Cardiac Trauma (Hits to the Chest and Heart)

What is Cardiac Trauma (Hits to the Chest and Heart)?

Injuries, or trauma, are a major cause of death and disability for all age groups, especially for individuals under 44. Heart injuries, or cardiac trauma, can occur in two ways: blunt (like a blow to the chest) or penetrating (like a stab wound). These injuries can be lethal, or they can cause heart rhythm issues that resolve on their own. Even with medical advancements, survival rates for traumatic cardiac arrest (a condition where the heart unexpectedly stops beating due to injury) are still very low, generally between 3.3% and 9.2%.

People with severe heart injuries often get worse quickly, to the point where some don’t even make it to the hospital. In fact, some studies show that more than 90% of these people die before arriving at a hospital. For those who do get to the hospital in time, the survival rate ranges from only 20% to 75%.

What Causes Cardiac Trauma (Hits to the Chest and Heart)?

Since the heart attack of NFL player Damar Hamlin was broadcasted live on national TV in January 2023, a heart condition called “commotio cordis” has been getting a lot of attention. This condition happens when a sudden and hard hit to the chest causes the heart to go into a dangerous and irregular rhythm (known as ventricular fibrillation or ventricular tachycardia).

This kind of heart injury can happen in a few ways, such as a direct hit to the chest, sudden slowing down from high speed, pressure on the chest, or a combination of these. The most common cause is car accidents, but it can also happen from things like falls, being crushed, or even unexpected incidents during sports (like a baseball hitting the chest) or from animals (like a kick).

Another type of injury, called penetrating cardiac trauma, is one of the deadliest types of chest injuries. You can expect to see death rates ranging from around 16% to 43%, and that’s even with the best possible care. This type of injury can cause death by bleeding, a condition where fluid builds up around the heart and prevents it from pumping properly (called cardiac tamponade), or heart failure. The ones with cardiac tamponade have an early but critical chance for survival. The most important aspect for anyone with this injury is getting immediate help, with treatment usually involving draining blood from around the heart and fixing the heart injury with surgery.

Risk Factors and Frequency for Cardiac Trauma (Hits to the Chest and Heart)

Blunt Cardiac Injury (BCI) can happen to anyone. However, it is most frequently seen in males, with an average age in the 30s. Children who experience BCI are also typically boys, with an average age of 7, and this often results from car accidents. People with blunt injuries to the chest can have heart irregularities in nearly 30% of cases. Initial heart scans and studies carried out with animals suggest that irregular heart rhythms like ventricular fibrillation and tachycardia are the most common.

• Blunt Cardiac Injury can happen to anyone, but usually affects males in their 30s.
• In cases of BCI in children, the patient is most often a boy around 7 years old, often resulting from car accidents.
• Irregularities in the heart’s rhythm occur in almost 30% of people with blunt chest injuries.
• Based on initial heart scans and animal studies, ventricular fibrillation and tachycardia (rapid heart rhythms) are the most common conditions found in these patients.

On the other hand, anyone, regardless of age or gender, can suffer a penetrating cardiac injury. Yet, these kinds of heart injuries are most prevalent in males and individuals in their 30s or 40s. The right ventricle of the heart is the area most often affected, followed by the left ventricle, while cases involving multiple chambers of the heart or the atria are rarest.

• Penetrating cardiac injuries can occur in anyone, of any gender or age.
• Such injuries are most likely to happen in males in their 30s or 40s.
• The right ventricle of the heart is most commonly hurt in these cases, followed by the left ventricle.
• Damage to the atria or to many chambers of the heart at once is least common.

Signs and Symptoms of Cardiac Trauma (Hits to the Chest and Heart)

When a person experiences a heart injury, they usually describe an event that caused chest or back damage. However, some people might provide unclear or conflicting stories due to the potential legal concerns or confusion. In some cases, the patient may be unconscious or without a pulse, and the only available information may come from the first responders.

When doctors examine a patient who may have experienced heart trauma, they typically follow a procedure called the Advanced Trauma Life Support (ATLS). Initially, doctors check the blood circulation and the basic functioning of the heart, culminating in a quick check of vital signs and confirmation that the patient’s airway and breathing are not compromised. The doctors will also inspect for visible chest wounds and listen for any unusual heart sounds. They will check the patient’s pulse and make sure it’s strong and consistent.

After the initial survey is done, a more detailed examination follows, in which doctors look for signs that could suggest a heart injury. This may include an examination for swollen veins in the neck and signs indicating trauma to the patient’s rear and side areas. While a patient might appear stable and show few signs of heart injury, doctors pay attention to signs like low blood pressure, fast heart rate, irregular heart rhythms, visible physical injuries, swollen neck veins, muffled heart sounds, and other signs of shock.

