Cardiovascular Trauma

Definition/Etiology:

• Aortic injury is the second leading mechanism of death from blunt trauma (head trauma is first). Aortic trauma has 2% survival overall from blunt trauma.
• Innominate artery is the second most frequently injured great vessel and is commonly associated with seat belt sign and sternal fracture.
• Sudden deceleration can cause vessels to tear due to the relatively mobile heart within the thoracic cavity.
• High speed MVC, intrusion, steering wheel deformity, no seatbelt are all associated with major blunt thoracic injury.
• Cardiac contusion and/or tamponade can decrease SV and can develop late.

Pathophysiology:

• Research has shown that normal vital signs do not rule out aortic injury.
• Almost 80 percent of blunt aortic injuries (BAIs) cause immediate death from aortic transection. In a minority of patients, the adventitia and mediastinal structures contain the rupture, allowing the patient to survive transport to the hospital. If BAI goes undiagnosed, these patients generally sustain an aortic rupture within 24 hours.
• With cardiac contusion and tamponade, symptoms can develop late, and can be sneaky as swelling occurs and effusion grows

Clinical Presentation:

• Active hemorrhage
• Expanding or pulsatile hematoma
• Bruit or thrill over wound
• Absent distal pulses
• Extremity ischemia (pale, cool, painful, paralysis)
• Deformity
• Electrical alternans on 12-lead (cardiac tamponade)

Beck’s Triad (cardiac tamponade):

• Jugular venous distention
• Muffled heart tones
• Hypotension with narrow pulse pressure

Collaborative Management:

• CT angiogram chest
• Echocardiogram
• Thoracotomy/Sternotomy to explore and find bleed
• Chest tube (thoracostomy) to relieve hemo/pneumothorax
• eFAST ultrasound exam to look for tamponade and hemo/pneumothorax
• Pericardiocentesis for tamponade
• Massive transfusion protocol
• Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
• Labs: CBC, type and cross, CMP, lactic acid, coags
• 12-lead EKG

Evaluation | Patient Monitoring | Education:

• Frequent BPs.
• Continuous cardiac and SpO2 monitoring.
• Serial labs.

Linchpins: (Key Points)

• Assess rapidly
• Whole team is needed (surg, cards, ER)
• Get info from EMS re: MVC scene
• Some symptoms can develop late