295.1 🎓 醫孞生版

295.1.0.1 📌 䞀頁重點

295.1.0.1.1 Classification
295.1.0.1.1.1 Blunt Cardiac Trauma
  • Cardiac contusion (myocardial injury without rupture)
  • Cardiac rupture (chamber, septum)
  • Valvular injury (TV most common in blunt)
  • Coronary artery injury (dissection, thrombosis, transection)
  • Pericardial injury / hemopericardium
  • Aortic injury / transection (deceleration injury)
  • Commotio cordis (Ch293)
  • Conduction system injury
295.1.0.1.1.2 Penetrating Cardiac Trauma
  • Stab wound, gunshot wound, impalement
  • Cardiac wall, septum
  • Coronary artery injury
  • Valvular damage
  • High mortality (~ 80% pre-hospital; 50% if reach ED)
295.1.0.1.1.3 Iatrogenic Trauma
  • Cardiac catheterization complications (perforation, dissection, embolism)
  • Pacemaker lead perforation
  • Endomyocardial biopsy injury
  • TAVR / TEER complications
  • Cardiopulmonary bypass
295.1.0.1.2 Blunt Cardiac Trauma
295.1.0.1.2.1 Mechanism
  • High-speed deceleration (MVA, falls)
  • Direct chest impact (steering wheel, blunt object)
  • Crush injury
  • Blast (explosion)
  • Athletic / commotio cordis
295.1.0.1.2.2 Cardiac Contusion (Myocardial Injury)
  • Most common blunt cardiac injury (in survivors)
  • RV most affected (anatomically anterior)
  • Spectrum: subclinical → severe

Clinical Features: - Chest pain (may be from rib fractures too) - Tachycardia, hypotension - Arrhythmias (PVCs, AF, VT) - ECG changes - Hemodynamic instability

Diagnosis: - ECG: ST/T changes, conduction abnormalities, arrhythmias - Troponin: elevated; high NPV at 4-6 hours post-injury - Echo: regional wall motion abnormalities - CT for screening if concomitant trauma

Management: - Telemetry monitoring for arrhythmia - Hemodynamic support if unstable - Echocardiogram within 24 hours - Watch for delayed complications

Prognosis: most recover; complications rare; few late-onset arrhythmias

295.1.0.1.2.3 Cardiac Rupture
  • Devastating, often fatal pre-hospital
  • Right atrium most common (thin wall)
  • Mortality > 80% pre-hospital
  • Survivors: emergent surgery

Clinical Features: - Pericardial tamponade - Massive hemothorax - Cardiogenic shock - Death within minutes if not immediately addressed

Diagnosis: - FAST (Focused Assessment with Sonography for Trauma) in ED - Pericardial effusion + hemodynamic instability - TEE in stable patient - Emergent thoracotomy / sternotomy

Management: - Emergent surgical repair - IV fluids + blood - Vasopressors as bridge - Avoid mechanical ventilation if possible (decreases preload)

295.1.0.1.2.4 Valvular Injury (Blunt)
  • Tricuspid most commonly injured (most exposed anatomically)
  • Aortic in 50% of cases (severe deceleration)
  • Mitral less common
  • Pulmonic rare

Clinical: - New murmur - HF symptoms - May be delayed (weeks-months)

Diagnosis: - Echocardiogram (TTE/TEE) - CMR for assessment

Management: - Surgical repair or replacement - Acute: medical management until stable

295.1.0.1.2.5 Coronary Artery Injury
  • Coronary dissection: traumatic SCAD-like
  • Coronary thrombosis: traumatic occlusion
  • Coronary transection: emergent surgery
  • Clinical: ACS-like presentation
  • Treatment: PCI or CABG depending
295.1.0.1.2.6 Aortic Transection / Injury

Mechanism: rapid deceleration → tear at fixed points (aortic isthmus, ligament arteriosum)

Presentation: - Often fatal at scene (50%) - Survivors: hypertension, asymmetric pulses, new murmur, dyspnea

Diagnosis: - CXR: widened mediastinum, blurred aortic knob, deviation of trachea, depressed L main bronchus, apical cap (mediastinal hematoma) - CT angiography: gold standard - TEE alternative

Management: - TEVAR (Thoracic Endovascular Aortic Repair) = first-line (less morbidity than open repair) - Open surgery if TEVAR not feasible - Hemodynamic stabilization, BP < 120 - IV β-blocker (esmolol) prior to definitive repair

295.1.0.1.2.7 Cardiac Conduction System Injury
  • AV block from septal hematoma or scar
  • Bundle branch blocks
  • May need permanent pacing
295.1.0.1.3 Penetrating Cardiac Trauma
295.1.0.1.3.1 Stab Wounds vs Gunshot Wounds
  • Stab: cleaner; smaller wounds; survivable more often
  • Gunshot: tissue destruction; higher mortality; multi-organ
295.1.0.1.3.2 Pre-Hospital Care
  • “Scoop and run” usually (rapid transport > pre-hospital intervention)
  • Some support: bilateral chest decompression, fluid resuscitation
  • Emergent thoracotomy in ED if peri-arrest
295.1.0.1.3.3 ED Thoracotomy
  • For penetrating chest trauma with peri-arrest
  • Best outcomes for stab wounds
  • Lower outcomes for gunshot wounds
  • Goals: relieve tamponade, control bleeding, internal cardiac massage, cross-clamp aorta
295.1.0.1.3.4 OR Repair
  • Median sternotomy or anterolateral thoracotomy
  • Direct repair (suture, patch)
  • CPB if needed for complex injuries
295.1.0.1.4 Iatrogenic Cardiac Trauma
295.1.0.1.4.2 Diagnostic
  • Echocardiogram during/after procedure
  • ECG for arrhythmia
  • Hemodynamic monitoring
295.1.0.1.4.3 Management
  • Reverse anticoagulation (protamine, andexanet, idarucizumab as needed)
  • Pericardiocentesis for tamponade
  • Emergent surgery for sustained bleeding
  • Multidisciplinary
295.1.0.1.5 Pulmonary + Aortic Considerations
295.1.0.1.5.1 Pneumothorax / Hemothorax Common
  • Tension pneumothorax → needle decompression
  • Chest tube drainage
  • Address hemothorax with chest tube
295.1.0.1.5.2 Aortic Injury Differential
  • Traumatic vs spontaneous (dissection in elderly with HTN)
  • Penetrating vs blunt mechanism
295.1.0.1.6 Pediatric Cardiac Trauma
295.1.0.1.6.1 Special Considerations
  • Different mechanism: bicycle handlebars, sports
  • Greater compliance of chest wall
  • Commotio cordis more common
  • AED + CPR life-saving

295.1.0.2 🩺 床邊速查

  • Blunt cardiac contusion: troponin + ECG + echo; telemetry monitor for arrhythmia
  • Cardiac rupture: FAST → emergent surgery
  • Aortic transection: CT angio gold standard; TEVAR first-line + esmolol pre-repair
  • Penetrating: ED thoracotomy for peri-arrest stab; OR repair
  • Iatrogenic: reverse AC + pericardiocentesis if tamponade
  • Commotio cordis: AED + CPR life-saving