• Low blood pressure
• Fast heartbeat
• Abnormal heart rhythms
• Visible physical injuries
• Swollen neck veins
• Muffled heart sounds
• Other signs of shock

Testing for Cardiac Trauma (Hits to the Chest and Heart)

In assessing potential heart damage after an injury, doctors will perform a thorough examination that typically involves chest x-rays and a type of ultrasound called POCUS. Chest x-rays can help understand non-heart related chest injuries and can provide a rough idea of bullet or shrapnel location in cases of resultant heart damage from penetrative injuries, but they are not very useful for pinpointing heart injuries on their own.

POCUS, an ultrasound method commonly used in emergency departments, is a quicker way to diagnose fluid around the heart. The standard POCUS procedure checks four main regions: the covering around the heart, the upper right and left sections of the abdomen, and the pelvis. An extended version of POCUS also examines the chest space for possible blood or air collection.

To detect fluid build-up around the heart, doctors can combine physical symptoms like bulging neck veins and abnormal checkup results with POCUS. For instance, certain patterns including swollen lower heart chambers and a moving heart wall can be seen on POCUS. More detailed heart scans may be needed if the POCUS results are not clear, or if the patient’s condition is stable. In such cases, a more advanced ultrasound technique known as transesophageal echocardiography (TEE) might be beneficial.

A computerized tomography (CT) scan is also a helpful part of the injury assessment process in stable patients. It’s particularly good at spotting heart or tissue tears, dislocated hearts, and other chest injuries. Plus, it can help trace the path of a penetrating object and location of foreign bodies in the body.

Detecting heart injuries caused by a forceful blow is hard, as there is no established set of criteria to confirm such damage. One beneficial tool in this process is an ECG. This device, while not standard in injury assessments, can help reveal new heart rhythms, which may indicate trauma at the heart, excluding rapid heart rate. The concentration of certain enzymes in the body, like heart-specific troponins, is another potential sign of the presence of a heart injury.

Any individual with a puncture wound to the chest area should be evaluated for a possible penetrating heart injury, especially if the wound is located within the imaginary box bordered by the lower ends of the collarbone, the lower edges of the rib cage, and the mid-collarbone lines. Echocardiography, an ultrasound of the heart, is highly accurate and precise in identifying heart wounds. Sometimes, further evaluation, like chest x-rays to locate and identify foreign objects, may be necessary.

Treatment Options for Cardiac Trauma (Hits to the Chest and Heart)

The first step in treating patients with heart injuries caused by trauma is to follow the ATLS (Advanced Trauma Life Support) protocol. This protocol includes securing the patient’s airway and breathing, and protecting their cervical spine. The patient’s subsequent treatment should be based on whether the heart trauma was blunt or penetrating.

Blunt Cardiac Injury (BCI) can manifest in different ways including heart rhythm problems, heart muscle injuries, ruptures, damage to the heart valves, and injuries to the coronary artery. Heart rhythm issues can range from severe conditions like nonperfusing ventricular fibrillation, a condition where the heart quivers instead of pumping blood, to less severe conditions like stable first-degree atrioventricular blocks, a mild heart block where the electrical signal between the upper and lower chambers of the heart is slowed.

Patients with these conditions should be provided with Advanced Cardiovascular Life Support (ACLS), ensuring that other injuries or possible causes of the heart rhythm issue are explored. A new heart rhythm issue should warrant further heart monitoring and possibly an echocardiogram, a procedure that uses sound waves to produce images of the heart. If patients have heart rhythm issues originating from the upper chambers or atria of the heart, recommended treatments include beta or calcium channel blocker medications for stable patients. It may also be possible to use electrical cardioversion, a procedure that uses electricity to reset the heart rhythm, for unstable patients where the heart rhythm issue is the cause of the instability.

Heart muscle injuries can present themselves through electrical disturbances or a raised troponin, a protein that is elevated in the blood after a heart attack. The treatment is supportive and based on the severity of other findings. The evaluation of these patients is similar to those who have had heart attacks. For severe injuries where the heart has ruptured, surgery is usually necessary and may involve employing a heart-lung machine. Damage to the heart valves may also require repair, and in certain cases, such as a torn papillary muscle (muscles located in the ventricles of the heart), it might be necessary to replace the valve.

If there is a cut or bleeding in the coronary artery (the main blood vessels that supply the heart with blood), the recommended treatment is surgery to control the bleeding and possibly a coronary bypass surgery. Should there be suspected injuries that are not bleeding significantly, an angiogram (a type of X-ray used to check the blood vessels) may be conducted and the treatment can be determined based on the findings. Other temporary methods to close a heart wound might include using a type of catheter called a Foley, sutures, or staples. However, only the Foley catheter allows for quick transfusion of blood while also closing the wound. These temporary measures can prevent severe blood loss while waiting for definitive repair.

