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CARDIAC TRAUMAA primer on blunt and penetrating heart
trauma and pearls for emergency care
Jeremy Webb, M.D.PGY-3, Emergency MedicineWake Forest Baptist Health
Topics Covered
History: A Paradigm Shift
Blunt Cardiac Trauma
Penetrating Cardiac Trauma
Role of Emergency Department Thoracotomy
1829
1896
"Surgery of the heart has probably reached the limits set by nature to all surgery: no new method and no discovery can overcome the natural difficulties that attend a wound of the heart"
Paget, 1896
1902
Dr. Luther Hill
“the road to the heart is only 2 or 3 cm, in a direct line, but it has taken surgery nearly
2400 years to travel it."
- Harry Sherman, 1902
Blunt Cardiac Trauma
What are the mechanisms of injury?
What injury patterns can be seen?
Right heart > Left heart
Left heart valves > Right heart valves
Rupture: Atria > Ventricles
Location Pearls
History and Physical
Pulse?, Pain, Palpitations
Extremis? Tamponade? Heart Failure?
Associated injuries?
Pulsus ParadoxusPulse?, Pain, Palpitations
Extremis? Tamponade? Heart Failure?
Blunt Cardiac InjuryMyocardial Contusion
Role of ECG
Mandated if BCI suspected
Sensitivity? Specificity?
Common abnormalities in BCI
Dr. Steven W. Smith, Hennepin County Medical Center http://hqmeded-ecg.blogspot.com/search/label/myocardial%20contusion
The Role of Cardiac Enzymes
Controversial
Sensitivity? Specificity?
When to test?
Enzymes Made Simple
"Intermediate Risk" of BCI
ECG Changes
Hemodynamically Unstable
Medical work-up (syncope, ischemia)
Role of Radiology
Study of Choice: Echocardiography
Angiography as adjunct
Indications?
Radiography Made Simple
Hemodynamically Unstable: FAST
ECG or Enzyme Abnormalities
High Clinical Suspicion: Mechanism or associated injuries
BCI: Putting it All Together
Words from a Trauma Surgeon...
"Diagnosis is relatively simple: any trauma patient with a likely mechanism who has chest wall pain and a new arrhythmia or cardiac pump failure has a cardiac contusion. Atrial or ventricular arrhythmias are significant, but a ventricular one is significant because it can degenerate into v-tach or worse.
Enzyme measurements do not indicate severity of injury or outcome and should not be obtained.Remember, true cardiac contusion is rare! If suspected, telemetry is indicated, along with frequent vital signs. Cardiac enzymes should not be ordered, and any indication of cardiac problems (arrhythmia or failure) should be reported and treated promptly."
http://regionstraumapro.com/tagged/cardiac-contusion
Blunt Cardiac InjuryCommotio Cordis
Blunt Cardiac InjuryMyocardial Rupture
Blunt Cardiac InjuryCardiac Luxation
Penetrating Cardiac Trauma
Gunshot Wounds > Stab Wounds
Exsanguination, Tamponade
Mortality by Mechanism
Prehospital Considerations
SCOOP AND RUN SAVES LIVES!
Airway ConsiderationsThe laryngoscope as a murder weapon...
Airway ConsiderationsSympathetic Crash
Cause Tamponade
Air Embolism
Diagnosis and TreatmentPericardiocentesis NOPE
Subxiphoid Window FAST
Pre-Operative Resus LIMITED
!!! GET THEM TO AN OR QUICKLY !!!
Emergency Department Thoracotomy
When to make a stab wound of your own...
The liberal application of thoracotomy in the resuscitation of blunt trauma cannot be justified and should only be undertaken when there are documented signs of life in the emergency department or within five minutes prior to arrival; prolonged (>5 mins) CPR after blunt injury equates to fatality.
Emergency Thoracotomy – The Indications, Contraindications, and Evidence. Morgan BS, Garner JP. JR Army Med Corps 155(2): 87-93
Maintain high suspicion
Blunt Cardiac Trauma
Penetrating Cardiac Trauma
When to perform ED Thoractomy
Cardiac Trauma Review
Questions?
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