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Case – Fall of the Lumberjack 22 yr old m in remote area of Northwest fell 40 feet when his ropes failed Stuck chest/torso on a large limb prior impact with ground Conscious c/o chest/lower back/hip pain Taken to camp infirmary, then by helicopter In flight – Developed tachycardia and SOB (sats 90%) – BS bilaterally and BP stable – Increased oxygen by FM 50% – LR at 200 cc/hr Case – Lumberjack 40 ft fall Arrived to trauma center 90 mins. later Agitated and tachypnea (50 br/min) O2 Sats 89% on 50% FM BP 90/60, HR 120 Continued BS bilaterally Management? Case – Lumberjack 40 ft fall Intubated and bolus 1L LR Initial CXR (poor) – no PTX, B infiltrative process O2 Sats improved, BP 110/60 PE – Tenderness anterior chest wall, no crepitus – Heart sound normal, no rub or murmurs Management ? CXR EKG Hemodynamics Case – Lumberjack 40 ft fall CT head – no contusion or bleed CT abdomen – retroperitoneal blood collection (700-1000 cc), no solid organ injury or free fluid ECHO – dilated, moderately hypokinetic right ventricle, no effusion Diagnosis and further management? Traps – Blunt Cardiac Injury Hypotension after trauma – – – – – Hemorrhage Tension PTX Tamponade Myocardial contusion Neurogenic shock (high spinal cord injury) ? Gold standard of myocardial contusion – 44 % of abnl ECHO, normal EKG/CPK’s – 67% of abnl CPK’s, normal ECHO Tricks – Blunt Cardiac Injury Rule out hemorrhage (hypotension) Mechanism of injury and physical signs – Any blow to the thorax or rapid deceleration – Fractures of 1st/2nd ribs, multiple ribs Multiple tests often required to diagnosis blunt cardiac injury – – – – EKG Cardiac Isoenzymes PA catheter Echo Follow up – Lumberjack 40 ft fall Transferred to SICU Transfusion PRBC/NS ( no pressors) PVC’s during first 24 hrs. Total CPK 4000, MB 4% PA catheter used to monitor hydration HD 3 – CXR improved and extubated HD 7 – ECHO showed right ventricular dilation and hypokinesis largely resolved. Blunt Cardiac Injury Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics Incidence - BCI Most frequent, unsuspected visceral injury responsible for death in accident victims On scene – accounts for 25% of deaths Hospital – 15-25% of all blunt chest trauma Definition Old Terminology – concussion = no anatomic cellular damage, but functional damage seen on ECHO – contusion = anatomic injury with release of elevated CPK-MB or direct visualization at surgery or autopsy Blunt cardiac injury = spectrum of injury Myocardial contusion = trauma to myocardium Pathophysiology Wide spectrum of injury – * direct myocardial injury – – – – – laceration/thrombosis coronary arteries pericardial tears rupture of wall leading to tamponade septal rupture valvular injury (aorta most common) Emergent Management Cardiac rupture Ventricular septal defect (VSD) Atrial septal defect (ASD) Valvular injury Myocardial contusion Cardiac Rupture Most severe form of BCI Most frequent heart lesion found at autopsy in patient dead at scene Locations (common) – historically reported anterior right ventricle – experience demonstrate tear of R atrium at junction of SVC and IVC (reach hospital) Shock out of proportion to injury/fluid resuscitation Treatment = immediate sternotomy Ventricular Septal Defect Incidence – Parmeley et al (Circulation, 1958) • 5-7 % VSD Diagnosis – critically ill (VSD, myocardial and pulm injury) – EKG changes and new murmur – loud holosystolic murmur and thrill Treatment – severe = immediate catherization/repair – small = spontaneous repair – moderate = repair 6-8 weeks post injury Atrial Septal Defect Extremely rare Most die within minutes of injury – larger defects – complications from hypoxemia Valvular Injury Aortic insufficiency most common – rupture of cusp or tear of commissural attachment – severe heart failure – often manage acutely with titrating preload/afterload Long-term treatment – replace valves – preferable to wait 6-8 weeks Myocardial Contusion Incidence – 90% of all admitted BCI – 5-15 % of blunt chest trauma – unstable ICU patients = as high as 75% Pathology – – – – – subendothelial/interstitial hemorrhage surrounding area of focal edema myofibrillar degeneration infiltration of PMN’s resemble MI but more patchy Myocardial Contusion Physiologic changes – rhythm or conduction disturbances – impair contractility in 10-20% of patients • CO reduction directly related to contusion – significant reduction in cardiac function if • preexisting cardiac disease • multiple injuries • general anesthesia Myocardial Contusion - Dysfunction Torres-Mirabal et al (Crit Care Med, 1982) – Death from biventricular failure, cardiogenic shock, L ventricular failure – PA catheter only slight CO and wedge – Fluid challenge = rapid increases in wedge with little changes in CO Sutherland et al (Am J Cardio, 1986) – RVEF reduced 29% (cardiac scintigraphy) – compensated by increased RVEDV Myocardial Contusion -ICU Monitoring Arrhythmia Clinical evidence of heart failure Multiple other injuries Preexisting cardiac disease General anesthesia Clinical Presentation Arrhythmias – tachycardia out of proportion of degree of trauma or blood loss – others = atrial fibrillation, PAC’s, PVC’s