For penetrating heart injuries, surgery is typically required. An unstable patient can be temporarily stabilized by draining fluid from the sac that surrounds the heart (pericardiocentesis) with a catheter. The heart is accessed using a sternotomy (incision through the middle of the chest) or thoracotomy (incision into the chest wall) to perform a pericardiotomy (creating an opening in the sac around the heart) while avoiding the phrenic nerve. It’s important for surgeons to use care when repairing the wound, by ensuring reliable suturing to prevent tearing tissue, placing sutures during the heart’s contraction phase to avoid tearing the heart muscles, and avoiding the coronary arteries while repairing the wound. Wounds at the rear part of the heart require special caution to repair since lifting the heart for greater visibility can cause low blood pressure and potentially a cardiac arrest.

What else can Cardiac Trauma (Hits to the Chest and Heart) be?

Doctors need to consider various possible conditions when assessing a patient with heart trauma. These conditions include:

• Cardiac tamponade, a serious condition in which the heart is compressed by too much fluid around it.
• Cardiogenic pulmonary edema, a condition where the heart is not able to pump effectively, leading to fluid build-up in the lungs.
• Cardiogenic shock, which happens when your heart suddenly can’t pump enough blood to meet your body’s needs.
• Hemorrhagic shock, a severe type of shock which occurs when you lose more than one fifth of your blood or fluid supply.
• Mitral regurgitation, which is a condition where the mitral valve in the heart doesn’t close properly, causing blood to flow back into the heart.
• Right ventricular infarction, a type of heart attack that affects the right side of your heart.

It’s crucial for doctors to accurately consider these possibilities when examining a patient and carry out necessary tests to give a correct diagnosis.

What to expect with Cardiac Trauma (Hits to the Chest and Heart)

The way we manage penetrating heart injuries has significantly improved in recent times, which has greatly influenced the recovery of patients. Instead of merely relying on simple clinical observations, we now utilize various diagnostic tests like the FAST examination, chest ultrasound, and CT scans. Together, these changes have significantly improved the survival rate for patients with penetrating heart injuries.

Despite these advances, it’s important to note that penetrating heart injuries are still serious. In fact, the death rate from such injuries remains around 40%.

Possible Complications When Diagnosed with Cardiac Trauma (Hits to the Chest and Heart)

Cardiac trauma, or damage to the heart, can lead to several complications, such as:

• Excess fluid around the heart (Pericardial effusion)
• Unusual movement of the heart’s wall (Abnormal wall motion)
• Reduced amount of blood pumped out by the heart (Decreased ejection fraction)
• Blood clots within the heart wall (Intramural thrombus)
• Injury to the heart valves (Valve injury)
• Enlarged size of the heart (Cardiac enlargement)
• Irregular heart rhythm (Conduction abnormality)
• Fake bulge in the artery or heart wall (Pseudoaneurysm)
• Actual bulge in the artery or heart wall (Aneurysm)
• Holes in the wall separating the heart’s chambers (Septal defect)

Recovery from Cardiac Trauma (Hits to the Chest and Heart)

Instructions for quick rehabilitation after treatment of people with heart trauma are often not followed closely. This is particularly true when it comes to early evaluations by physical therapy and rehabilitation experts, and the direct transfer of patients with serious injuries from urgent care to recovery. This lack of optimal post-therapy care emphasizes the need for a more organized inclusion of rehabilitation therapy into immediate treatment plans for patients with serious injuries.

Preventing Cardiac Trauma (Hits to the Chest and Heart)

Teaching patients about how to prevent heart injuries is key to lowering the chances of these injuries happening and for improving recovery if they do. It’s important to let patients know about the risks and ways to prevent them, especially as injuries remain a leading cause of death and disability for all ages, and have a big effect on kids and young adults. Patients should be taught how important it is to use safety measures, like wearing seat belts, using safety gear in sports, and following rules for safety at work.

Public awareness campaigns can warn about the dangers of risky behavior, like driving under the influence or engaging in violent activities, which are big contributors to heart injuries. For those at higher risk, like people in contact sports or jobs with high physical impact, special education can even further lower the chances of heart injuries. It’s also crucial to stress the importance of getting medical help right away if they have serious chest injuries, as they can get worse quickly.

Patients should be told about signs of heart injuries, such as chest pain, difficulty breathing, and irregular heartbeats, and know to get medical help promptly. Doctors can also teach patients about the good things that come from having regular checks with them and getting early treatment, which can improve the recovery from heart injuries. Strategies to prevent injuries, like using advanced safety gear and following safety rules, are key in lessening the risk and severity of heart injuries.

By helping patients have a full understanding of prevention and early detection, doctors can give them the power to protect themselves from heart injuries. This approach not only protects individual patients better but also helps the general community by reducing the damage and deaths caused by injuries.