Comprehensive Management of the Patient With Traumatic Cardiac Injury

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. (Anesth Analg 2023;136:877-93) GLOSSARY ACLS = advanced cardiac life support; ATLS = advanced trauma life support; BCI = blunt cardiac injury; BP = blood pressure; CK = creatine kinase; CO = cardiac output; CPB = cardiopulmonary bypass; CPK = creatine phosphokinase; CPR = cardiopulmonary resuscitation; CRASH = Clinical Randomisation of an Antifibrinolytic in Significant Hemorrhage; CXR = chest X-ray; DOR = direct to operating room; EAST = Eastern Association for trauma; ECG = electrocardiogram; ED = emergency department; EDT: ED thoracotomy; EPR = emergency preservation and resuscitation; EPR-CAT = EPR for cardiac arrest from trauma; Etco 2 = end-tidal carbon dioxide; ETT = endotracheal tube; FAST = focused assessment with sonography for t...