rents ( J. Trauma 1973)
• Clinical features
• Traumatic pericarditis p/w friction rub, ST-T
  changes
• Hemopericardium and Tamponade
• Treatment
• Uncomplicated pericarditis resolves itself
• Glucocorticosteroids occasionally used for
  recurrent effusions
• Constrictive Pericarditis is a rare compication
  with/without effusion

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Myocardial Contusion

• There is higher frequency of diagnosis of cardiac
  contusion because of signs of external chest
  injury
• 75 detection in a series by Snow et al , Surgery
  1982
• Clinical features
• Usually symptomatic
• Precordial chest pain
• ECG helpful for LV contusion
• Non specific ST-T changes and pericarditis
  findings are commonly noted
• Pathological Q waves may be dwarfed by
  pericardial inflammation
• Serial findings are crucial
• Cardiac failure is rare

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Serum Enzymes

• CK alone is of limited value
• CK-MB measurements are better
• With ECG and MB fraction the detection can be
  increased from 7 to 17. Screening tests are
  sensitive but poor predictors of events. Direct
  Hemodynamic measurement with contusion are better
  to assess the patients at greatest risk
  (Torres-Mirabel et al, AM Surg 1982).
• Freeze et al. J. Trauma 1986, Mayo Clinic
• 58/291 patients (20) had positive MB. 60
  (35/58) had nl 2-DE(concussion) and 40 (23/58)
  had abnormal 2-DE (cardiac Contusion) 1/35 (3)
  of concussion and 9/23 (39) contusion patients
  developed cardiac arrythmias within 72 hrs.

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Circulating cardiac troponin T in myocardial
contusion Ferjani M, MD - France

• Prospective study to assess value of troponin T
  in diagnosing contusion
• CONCLUSIONS
• Circulating cardiac troponin T measurement had a
  slightly greater diagnostic value than usual
  biological parameters (CK-MB, CK-MB/CK) in
  myocardial contusion. Nevertheless, an elevated
  circulating cardiac troponin T concentration has
  no important clinical value in the diagnosis of
  myocardial contusion.

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Radionuclide Imaging

• Myocardial perfusion is reduced in areas of
  contusion. Radionuclide ventriculography reveals
  reduced ventricular EF.
• Sutherland et al. AJC, 1986
• 28/43 abnormal gated studies. 18 had RV alone
  (1A), 4 LV alone (1B), 6 both ventricles (1C).
  Normal Ventricular functions in 15 (2). RV stroke
  volume was similar and pump function was
  identical by virtue of a larger RV preload in
  Group 1A than in group 2.
• Traumatic RV contusion maintains RV pump
  function at a level similar to pts without
  contusion.
• Schamp et al, Am Heart J 1988 Aug
• 36 (40/111) had abnormal RNA. 33/40 RV
  abnormality. But complication is rare and adds
  little to clinical management

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Echocardiography

• Pericardial effusion, abnormal wall motion,
  chamber enlargement, intracardiac shunts,
  regurgitant lesions.
• TTE has limited value in some due to the
  difficulty in obtaining optimal Echo pictures in
  severe chest injury patients
• Karalis et al reported 20/105 non diagnostic TTE
  and had TEE with detection of WMA in 10/20,
  Aortic injury in 5/20.

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An evaluation of serum troponin T and
signal-averaged electrocardiography in predicting
ECG abnormalities after blunt chest trauma
Department of Surgery, Medical Center of
Delaware, Wilmington, USA.

• Evaluated 71 adult patients admitted to a
  regional center with chest wall injuries not
  requiring ICU admission. Sensitivity and
  specificity of troponin T in predicting
  clinically significant abnormalities were 27 and
  91, respectively.
• CONCLUSIONS1. The best predictors for the
  development of significant electrocardiographic
  changes are an admission ECG abnormality and
  an elevated serum troponin T level. 2. Both
  tests have high specificity with low to moderate
  sensitivity. 3. Patients with normal ECGs may
  develop clinically significant events. 4. CPK-MB
  and echocardiograms continue to be poor
  predictors of significant electrocardiographic
  events.

