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Comprehensive Management of the Patient With Traumatic Cardiac Injury
Babita Gupta1, Yudhyavir Singh1, Dinesh Bagaria2
1From the Department of Anaesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India.
Insights
Cardiac trauma is life-threatening, with high mortality. Prompt recognition, rapid transport, and multidisciplinary care, including anesthesiologists, are crucial for improving outcomes in cardiac injury patients.
Area of Science:
- Trauma Surgery
- Cardiovascular Medicine
- Anesthesiology
Background:
- Cardiac injuries, though rare, present significant mortality risks, both pre-hospital and in-hospital.
- Penetrating cardiac trauma often results from assaults, while blunt cardiac trauma is commonly associated with accidents.
- Existing trauma care protocols, like Advanced Trauma Life Support (ATLS), require continuous updates to address these critical injuries.
Approach:
- Emphasizes rapid transport to trauma centers and prompt diagnosis using clinical evaluation and Focused Assessment with Sonography for Trauma (FAST).
- Highlights the critical role of timely interventions such as emergency department thoracotomy and operative management for cardiac tamponade or hemorrhage.
- Discusses the necessity of continuous cardiac monitoring and anesthetic care for blunt cardiac injuries involving arrhythmias or myocardial dysfunction.
Key Points:
- Successful outcomes in cardiac injury hinge on swift decision-making, operative intervention, and ongoing resuscitation.
- A multidisciplinary approach with clear protocols and shared goals is essential for managing these complex cases.
- Anesthesiologists play a vital role throughout the trauma pathway, from pre-hospital systems to perioperative care and training.
Conclusions:
- There is a need for comprehensive literature on the anesthetic management of both penetrating and blunt cardiac injuries.
- This review provides insights into cardiac injury management, focusing on anesthetic concerns, based on experience at a major trauma center.
- Effective management necessitates a coordinated effort involving pre-hospital care, emergency department interventions, and surgical/anesthetic expertise.
Abstract:
Cardiac injuries are rare but potentially life-threatening, with a significant proportion of victims dying before arrival at the hospital. The in-hospital mortality among patients who arrive in-hospital alive also remains significantly high, despite major advancements in trauma care including the continuous updating of the Advanced Trauma Life Support (ATLS) program. Stab and gunshot wounds due to assault or self-inflicted injuries are the common causes of penetrating cardiac injuries, while motor vehicular accidents and fall from height are attributable causes of blunt cardiac injury. Rapid transport of victim to trauma care facility, prompt recognition of cardiac trauma by clinical evaluation and focused assessment with sonography for trauma (FAST) examination, quick decision-making to perform emergency department thoracotomy, and/or shifting the patient expeditiously to the operating room for operative intervention with ongoing resuscitation are the key components for a successful outcome in cardiac injury victims with cardiac tamponade or exsanguinating hemorrhage. Blunt cardiac injury with arrhythmias, myocardial dysfunction, or cardiac failure may need continuous cardiac monitoring or anesthetic care for operative procedure of other associated injuries. This mandates a multidisciplinary approach working in concert with agreed local protocols and shared goals. An anesthesiologist has a pivotal role to play as a team leader or member in the trauma pathway of severely injured patients. They are not only involved in in-hospital care as a perioperative physician but also participate in the organizational aspects of prehospital trauma systems and training of prehospital care providers/paramedics. There is sparse literature available on the anesthetic management of cardiac injury (penetrating as well as blunt) patients. This narrative review discusses the comprehensive management of cardiac injury patients, focusing on the anesthetic concerns and is guided by our experience in managing cardiac injury cases at Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences, New Delhi. JPNATC is the only level 1 trauma center in north India, providing services to a population of approximately 30 million with around 9000 operations being performed annually.
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