Here’s Dr. Kazzi with today’s Morning Report!
Blunt Cardiac Injury
Right heart most common site of BCI.
MVCs and sports injuries are most common.
Types of Injury:
a) Myocardial contusion
b) Chamber rupture (if free wall do not make it to ED, but other VSD / ASD may make it)
c) Valve injury
Complications:
Hemopericardium can result in cardiac tamponade with as much as 200 mL of blood.
VSD/ASD may result in shunting and heart failure down the road.
Diagnosis:
Few signs / symptoms are specific for BCI. Most common finding is chest pain.
Dyspnea, chest wall ecchymosis, flail chest and sternal fractures should raise suspicion. (Sternal Fracture is not predictive of BCI per EAST Guidelines)
EKG:
No EKG finding is pathognomonic. Using any EKG change including: Sinus tachycardia, sinus bradycardia, conduction delays or atrial or ventricular dysrhythmias provides sensitivity of 100% and specificity of 47% and NPV of 90% in detection of BCI-related complications requiring treatment.
Other studies have excluded sinus tachycardia, sinus bradycardia and non-specific ST/T wave changes and concluded that the EKG would still rule out clinically significant injury.
In young, hemodynamically stable patients, a normal EKG = no need for further evaluation.
ECHO:
Not beneficial as screening tool for BCI, should be reserved for patients with hypotension and / or arrhythmias.
Cardiac Enzymes:
CPK and CK-MB do not predict risk of developing complications secondary to BCI. CPK and CK-MB are located in other tissues and may be falsely elevated in the poly-trauma patient. Have a very low specificity and are NOT recommended for BCI screening.
Troponin I and Troponin T have higher specificity in patients defined as having BCI by ECG or ECHO criteria and were 97% and 100% respectively.
Very low sensitivity however 23% and 12%.
Management:
EAST Guidelines:
New arrhythmia on EKG – admit for monitoring
EKG Normal and Troponin I normal – BCI ruled out.
AEKG normal / Troponin I abnormal – Admit for monitoring
CT Surgeon consult for any suspected free-wall rupture, septal rupture, coronary artery injury or valve injury.
Prognosis:
Most traumatic BCI of left or right ventricle usually resolves without functional sequela within 1 year.
Sources:
Blunt Cardiac Injury. Shultz JM, Trunkey DD. Critical Care Clinics 2004
Screening for Blunt Cardiac Injury: An EAST Practice Guideline. Journal of Trauma and Acute Care Surgery 2012.
Jay Khadpe MD
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