Chapter 262: Cardiac Trauma

BLUNT AND PENETRATING CARDIAC TRAUMA AND GREAT VESSEL INJURY

INTRODUCTION

Detection of cardiac injuries is critical for patient survival in trauma. Penetrating cardiothoracic injury causes one quarter to one third of deaths immediately following trauma, and the majority of these fatalities involve either cardiac or great vessel injury.^1,2 Penetrating cardiac injury results when a foreign object enters the body, piercing the pericardium or heart, and cardiac injury may account for close to 10% of deaths from gunshot wounds.^2,3 Invasive cardiac procedures or therapies may cause iatrogenic trauma to the pericardium and myocardium. Even noncardiac procedures like central lines placed into the internal jugular vein can lead to penetration of the pericardium, heart, and great vessels.⁴ The incidence of blunt cardiac injury has been reported to range anywhere from 8% to 71%.^5,6 Blunt cardiac injury results from physical forces acting externally on the body, and up to 20% of all motor vehicle collision deaths are due to blunt cardiac injury.^2,3

Suspect the diagnosis of cardiac or great vessel injury in a patient with chest, lower neck, epigastric, or precordial injury. Closely observe for evidence of hemodynamic instability, loss of circulating blood volume, electrocardiographic changes, cardiac tamponade, and hemothorax.^2,6

EPIDEMIOLOGY

Most penetrating injuries occur from guns and knives, with a shift toward gunshot wounds becoming more common than knife wounds.^2,7-9 The injury usually involves only the free cardiac wall, but other structures can be injured, such as cardiac valves, chordae tendineae, papillary muscles, atrial or ventricular septum, coronary arteries, and conduction system (Table 262-1).^2,10 Rates of involvement of cardiac structures due to penetrating injuries to the right ventricle, left ventricle, right atrium, and left atrium are approximately 40%, 35%, 20%, and 5%, respectively.^11,12 Mortality approximates 40% for penetrating cardiac injury.⁷

Types of blunt cardiac injury can be sustained from any of the mechanisms listed in Table 262-2.¹³ Rapid deceleration is the most common mechanism responsible for most blunt cardiac injury followed by a direct blow to the precordium. Blunt cardiac injury results in a range of conditions from clinically silent transient ...