Penetrating cardiac injury: Difference between revisions
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==Background== | ==Background== | ||
*Ventricles are at greatest risk due to anterior location | *Ventricles are at greatest risk due to anterior location | ||
**RV (involved in 40% of injuries) | **RV (involved in 40% of injuries) | ||
| Line 14: | Line 5: | ||
**RA (involved in 20% of injuries) | **RA (involved in 20% of injuries) | ||
**LA (involved in 5% of injuries) | **LA (involved in 5% of injuries) | ||
* | ==Clinical Features== | ||
** | *Stab wounds | ||
* | **Usually affect heart if enter via the "cardiac box" | ||
** | ***Chest area bounded by sternal notch, xiphoid, and nipple | ||
* | *Gun shot wound can affect heart even if enters at distant site | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 26: | Line 17: | ||
==Evaluation== | ==Evaluation== | ||
===Workup=== | ===Workup=== | ||
[[File:PericardialeffusionUS.png|thumb|Pericardial fluid on ultrasound]] | |||
[[File:Pericardial effusion with tamponade (cropped).gif|thumb|Transthoracic echo of pericardial fluid showing "swinging heart"]] | |||
*[[FAST exam]] | *[[FAST exam]] | ||
**First view of FAST in penetrating injury should be pericardial | **First view of FAST in penetrating injury should be pericardial | ||
**Pericardial fluid detection (Sn 100%, Sp 97%) | **Pericardial fluid detection (Sn 100%, Sp 97%) | ||
***In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise | |||
***Differentiate pericardial effusion from pleural effusion using the parasternal long axis view. Pericardial effusions will have an anechoic stripe between the left atrium and descending thoracic aorta. In a pleural effusion, the stripe will be seen behind the descending thoracic aorta.<ref>Randazzo MR et al. Acad Emerg Med, 2003. PMID: 12957982</ref> | |||
*CTA | *CTA | ||
**Imaging study of choice for penetrating and blunt trauma | **Imaging study of choice for penetrating and blunt trauma | ||
==Management== | ==Management== | ||
*[[Thoracotomy]] | *[[Thoracotomy]] vs. [[pericardiocentesis]] | ||
===[[Cardiac tamponade]]=== | |||
*Most often results from stab wounds; up to 80% of myocardial stab wounds may develop cardiac tamponade | |||
*GSW less likely to develop into tamponade because it is more difficult for the pericardium to seal the defect (larger, more irregular in shape) <ref>Tintinalli's</ref> | |||
===Cardiac missiles=== | |||
*Those that cause BP instability, free or partially exposed should be removed | |||
*Most intramyocardial and intrapericadrial bullets can be left in place | |||
==Disposition== | ==Disposition== | ||
Latest revision as of 20:10, 17 August 2019
Background
- Ventricles are at greatest risk due to anterior location
- RV (involved in 40% of injuries)
- LV (involved in 35% of injuries)
- RA (involved in 20% of injuries)
- LA (involved in 5% of injuries)
Clinical Features
- Stab wounds
- Usually affect heart if enter via the "cardiac box"
- Chest area bounded by sternal notch, xiphoid, and nipple
- Usually affect heart if enter via the "cardiac box"
- Gun shot wound can affect heart even if enters at distant site
Differential Diagnosis
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Evaluation
Workup
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- FAST exam
- First view of FAST in penetrating injury should be pericardial
- Pericardial fluid detection (Sn 100%, Sp 97%)
- In acute cases, even a relatively small build up of pericardial fluid can lead to hemodynamic compromise
- Differentiate pericardial effusion from pleural effusion using the parasternal long axis view. Pericardial effusions will have an anechoic stripe between the left atrium and descending thoracic aorta. In a pleural effusion, the stripe will be seen behind the descending thoracic aorta.[1]
- CTA
- Imaging study of choice for penetrating and blunt trauma
Management
Cardiac tamponade
- Most often results from stab wounds; up to 80% of myocardial stab wounds may develop cardiac tamponade
- GSW less likely to develop into tamponade because it is more difficult for the pericardium to seal the defect (larger, more irregular in shape) [2]
Cardiac missiles
- Those that cause BP instability, free or partially exposed should be removed
- Most intramyocardial and intrapericadrial bullets can be left in place
Disposition
- Admit