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Correlation of Echocardiographic Findings with
the Electrocardiogram and Creatine Kinase
Monoclonal Antibody Measurements

• Relative to pathologic TEE findings, the
  sensitivity and specificity of an abnormal ECG
  were 59 and 73 and of high CK-MB with CK-MB/CK
  gt5 were 64 and 52, respectively.
• Conclusions TEE can be routinely and safely
  performed for diagnosing cardiac injuries after a
  BCT. EGG and CK-MB assay are not good methods
  for detecting cardiac damage in this setting

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ARRYTHMIAS

• Ventricular Tachycardia that degenerates into VF
  is the frequent cause of death
• AF is associated with poor outcome
• Mechanism is poorly understood
• Atrioventricular, intraventricular conduction
  defects and SND are seen
• Blunt impact can cause cardiac arrest without
  obvious signs of structural injury

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The Clinical Significance of Myocardial Contusion

• Attempt to identify a group of blunt trauma
  victims with asymptomatic myocardial contusion
  who do not benefit ICU monitoring
• Prospectively divided 336 pts admitted with
  possible MC during 6 yr.. Into
• Group I n155 age 30.5/- 9 with J point
  elevation with /without minor chest injuries,
  SICU LOS 2.4/- 0.77 days
• GroupII n43, age 31.5/- 10, same criteria with
  ED ECG showing arrythmia, heart block, ischemia,
  SICU LOS 2.47/-0.9 days
• Group III n138, age 40 /- 20, 4 or more rib
  fractures, a pulmonary contusion, a flail chest
  or extra-thoracic injuries, or were greater than
  60 yrs age. 19 pts had cardiac complications
  requiring treatment. No cardiac deaths. SICU LOS
  10 /- 22 days.
• CONCLUSION Young patients with minor blunt
  thoracic injuries and a normal or minimally
  abnormal ECG do not benefit from cardiac
  monitoring

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The Clinical Significance of Myocardial Contusion
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Treatment /Prognosis of Contusion Injuries

• Several days of close observation
• Trauma pts in stable condition, contusion neither
  increases complication rate nor necessitates ICU
  monitoring
• Treatment with anti-coagulants and thrombolytics
  is contra-indicated due to intramyocardial and
  intrapericardial hemorrhage
• AF if present usually reverts to NSR
  spontaneously.
• Digitalis can be used to slow VR and and may also
  cause reversion to SR
• Chest pain is best treated with analgesics. Avoid
  NSAIDS as may interfere with myocardial healing
• Corticosteroids indicated in post cardiac injury
  syndrome
• Late complications including Ventricular
  arrythmias to cardiac rupture, aorto-right atrial
  fistula, ventricular aneurysms can occur
• Operate for aneurysms only if they cause heart
  failure like postinfart aneurysms
• Pseudoaneurysms need immediate repair
• Long term prognosis in survivors with myocardial
  necrosis secondary to trauma tends to be far
  better than MI secondary to atherosclerosis.

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Cardiac Rupture

• Mechanisms
• Acute laceration by direct force to the heart.
• Contusion and hemorrhage leading to necrosis,
  softening, and rupture several days following
  trauma
• Catastrophic if not recognized and treated
  immediately in the ED setting
• Rupture of atrium and IVS may not be rapidly
  fatal. Successful correction by surgery is
  possible

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Location of Cardiac Rupture Kato et al, Blunt
traumatic rupture, An experience in Tokyo

• Right atrium 32 (14)
• Left atrium 19 (11)
• Right Ventricle 24 (12)
• Left ventricle 13 (10)
• 14/20 patients had 2 chambers ruptured,
• 5/20 had 3 chamber rupture and one had 4 chamber
  rupture

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Location of Cardiac Rupture
Kato et al, Blunt traumatic rupture, An
experience in Tokyo 14/20 patients had 2
chambers ruptured, 5/20 had 3 chamber rupture and
one had 4 chamber rupture
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Complications of Cardiac Resuscitation

• Rupture of LV is more common than the RV but
  rupture of either ventricle may occur
• Rupture of RV papillary muscle with Tricuspid
  regurgitation has been reported as has the
  rupture of the atria, aorta and dissecting
  hematoma of the coronary artery
• Educational programs may stem the increased
  incidence of these complication

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PENETRATING CARDIAC INJURY

• In civilians, likely due to bullets , knives, ice
  picks and the likes
• Naughton et al study of demographics in
  Jefferson County, AL reviewed. Males victims
  predominated and gunshot wounds were the major
  mechanism of injury
• Penetrating injuries may also be due to
  displacement of ribs inward, sternal fragments.
  RV is involved most often, followed in descending
  order by the LV, the RA and the LA
• Perforation of Pulmonary artery by migration of
  indwelling venous catheters occur in ICU
• RV perforation with Transvenous pacer electrode,
  perforation of RA and RV outflow tract have been
  reported. PTCA and Endomyocardial bx can result
  in tamponade.
• Laceration of pericardium with laceration of
  myocardium is seen in penetrating wounds
• Bullet injuries are associated with bleeding that
  is usually not self limiting unlike stab injuries
  and and extensive cellular destruction in and
  around the path occur sometimes lacerating the
  coronaries with subsequent MI

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Penetrating Wounds of the Heart

