Blunt Thoracic Injury blunt cardiac injury and others

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Blunt Thoracic Injury - blunt cardiac injury and
others-

• Chao-Wen Chen M.D.
• Division of Surgical Emergency and Trauma,
  Department of Emergency, KMUH

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Preface

• 2/3 of victims of major blunt trauma suffer from
  thoracic injury.
• Thoracic injury account for 20-25 of deaths due
  to trauma.
• Major thoracic trauma is associated with
  multisystem injuries in 70 of cases.

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Common Injuries Develop After Blunt Chest Trauma

• Thoracic cage fractures
• Lung contusion and tears
• Myocardium contusion
• Aortic rupture

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Initial Survey

• Assume the existence of C-spine injury
• ABCs
• Gerneral evaluation PE, PH, ECG, or ABG
• Chest x-ray
• Administer oxygen

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Imaging Survey

• Chest x-ray serve as a screening rather than a
  definite test ? repeat radiography should be
  ordered if suspicious
• Computed tomography highly sensitive in
  detecting injuries and superior to routine chest
  x-ray? recommended in patients with multiple
  trauma and suspected chest trauma
• Angiogram for suspicious great vessel injuries
• Chest ultrasound detect hemothorax, FAST

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Troublesome Injuries

• Sternal fracture
• More serious injuries may accompany
• If suspected, a lateral CxR may be diagnostic
• Operative reduction is usually unnecessary
• Hospitalization is not mandatory if the ECG is
  normal and the patients vital sign is stable

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Associated Literature

• a 38-year-old female patient transferred to our
  hospital after being injured in a MVAOn arrival
  her blood pressure (BP) was 90/50 mmHg but it
  then dropped to 60/30 mmHg two hours later.her
  chest x-ray and ECG did not reveal any
  significant findings, the cardiac
  echocardiography was performed and revealed
  pericardial effusion. The chest CT revealed
  sternal fracture and cardiac tamponade A
  diagnosis of cardiac rupture resulting from
  sternal fracture following blunt chest trauma was
  made. Under midline sternotomy, her right atrial
  rupture was repaired..
• Traumatic cardiac injury following sternal
  fracture a case report and literature
  reviewKaohsiung Journal of Medical Sciences.
  18(7)363-7, 2002 Jul.

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Troublesome Injuries

• Flail chest
• Fracture of 2 or more consecutive ribs in at
  least 2 places each
• About 30-40 of patients need mechanical
  ventilation
• ARDS is increased 20-30 in the presence of flail
  chest

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Troublesome Injuries

• Flail chest
• Close monitoring of respiratory performance
• Adequate analgesic therapy
• Provide oxygen therapy and ventilatory support
• Aggressive pulmonary toilet

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Troublesome Injuries

• Lung contusion
• CxR finding may range from minimal interstitial
  infiltrate to extensive lobar consolidation
• Chest CT is accurate diagnostic tool but not
  always mandatory
• Tx same as flail chest, but pay attention to
  avoid overhydration use of steroid and
  prophylactic antibiotic are still controversial

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Troublesome Injuries

• Blunt Cardiac Trauma - spectrum
• Asymptomatic myocardiac contusion
• Symptomatic myocardiac contusion
• Free wall or septal wall rupture
• Valvular tears
• Coronary artery thrombosis

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Troublesome Injuries

• Blunt Cardiac Trauma risk factors
• Chest impact gt 15 mph
• Marked precordial tenderness, ecchymosis or
  contusion
• PH of cardiac disease
• Fractured sternum
• Thoracic spine or ribs fractures
• Hemodynamic instability, or multiple injuries
• Age gt 50

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Troublesome Injuries

• Blunt Cardiac Trauma - assessment
• Most are asymptomatic severe cases die before
  arrival
• Common manifestation arrhythmia, hemo-dynamic
  instability
• Evaluation CxR, ECG, cardiac enzymes,
  echo-cardigram, MUGA

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Associated literature

• The ratio of MBCK to total creatine kinase
  improved specificity at the expense of
  sensitivity. Measurement of cTnl accurately
  detects cardiac injury in patients with blunt
  chest trauma and should facilitate the diagnosis
  and management of such patients
• Improved detection of cardiac contusion with
  cardiac troponin I.American Heart Journal.
  131(2)308-12, 1996 Feb

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Associated literature

• The combination of normal ECG and TnI at
  admission and 8 hours later rules out the
  diagnosis of SigBCI. In the absence of other
  reasons for hospitalization, such patients can be
  safely discharged
• Normal electrocardiography and serum troponin
  I levels preclude the presence of clinically
  significant blunt cardiac injury
• Journal of Trauma-Injury Infection Critical
  Care. 54(1)45-50 discussion 50-1, 2003 Jan.

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Associated Literature

• Heat shock protein (HSP) synthesis arises
  transiently as a tool to protect cellular
  homeostasis after exposure to heat and a wide
  spectrum of stressful and potentially deleterious
  stimuli
• Normal electrocardiography and serum troponin
  I levels preclude the presence of clinically
  significant blunt cardiac injury
• Journal of trauma-injury infection critical
  care. 54(1)45-50 Discussion 50-1, 2003 Jan.

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Troublesome Injuries

• Blunt cardiac trauma - management
• Most cases do not require Tx Symptomatic
  arrhythmia (2-5) ? antiarrthythmics
• Abnormal ECG and cardiac enzymes almost return to
  normal within one week.
• Patients with abnormal cardiac echo finding or
  MUGA ? keep hospitalization till a repeat test
  show acceptable finding
• Cardiac rupture ? prompt surgical repair

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Troublesome Injuries

• Blunt cardiac trauma - Guideline (USCLAC)
• Obtain admission ECG and CPK-MB/TnT in patient
  with suspect BCI
• Repeat ECG 8-12 hours after admission
• For unexplained hemodynamic instability, abnormal
  ECG, and abnormal cardiac enzyme levels ? perform
  cardiac echogram
• If no suspect symptomatolgy, lab tests or ECG
  finding? discharge after 12 hours

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Pitfalls

• Ignore the presence of blunt cardiac injury in
  patients with blunt thoracic injury
• Failure to recognize the blunt cardiac injury as
  the reason of hemodynamic instability in the
  absence of bleeding

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Thank you for your attention!