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Summary

This chapter discusses traumatic injury to the heart and the great vessels. Thoracic injuries are a contributing factor in up to 75% of all trauma-related deaths. Causes of traumatic cardiovascular injury can be broadly classified into having arisen from penetrating or blunt mechanisms (see accompanying Hurst’s Central Illustration). Penetrating injuries to the heart and great vessels are associated with high mortality; early diagnosis is critical for survival and penetrating cardiovascular injuries should therefore be suspected with any missile or knife wound to the thorax or upper abdomen. Repair is often performed through a left thoracotomy in the emergency department. If patients with a penetrating heart injury are sufficiently stable, a median sternotomy in the operating room is preferred. Blunt injury requires significant force, such as occurs in motor vehicle crashes or falls from heights. Diagnosis of blunt trauma to the heart can be difficult, because a majority of patients are asymptomatic. In cases of blunt heart injury with severe ventricular dysfunction and low cardiac output, inotropic support is appropriate and, if no satisfactory improvement occurs, intra-aortic balloon counterpulsation should be considered. Emergency surgical intervention via sternotomy is mandatory for pericardial rupture. Management options for blunt trauma to the great vessels include immediate repair through a left thoracotomy, delayed repair in multiply injured patients requiring ongoing resuscitation, or endovascular stent graft insertion in selected patients.

eFig 104-01

Traumatic cardiovascular injury

Traumatic cardiovascular injury can occur through penetrating or blunt mechanisms. CT, computed tomography; ECG, electrocardiography; MRI, magnetic resonance imaging.

INTRODUCTION

Trauma is the leading cause of death and disability among young people in the United States.1,2,3 Thoracic injures account for 20% to 25% of deaths from trauma, and contribute to 25% to 50% of the remaining deaths. Thus, thoracic injures are a contributing factor in up to 75% of all trauma-related deaths.4 Cardiac and great vessel injuries are common contributors to the morbidity and mortality of severely injured patients.5 Causes of injury to the heart and thoracic aorta can be broadly divided into penetrating or blunt mechanisms.

CARDIAC INJURY

Penetrating Cardiac Injuries

Penetrating injury to the heart must be suspected with any missile or knife wound to the thorax or upper abdomen. The mechanism of injury may be categorized as low, medium, or high velocity. Knife wounds are low velocity, shotgun injuries are medium velocity, and high-velocity injuries include bullet wounds caused by rifles and wounds resulting from military and civilian weapons. The amount of tissue damage is directly related to the amount of energy exchange between the penetrating object and the body part.4

Traumatic cardiac penetration injuries are highly lethal, at 70% to 80%. The anteriorly positioned right ventricle is most frequently injured, followed by the left ventricle, right atrium, and ...

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