• 1. Pericardial damage
• a. Laceration or perforation
• b. Hemopericardium with or without cardiac
  tamponade
• c. Serofibrinous or suppurative
  pericarditis
• d. Pneumopericardium
• c. Constrictive pericarditis
• 2. Myocardial damage
• a.. Laceration
• b. Penetraion or perforation
• c. Retained foreign body
• d. Structural defects
• (1) Aneurysm formation
• (2) Septal defects
• (3) Aorticocardiac fistula

• 3. Valvular injury
• a. Leaflet or cusp injury
• b. Papillary muscle or chordaetendineae
  laceration
• 4. Coronary artery injury
• a. Laceration or thrombosis with or without
  myocardial infarction
• b. Arteriovenous fistula
• c. Aneurysm
• 5. Embolism
• a. Foreign body
• b. Thrombus (septic or sterile)
• 6. Infective endocarditis
• 7. Rhythm or conduction disturbances

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PCI Clinical features/Diagnosis

• Depends on the object (knife, bullet etc), size
  of the wound, location of the structure injured
• Nature of Pericardial wound is important. Open
  wound allows drainage of intrapericardial blood
  and tamponade will not develop and presenting s/s
  will be those of hemorrhage and hemothorax.
• Tamponade may occur if pericardium does not
  permit free drainage secondary to a clot, flap,
  adjacent lung tissue or other structures
• Delayed manifestations of cardiac injuries as a
  result of hemorrhage, infection, retained foreign
  bodies or arrythmias may become apparent later
• Echocardiography is extremely valuable for
  detection of pericardial effusion, foreign bodies
  in the heart, and intracardiac shunts.

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Management

• Immediate thoracotomy and cardiorarrhaphy is the
  definitive treatment of cardiac wounds with
  severe hemorrhage
• Pericardial aspiration while the patient is being
  prepped for surgery
• Successful prehospital resuscitative measures can
  increase the success of a hospital ED procedure
• Operative treatment include repair of the
  pericardium, myocardium, valves aorta and the
  lacerations of the coronaries.. Both entry and
  exit wound thoroughly checked prior to closing
  the chest
• Gun shot wounds of heart are often fatal than
  stab wounds.
• Salvage is lower in extrpericardial hemorrhage
  compared with tamponade and also penetrating
  wounds of thin walled structures such as atria
  and pulmonary artery as they rarely seal off
  spontaneously
• Delayed initial thoracotomy adversely effects
  survival

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Upon arrival to ER or during stay in ER, is
patient conscious, and /or does patient have VS
present ?
ATLS protocol for evaluation and management
Yes
No
Mechanism of injury
Blunt trauma
Penetrating trauma
Absent
Absent
DOA
SOL at the scene
SOL in ER
Present
No
Absent
SOL absent less than 5 minutes
SOL in ER
Present
Yes
Present
ERRT
Take patient to OR for definitive treatment
Close chest in ER, pronounce patient dead
Yes
No
Return of VS
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INJURIES CARDIAC VALVES, PAPILLARY MUSCLES AND
CHORDAE TENDINAE

• Preexisting valve disease may be at highest risk
  for development of valvular injury following
  blunt trauma.
• Parmley et al reports 9 incidence of valve
  disorders and damage of the aortic valve is by
  far the most common of these lesions
• Penetrating injuries can involve valves often
  accompanied by other injuries
• Loud high pitched diastolic blowing murmur with a
  widened pulse pressure suggests a aortic rupture.
  Murmur and the Hemodynamic consequence may not
  appear for several days following trauma
• Rupture of the mitral valve or of the papillary
  muscle associated with precordial pain, loud ,
  harsh holosystolic murmur and fulminant pulmonary
  edema may quickly develop
• Rupture of Tricuspid valve is more benign with
  symptoms of fatigue to ascites and edema
• Baseline condition of the ventricle prior to
  injury, other injuries, and severity of
  regurgitation affects hearts ability to tolerate
  the insult.
• In severe LV failure with ruptured Mitral valve
  or papillary muscles early surgery is mandatory

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Laceration of noncoronary cusp
Avulsion at annulus
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Injuries to the Coronary Arteries

• Transmural MI reported with trauma
• In many cases preexisting CAD has been present .
  Postulated that injury may dislodge a plaque.
• Normal Coronaries get occluded by either a
  traumatic intimal tear or hemorrhage
• Long term prognosis is better after the initial
  episode in traumatic damage of coronary artery

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Injuries to Great Vessels

• Rupture of Aorta is one of the common lesions of
  closed chest trauma from deceleration automobile
  accidents. Other causes include falls from
  heights and crushing injuries
• Just distal to the origin of left subclavian
  artery is a common site of tear.
• The second place is the just distal to aortic
  annulus
• Patients c/o chest pain and back pain
• If aortic lumen is narrowed by intramural
  hematoma or mediastinal hematoma
• ischemia of spinal cord and kidneys can occur
  Systolic murmur in the mid scapular region ,
  Widened mediastinum on x-ray seen
• Symbas etal., Am Th Surgery, 1973Rupture of the
  Aorta, A diagnostic triad
• 1) increased arterial pressure and pulse
  amplitude in upper extremities.
• 2) decreased pulse and pressure amplitude in the
  lower exts
• 3) radiological evidence of widening of superior
  mediastinum

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Role of CT in diagnosis of major arterial injury
after blunt thoracic trauma.

