MANAGEMENT OF ACUTE TRAUMA IN ER - CARDIOLOGIST PERSPECTIVE.pptx

Management of acute trauma in ER. What are the cardiac causes? How to manage? See the case scenarios.

1. MANAGEMENT OF ACUTE TRAUMA IN ER – CARDIOLOGIST PERSPECTIVE Dr. Vaasanthi C. 2 nd yr. DM (Cardiology) Resident

2. INTRODUCTION Traumatic injuries are one of the leading causes of death worldwide. Thoracic injuries account for significant mortality and morbidity among trauma patients as significant injury to the myocardium is fatal. Up to 10-25% of all traumatic fatalities were found to be cardiac or aortic injuries.

3. SPECTRUM OF CARDIAC EMERGENCIES IN TRAUMATIC INJURY

4. CASE SCENARIOS

5. CASE -1 A 35-year-old male had a penetrating injury with a knife in the thorax region and was brought to casualty. On examination he was conscious, bleeding from the wound site. Pulse -120/min, low volume BP - 80/60 mm Hg Auscultation – distant heart sounds, and equal bilateral air entry, normal breath sounds.

6. ECG at Presentation 12 lead ECG showing Electrical alternans

7. BEDSIDE ECHOCARDIOGRAPHY

8. What do you think? MASSIVE PERICARDIAL EFFUSION WITH TAMPONADE

9. MANAGEMENT Pericardiocentesis can be performed bedside to aid in diagnosis and can temporarily restore filling pressures by drainage of a small amount of pericardial blood.

10. In case of profuse and persistent bleeding - a left lateral thoracotomy , simultaneously with endotracheal intubation and IV catheterization. The cardiac wound is sutured and the thoracic aorta is cross-clamped to improve coronary and cerebral circulation.

11. PENETRATING CARDIAC INJURY Spectrum of injury by anatomic location RIGHT VENTRICLE 37-67% LEFT VENTRICLE 19-40% RIGHT ATRIUM 5-20% LEFT ATRIUM 2-12%

12. PROGNOSIS Poor prognosis Overall mortality 65-80%. Mode of presentation also affects mortality - those requiring resuscitative thoracotomy have increased mortality. Post-operative monitoring and echocardiography need to be done to look for any decrease in the ejection fraction, septal defects, or valvular and papillary muscle damage.

13. CASE -2 A 16-year-old boy while playing baseball had an accidental hit by a baseball over the chest. He was alright for a few seconds but later he collapsed and was brought dead to casualty.

14. What do you think ???? Commotio cordis Pericardial injury with strangulation of great vessels

15. COMMOTIO CORDIS It is the Latin term for agitation or disturbance of the heart. Most common in young people (thin chest wall) and baseball is the most provocative event. Here in this case the timing of trauma might have occurred during the upstroke of the T wave of ventricular repolarization leading to the generation of malignant VPC and ultimately Ventricular fibrillation.

16. Famous football player who survived commotio cordis DAMAR HAMLIN

17. PERICARDIAL INJURY Pericardial injury secondary to blunt trauma is rare. The risk of cardiac herniation through tear or laceration and even strangulation is also possible. If strangulation occurs, the patient is at high risk of immediate death secondary to inflow and outflow obstruction, resulting in hypotension and hypoperfusion.

18. When there is herniation into the thoracic cavity without strangulation, the physical examination may reveal heart sounds auscultated in an abnormal location . Position changes can shift the position of the heart and there can be a sudden loss of pulse with a change of position . The same is true for those patients in cardiac arrest following blunt thoracic trauma who suddenly regain pulses after the change of position . But we need to be careful because the change of position even causes strangulation.

19. Chest X-ray reveals abnormal heart position. Echocardiography and CT chest also aids in diagnosis. Management Thoracotomy and relieving strangulation and repair of pericardium.

20. CASE -3 A 27-year-old male was brought to casualty, who was injured in a bomb blast. On examination he had multiple injuries and a foreign body penetrating the right chest Cardiac evaluation at the time of admission was normal. He underwent surgery for the removal of a foreign body and was doing well in the post-operative period. 24 hours after surgery he complained of chest pain and sweating his vitals were fine and an ECG was taken which revealed Inferior wall STEMI.

