Cardiovascular Trauma

Blunt cardiac injury, penetrating wounds, traumatic aortic disruption and commotio cordis: what to suspect from the mechanism before anything hurts.

CEN Content Outline, Cardiovascular Emergencies K. In cardiovascular trauma the mechanism tells you what to look for before the patient tells you anything.

Blunt Cardiac Injury

A direct blow to the sternum, or rapid deceleration. Steering wheel, handlebars, a fall, a horse. • Ranges from a bruised myocardium to rupture. • Presents with chest pain, dysrhythmias, or hypotension out of proportion to the visible injury. • The commonest finding is a dysrhythmia, most often sinus tachycardia, then atrial fibrillation, premature beats, or conduction blocks. • The right ventricle sits directly behind the sternum and is the chamber most often injured. What to do: 12-lead ECG and troponin. A normal ECG and normal troponin together largely exclude a clinically significant blunt cardiac injury. An abnormal ECG means continuous monitoring for at least 24 hours. Echo if there is haemodynamic instability.

Penetrating Cardiac Injury

Stab or gunshot wound in the "cardiac box" — roughly between the nipples, from the clavicles to the costal margins, and anything transmediastinal. • A stab wound to the heart most often tamponades. A gunshot wound more often exsanguinates. • A tamponading patient may look deceptively stable at first, then crash. • FAST exam, pericardial view. Large-bore access. Blood, not crystalloid. Activate massive transfusion. • Emergency thoracotomy is indicated for penetrating chest trauma with witnessed arrest or a patient who arrests in front of you. • Do not remove an impaled object. Stabilise it.

Traumatic Aortic Disruption

Rapid deceleration — a high-speed collision, a fall from height. The aorta tears where it is tethered, usually just distal to the left subclavian at the ligamentum arteriosum. • Most patients die at the scene. Those who arrive have a contained tear. • There may be no external sign of chest injury at all. • Suspect it from the mechanism, and from a widened mediastinum on the chest X-ray. • Other clues: a blood pressure difference between arms, upper extremity hypertension with diminished femoral pulses, a new murmur, back or interscapular pain, hoarseness. • CT angiography confirms it. Control the blood pressure and heart rate as for a dissection, and get surgery involved.

Commotio Cordis

A blunt blow to the chest at exactly the wrong moment of the cardiac cycle — during the vulnerable phase of repolarisation — throws the heart into ventricular fibrillation. There is no structural injury. • Typically a young athlete struck by a ball or a puck. • Collapse is immediate. • The treatment is prompt defibrillation and high-quality CPR. Nothing else fixes it, and outcomes depend almost entirely on how fast a defibrillator arrives.

Great Vessel and Other Injuries

Injury to the subclavian, innominate or pulmonary vessels causes massive haemothorax. Signs are decreased breath sounds, dullness to percussion, hypotension. A chest tube returning more than 1500 mL immediately, or more than 200 mL per hour for several hours, is an indication for thoracotomy.

Nursing Priorities

• Ask about the mechanism and take it seriously even when the patient looks well. Deceleration injuries hide. • Monitor continuously. The injury that kills after blunt cardiac trauma is usually a dysrhythmia. • Blood, not crystalloid, in haemorrhage. Warm it. Watch for the trauma triad of hypothermia, acidosis and coagulopathy. • Recheck the FAST. A pericardial view that was clear twenty minutes ago is not clear now. • Keep the thoracotomy tray and the rapid transfuser where they can be reached without leaving the room. Topic list from the CEN Examination Content Outline effective July 2026 (BCEN, public document). This chapter was written for this app as study material and is not from any BCEN course.

Cardiovascular Trauma