• Prospectively evaluated 153 consecutive trauma
  patients in whom we suspected blunt aortic injury
  between September 1985 and August 1988.
• Conclusions Chest CT has no screening role in
  the evaluation of blunt trauma patients with
  possible major vascular injury.

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Use of spiral computed tomography for the
assessment of blunt trauma patients with
potential aortic injury
PURPOSE examine the accuracy of
contrast-enhanced spiral thoracic computed
tomography (CEST-CT) for direct detection of
traumatic aortic injury resulting from blunt
thoracic trauma. METHODS 25-month period,
7,826 patients, 1,104 (14.3) had CEST-CT
performed. Mediastinal hemorrhage seen in 118
(10.7) of all thoracic computed tomographic
scans. Direct evidence of aortic injury was
detected in 24 patients (20.3) with mediastinal
hemorrhage and 2.2 of all patients undergoing
CEST-CT. CEST-CT was 100 sensitive based on
clinical follow-up it was 99.7 specific, with
89 positive and 100 negative predictive values
and an overall diagnostic accuracy of 99.7.
CONCLUSION CEST-CT is a valuable ancillary
study for the detection of traumatic aortic
injury. Spiral computed tomography is accurate
for the detection and localization of both
hemomediastinum and direct signs of aortic
injury.
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Role of TEE

• Smith et al. NEJM Feb 1995 101 patients to ED
  with diagnosis of TDA were studied. Patients
  underwent TEE and Aortograms.
• There was 100 sensitivity and 98 specificity
  for detection of injury to aorta
• Vignon et al, France, Circ 1995 Nov Similar
  results in of 32 patients with sensitivity of 91
  and specificity of 100

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Noncardiovascular causes of death
Maron BJ et al, JAMA 1996 276 199 - 203
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Blunt Impact to the chest leading to sudden death
from cardiac arrest during sport activities

• Sudden death from cardiac arrest in a young
  person may occur during sports play after a blunt
  blow to the chest in the absence of structural
  cardiovascular disease or traumatic injury
• METHODS. 25 children and young adults, 3 to 19
  years of age.
• CONCLUSIONS.Most sudden deaths related to impact
  to the chest (not associated with traumatic
  injury) are due to ventricular dysrhythmia
  induced by an abrupt, blunt precordial blow,
  presumably delivered at an electrically
  vulnerable phase of ventricular excitability.

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Increased Cardiovascular Disease mortality in
Traumatic lower limb amputees

• 24 yr. mortality rates of males with traumatic
  lower limbs amputees (n201) of Israel army
  wounded between 1948-1974 compared with cohort
  population n1832
• 21.9 mortality Vs. 12.1, Plt0.001
• CVD mortality was the main cause
• Amputees had higher plasma insulin levels and
  increases blood coagulation activity
• Survivors had hyperinsulemia, increased
  co-agulation and increases sympathetic and
  parasympathetic responses

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Relative bradycardia in patients with traumatic
hypotension

• Retrospective during a 4-year period.
• 10,833 major trauma patients were seen during the
  study period.
• 750(6.9) had systolic blood pressure ltor 90 mm
  Hg
• 533 patients had tachycardia (overall incidence
  of 4.9, or71.1 of hypotensive patients), and
  217 patients had bradycardia (overall incidence
  of 2.0, or 28.9 of hypotensive patients).
• crude mortality was 29.2 among tachycardia
  patients and 21.7 among bradycardia (crude RR
  1.34 95 confidence interval 1.00-1.81p
  0.047).
• The adjusted relative mortality risk between the
  two groups was 1.23 (95 confidence interval
  0.84-1.73 p 0.284).
• Multivariate analysis relative bradycardia in
  the subgroups with Injury Severity Scores gt or
  16, chest Abbreviated Injury Scale scores gt or
  3, or abdominal Abbreviated Injury Scale scores gt
  or 3 had significantly better survival than
  patients with similar injuries presenting with
  tachycardia.
• CONCLUSION The presence of relative bradycardia
  in some subgroups of patients with severe
  injuries seems to be associated with better
  prognosis than the presence of tachycardia.