Cardiology

Background

Traumatic cardiac and mechanical disorders are structural or functional injuries to the heart and great vessels resulting from blunt or penetrating trauma, or from iatrogenic/device-related causes. These conditions include myocardial contusion, chamber rupture, pericardial tamponade, valvular disruption, septal defects, coronary injury, and prosthesis/device complications. They represent life-threatening emergencies requiring rapid recognition and intervention.

II) Classification/Types

By Mechanism

• Blunt Cardiac Injury (BCI): Myocardial contusion, chamber rupture, coronary artery injury, valvular disruption.

• Penetrating Cardiac Trauma: Stab wounds, gunshot wounds, iatrogenic perforation.

• Mechanical Complications: Pericardial tamponade, acute severe regurgitation, traumatic VSD, papillary muscle rupture.

• Great Vessel Trauma: Traumatic aortic rupture, pulmonary artery/vein laceration, SVC/IVC injury.

• Device/Prosthesis-Associated: Pacemaker lead perforation, LVAD trauma, prosthetic valve disruption.

III) Pathophysiology

• Blunt trauma: Rapid deceleration or direct chest compression → myocardial bruising, coronary dissection, chamber rupture.

• Penetrating trauma: Direct laceration or perforation of myocardium/pericardium → hemorrhage, tamponade.

• Mechanical complications: Secondary disruption of valves, septum, or pericardium → acute hemodynamic instability.

• Great vessel trauma: Aortic isthmus rupture or venous tears → rapid exsanguination.

• Device trauma: Malposition or migration causing perforation or obstruction.

IV) Epidemiology

• Accounts for up to 20% of fatalities in blunt chest trauma.

• Penetrating cardiac trauma: Mortality >50% pre-hospital; survival depends on rapid surgical access.

• Most common in young adults due to high-energy mechanisms (MVCs, gunshot wounds).

Etiology

I) Causes

• Blunt trauma: MVC, falls, sports injuries, crush injuries.

• Penetrating trauma: Firearm wounds, stab injuries, surgical/iatrogenic injury.

• Iatrogenic: Catheter perforation, pacemaker/ICD leads, ablation, central line placement.

• Device-related: LVAD malposition, prosthetic valve disruption.

II) Risk Factors

• High-speed collisions

• Chest wall deformities (sternal fractures, flail chest)

• Anticoagulation (exacerbates bleeding)

• Prior cardiac surgery (adhesions predispose to injury)

• Implanted devices

Clinical Presentation

I) History (Symptoms)

• Chest pain (sharp, crushing, pleuritic, or stabbing)

• Dyspnea or orthopnea

• Palpitations, syncope

• Fatigue, dizziness (low output state)

• History of recent trauma (MVC, fall, penetrating injury)

II) Physical Exam (Signs)

Vital Signs

• Hypotension (shock from tamponade, rupture, or hemorrhage)

• Tachycardia (compensatory or arrhythmia-related)

• Bradycardia (conduction block or vagal response)

• Pulsus paradoxus (tamponade)

General Appearance

• Acute distress, diaphoresis

• Cyanosis or pallor

• Respiratory distress (tachypnea, accessory muscle use)

• External trauma: ecchymosis, abrasions, “seatbelt sign,” rib or sternal tenderness

Cardiovascular

• Jugular venous distension (tamponade, right heart failure)

• Muffled or distant heart sounds (tamponade)

• New murmurs (valvular rupture, traumatic VSD)

• Pericardial rub (traumatic pericarditis)

• Irregular rhythm on auscultation (PVCs, AF, complete heart block)

• Precordial tenderness/crepitus

Respiratory

• Decreased breath sounds (hemothorax, pneumothorax)

• Tracheal deviation (tension pneumothorax or massive hemopericardium)

• Rales (pulmonary edema from acute MR or LV failure)

Abdominal

• Distension from hepatic congestion (tamponade, right heart failure)

• Associated visceral trauma

Extremities

• Cool, clammy skin (shock)

• Weak or absent peripheral pulses (aortic injury, hypoperfusion)

• Edema (delayed right-sided injury sequelae)

Differential Diagnosis (DDx)

• Acute coronary syndrome

• Aortic dissection

• Pulmonary embolism

• Pneumothorax/hemothorax

• Myocardial infarction without trauma

• Cardiac tamponade of non-traumatic etiology

• Myocarditis

Diagnostic Tests

Initial Tests

• ECG: Arrhythmias, ST-T changes, conduction delays

• Chest X-ray: Widened mediastinum (aortic rupture), cardiomegaly (tamponade), rib/sternal fractures

• Echocardiography (TTE/TEE): Pericardial effusion, tamponade, chamber rupture, valvular injury

• Troponin: Elevated in myocardial contusion or coronary injury

Advanced Tests

• CT Angiography: Aortic/great vessel evaluation; coronary artery trauma

• Cardiac MRI: Myocardial contusion or coronary dissection in stable patients

• Cardiac catheterization: Diagnostic/therapeutic in coronary injuries

• Pericardiocentesis fluid analysis: If effusion present

Treatment

I) Medical Management

• Initial stabilization (ATLS principles): Airway, breathing, circulation

• IV fluids and blood products for hemorrhagic shock

• Oxygen if hypoxemic

• Arrhythmia management: ACLS algorithms, temporary pacing for high-degree AV block

• Anticoagulation: Generally avoided unless clear coronary thrombosis without bleeding risk

II) Interventional/Surgical

• Pericardial tamponade: Emergent pericardiocentesis or thoracotomy

• Chamber or valvular rupture: Immediate surgical repair

• Coronary artery injury: PCI or CABG

• Great vessel trauma: Open surgical repair or endovascular stenting

• Device-related injury: Lead revision, LVAD repositioning, valve re-replacement

 Patient Education, Screening, Vaccines

• Education: Nature of traumatic cardiac injury, need for close monitoring, risk of late arrhythmias or heart failure

• Lifestyle: Avoid strenuous activity during recovery; follow post-surgical precautions

• Screening: Serial ECGs, echocardiograms for arrhythmia or structural changes

• Vaccinations: Influenza and pneumococcal vaccination for those with chronic cardiac dysfunction

Consults/Referrals

• Cardiothoracic Surgery: For repair of ruptures, valve injury, great vessel trauma

• Cardiology: Ongoing management of myocardial contusion, coronary trauma, arrhythmias

• Critical Care/Trauma Surgery: Initial stabilization and ICU management

• Rehabilitation/Physical Therapy: Recovery post-surgery or hospitalization

Follow-Up

• Short-term: Monitor for arrhythmias, effusion re-accumulation, heart failure

• Intermediate: Echocardiography at 2–6 weeks; stress testing if coronary injury suspected

• Long-term: Lifelong follow-up in survivors of major trauma for late complications (HF, aneurysm, arrhythmia)