CHAPTER SUMMARY AND CENTRAL ILLUSTRATION
This chapter discusses the diagnosis and management of traumatic heart disease. Traumatic thoracic injuries contribute to 75% of trauma-related deaths. These injuries are primarily from gunshot wounds and motor vehicle accidents. Penetrating cardiac injuries, in particular, are associated with high mortality. The American Association for the Surgery of Trauma Organ Injury Scale-Cardiac Surgery (AAST-OIS-CI) provides a description of cardiac injuries, where the increasing grade of injury is associated with increasing mortality. Echocardiography has replaced pericardial window as the gold standard for diagnosing cardiac injury (Focused Assessment by Sonography in Trauma [FAST]) (see Fuster and Hurst’s Central Illustration). A left anterior thoracotomy in the emergency department is the approach of choice in hemodynamically unstable patients; stable patients are more appropriate for transport to the operating room for median sternotomy. The diagnosis of blunt cardiac injury is difficult. Electrocardiography may show nonspecific ST and T wave changes, and echocardiography may show regional wall motion abnormalities or structural defects. Management of these injuries is usually expectant. Long-term follow-up is required of significant cardiac injuries. Blunt aortic injury has a high death rate at the time of injury, but 70% of patients who survive to the hospital in stable condition can survive. Thoracic endovascular aortic repair has become the standard of care for treating blunt aortic injury.
eFig 79-01 Chapter 79: Traumatic Heart Disease
Trauma is the leading cause of death and disability among young people in the United States,1–4 and the third leading cause of death across all age groups, accounting for 20% of all deaths.5 Thoracic injuries account for 20% to 25% of deaths due to trauma, and contribute to 25% to 50% of the remaining deaths. Thus, thoracic injuries are a contributing factor in up to 75% of all trauma-related deaths.6
The two prinicipal causes of thoracic injuries are gunshot wounds and motor vehicle accidents.7,8 Cardiac injury is present in a significant proportion of thoracic injuries that lead to death. Causes of thoracic injuries to the heart and great vessels can both be broadly divided into penetrating or blunt mechanisms. According to an analysis from the Oklahoma Trauma Registry, the mortality of patients with cardiac injury in the setting of trauma has increased, correlating with an increase in penetrating trauma.5
The American Association for the Surgery of Trauma Organ Injury Scale: Cardiac Injury (AAST OIS-CI) describes cardiac injuries in six grades (Table 79–1).9 Asensio et al. correlated AAST-OIS for cardiac injuries with mortality rate; 94% of deaths occurred in grades IV–VI.10
TABLE 79–1.AAST Injury Scale: Cardiac Injuries9