Signs/symptoms of MI – chest pain (not relieved by HTG) – increased CPK’s Hypotension – persistent after volume resuscitation Diagnostic Studies Physical exam/plain radiography EKG Cardiac enzymes Echocardiography Radionuclide Angiography BCI - Physical Exam/Radiography External chest injury not present in up to 1/3 Sternal fracture not predictive for BCI – Supportive • Shapira et al, J Trauma, 1994 – less than 5% had cardiac damage • Support by other studies – Non-supportive • Harley et al ( J Trauma, 1986) – 91 % of sternal fx had RV dysfunction by RNA EKG Best screening tool for BCI Should be obtained on admission and repeated 12 to 24 hrs later If no abnormalities at 24hrs, unlikely to develop complications New atrial fibrillation, multiple PVC’s, or conduction disturbance more important than STT wave changes for diagnosing cardiac injury Cardiac Enzymes - CPK-MB CPK-MB – sources: skeletal muscle, pancreas, lung, colon, liver, stomach, and small bowel – peaks 18-24 after myocardial contusion Evidence – no value in predicting outcome – no correlation to severity of contusion Role in Trauma – r/o MI in elderly or pts with h/o CAD Cardiac Enzymes - Troponin Specific to myocardial tissue Troponin T – Ferjani et al, Chest,1997 • prospective 128 pts blunt chest trauma • 29/128 BCI • higher diagnostic value, but no important clinical value Troponin I – Salim et al, J Trauma, 2001 • 115 patients with blunt chest trauma EKG/Trop I and Significant BCI 115 patients Abnl EKG 58 Abnl Trop I 16 Sig BCI 10 No Sig BCI 6 Normal EKG 57 Normal Trop I 42 Sig BCI 6 Sensitivity Specificity PP value NP value No Sig BCI 36 Abnl Trop I 11 Sig BCI 3 No Sig BCI 8 Normal Normal Trop Trop II 45 46 Sig BCI BCI Sig 80 No Sig BCI 46 EKG Trop I EKG + TropI 84% 68% 100% 56% 85% 88% 28% 48% 62% 95% 93% 100% Salim et al, J Trauma, 2001 Salim et al, J Trauma, 2001 Results – significant BCI (19 patients) • • • • arrhythmias (A fib 7, ST 3) < 24hrs hypotension requiring pressors (7) < 24 hrs. cardiogenic shock on inotropes (1) < 24 hrs. hemopericardium with drainage (1) HD6 Criticism – ? change in management (all ICU admitted) – sinus tachycardia not judged abnormal EKG – initial Trop I negative (4/19 patients) Echocardiography Most useful of tests for diagnosis/therapy – normal ECHO rules out significant contusion Findings with contusion – usually R ventricular dyskinesis – occasionally see thrombus attached TEE vs. TTE – TEE more sensitive if TTE inadequate – TEE useful to exclude causes of hypovolemia • r/o hypovolemia, tamponade Radionuclide Angiography Studies – Harley and Mena, J Trauma 1986 • 11/12 sternal fx abnormal study • none had abnormal CPK-MB, only 4 abnl EKG – Sutherland et al, Am J Cardiol, 1983 • similar findings (Harley and Mena study) • only 1/3 had abnormal CPK-MB or EKG Conclusion – excessively sensitive – no clinical significance – no added value to ECHO study Therapy - Myocardial Contusion Recognition Monitoring Support Special considerations – PA catheter – Anesthesia – Thrombus Cardiac Monitoring Study Monitoring Required Frazee et al, J Trauma 1986 Brune et al,J Int Care Med, 1988 Hiatt et al, J Trauma, 1988 Baxter et al, Am J Surg, 1989 Foil et al, Am J Surg, 1990 Healey et al, J Trauma, 1990 Fabian et al, J Trauma, 1991 McCarthy et al, CV Interv Rad 1991 Cachecho et al, J Trauma, 1992 Biffl et al, Am J Surg 1994 Abnormal EKG/ ECHO Abnormal EKG or unstable Abnormal EKG Abnormal EKG or CK-MB Abnormal EKG Abnormal EKG Not routinely applicable Abnormal EKG Abnormal EKG Abnormal EKG BCI - Hypotension Volume Resuscitation R/O Mechanical Problem (ie. tamponade, tension PTX) Inotropic Support Dopamine (1st line) Dobutamine (2nd line) Milrinone (3rd line) Intra-aortic Balloon Pump IABP Extra-Corporeal Membrane Oxygenation ECMO Anesthesia and Myocardial Contusion Dictums – no GA < 1 month of contusion – required PA catheter for emergent OR Evidence – Fabian et al, J Trauma 1988 • no problem with GA – Ross et al, Arch Surg, 1989 • PA catheter for OR – Krasna et al, Sem Thor CV Surg, 1992 • safe for emergent OR – Feghali et al, Chest, 1995 • ? invasive monitoring, no problems Complications - Delayed Pericarditis – 2-4 weeks post trauma – signs/symptoms • chest pain, fever, effusion • EKG ST-T c/w pericarditis – treatment • salicylates, rest • steroids for severe cases Aneurysms – unusual and occurs with large areas of necrosis – symptoms of CHF, emboli, dysrhythmias – treatment (asymptomatic/symptomatic) = resection Recommendations Admission EKG with suspected BCI (L I) – abnormal EKG = continuous monitoring 24 hrs – normal EKG = risk of BCI is insignificant Tropinin I (LII) – consider if planning ED discharge – if Trop I neg/EKG neg no clinical sig BCI Imaging study -Echocardiography (L II) – hemodynamically unstable – if TTE is suboptimal, TEE should be done – nuclear medicine studies add little to Echo Recommendations Level III data – presence of sternal fx does not predict BCI – CPK or troponin are not useful in predicting which pts will or will not have complications related to BCI – Patients with CAD, hemodynamically instability, or abnormal EKG can be safely operated on with appropriate monitoring Questions…? Bradley J. Phillips, MD SBH-UTMB