21. PROBABLE CAUSE OF MI Air embolism of RCA. Myocardial contusion Coronary artery dissection with thrombus formation

22. AIR EMBOLISM OF RCA Here in this case, due to penetrating injury there was a disturbance of alveolar and pulmonary capillaries leading to air bubbles entering circulation and reaching coronary arteries. Fibrinolytic therapy is not recommended. Coronary angiography should be done if coronary air embolism is suspected.

23. MYOCARDIAL CONTUSION Mechanisms include- Direct impact to the anterior aspect of the chest Bidirectional forces Acceleration/deceleration forces Blast forces Due to its anatomic location, RV is more frequently identified to have regional wall motion abnormalities and may serve as an arrhythmogenic source.

24. ECG abnormalities are often seen in myocardial contusions and these include ST changes Non-sustained ventricular tachycardia Varying degrees of heart block Atrial arrhythmias Cardiac enzymes are also raised and Echocardiography may show regional wall motion abnormalities or decreased myocardial contractility.

25. CASE - 4 A 29-year-old female had undergone a car accident. Due to the sudden application of brakes, she had been hit on her chest by the steering wheel. She visited the hospital and underwent basic investigations, which were normal, and hence discharged with painkillers. 24 hours later she presented to casualty with sudden onset of NHYA -4 breathlessness. Her presentation BP was 80/60 mm Hg and there was a pan systolic at the mitral area on auscultation.

26. What do you think ?? ACUTE MITRAL REGURGITATION LEADING TO ACUTE LV FAILURE. Cause - Blunt trauma causing papillary muscle contusion leading to necrosis.

27. 2D ECHOCARDIOGRAPHY PLAX showing ruptured papillary muscle PLAX Color Doppler showing mitral regurgitation

28. VALVULAR INJURY Injury to specific valves is cycle-dependent. Early diastole - Aortic and pulmonary valves-as they are just closed and unsupported by empty ventricles. Early systole - Atrioventricular valves Mechanisms Papillary muscle rupture(most common) Chordae tendinae rupture Tearing of leaflets Papillary muscle contusion leading to necrosis(delayed)

29. MANAGEMENT VALVE SIGNS AND SYMPTOMS TREATMENT TRICUSPID VALVE Late-onset pansystolic murmur increasing with inspiration RV dysfunction Afterload reduction Diuresis Intra-aortic balloon pump Surgical repair PULMONIC VALVE Late onset Diastolic decrescendo murmur RV dysfunction Often no treatment necessary MITRAL VALVE Acute or late onset Holosystolic high pitched murmur S3 Pulmonary edema and cardiogenic shock Afterload reduction Diuresis Intra aortic balloon pump Surgical repair AORTIC VALVE Acute onset Diastolic decrescendo murmur Pulmonary edema and cardiogenic shock Medical treatment is mostly unsuccessful Emergency surgical repair

30. CASE -5 A 41-year-old driver of a car was admitted to hospital, following a collision of his car with a lorry. On admission, he was found to have abrasions over his face and right knee and a closed fracture of the right femur with only external injuries over the chest. He complained of sudden dyspnea 6 hours later.

31. What do you think ?? Hemo -pneumothorax Bone injury Myocardial contusion or MI

32. His chest radiograph showed normal lung fields and did not reveal rib or sternal fracture or hemo -pneumothorax. ECG showed sinus tachycardia Saturation was 82% on room air. His Troponin I was elevated Echocardiography done bedside No regional wall abnormality, mild dilation of right-sided chambers CT pulmonary angiogram revealed a pulmonary embolism involving the right lobar pulmonary artery.

33. EARLY PUMONARY EMBOLISM Early PE may be associated with a pathophysiological mechanism that is different from one that occurs later after the development of DVT. Possibilities of early PE in the absence of DVT- Rapidly developing post-traumatic hypercoagulable disorder. Denovo thrombi in the pulmonary circulation (due to vascular endothelial inflammation)

34. MANAGEMENT Anticoagulation with low molecular weight heparin after ruling out ICH. Regarding thrombolysis it depends on the risk-benefit ratio as the risk of bleeding is higher in traumatic patients. In patients with clinical deterioration on anticoagulation and in whom systemic fibrinolysis is contraindicated catheter-based thrombectomy is considered.

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