Trauma is the leading cause of death in patients aged 1–44 years; cardiac and vascular trauma is second only to neurologic injury as the reason for these deaths. Penetrating wounds to the heart are often lethal unless surgically repaired. In a 20-year review of penetrating trauma at a single institution, it was found that gunshot wounds were fatal 13 times more often than stab wounds and that factors such as hypotension, Glasgow Coma Score less than 8, Revised Trauma Score less than 7.84, associated injuries, and the more severe the injuries (Injury Severity Score greater than 25) all added to the mortality and morbidity risk.
Blunt trauma is a more frequent cause of cardiac injuries. This type of injury is common in motor vehicle accidents and may occur with any form of chest trauma, including CPR efforts. The most common injuries are myocardial contusions or hematomas. Other forms of nonischemic cardiac injury include metabolic injury due to burns, electrical current, or sepsis. These may be asymptomatic (particularly in the setting of more severe injuries) or may present with chest pain of a nonspecific nature or, not uncommonly, with a pericardial component. Elevations of cardiac enzymes are frequent but the levels do not correlate with prognosis. There are some data that the presence of certain other cardiac biomarkers, such as NT-proBNP, correlate better with significant myocardial injury. Echocardiography may reveal an akinetic segment or pericardial effusion. Cardiac MRI may also suggest acute injury. Coronary CT angiography or angiography can reveal a coronary dissection or acute occlusion if that is a concern. Pericardiocentesis is warranted if tamponade is evident. As noted above, tako-tsubo transient segmental myocardial dysfunction can occur due to the accompanying stress.
Severe trauma may also cause myocardial or valvular rupture. Cardiac rupture can involve any chamber, but survival is most likely if injury is to one of the atria or the RV. Hemopericardium or pericardial tamponade is the usual clinical presentation, and surgery is almost always necessary. Mitral and aortic valve rupture may occur during severe blunt trauma—the former presumably if the impact occurs during systole and the latter if during diastole. Patients reach the hospital in shock or severe heart failure. Immediate surgical repair is essential. The same types of injuries may result in transection of the aorta, either at the level of the arch or distal to the takeoff of the left subclavian artery at the ligamentum arteriosum. Transthoracic echocardiography and TEE are the most helpful and immediately available diagnostic techniques. CT and MRI may also be required to better define the injury before surgical intervention.
Blunt trauma may also result in damage to the coronary arteries. Acute or subacute coronary thrombosis is the most common presentation. The clinical syndrome is one of acute MI with attendant ECG, enzymatic, and contractile abnormalities. Emergent revascularization is sometimes feasible, either by the percutaneous route or by coronary artery bypass surgery. LV aneurysms are common outcomes of traumatic coronary occlusions, likely due to sudden occlusion with no collateral vascular support. Coronary artery dissection or rupture may also occur in the setting of blunt cardiac trauma.
As expected, patients with severe preexisting conditions fare the least well after cardiac trauma. Data from ReCONECT, a trauma consortium, reveal that mortality is linked to volume of cases seen at various centers, preexisting coronary disease or heart failure, intubation, age, and a severity scoring index.
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