Author + information
- aCardiovascular Imaging Research Laboratory, Institute of Cardiology–University Foundation of Cardiology, Porto Alegre, Brazil
- bDiscipline of Emergency and Trauma of the Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
- ↵∗Address for correspondence:
Dr. Marcelo Haertel Miglioranza, Cardiovascular Imaging Research Laboratory, Institute of Cardiology–University Foundation of Cardiology, Av. Princesa Isabel, 370, Porto Alegre/RS, CEP 90620-000, Brazil.
Chest trauma proves challenging in terms of diagnosis and management. Potentially complex injuries may go unnoticed due to the subtlety of clinical findings, especially in extreme settings and environments. Due to the potential presence of multiple associated traumas and frequent respiratory failure and hemodynamic instability, recognition and management of the lesions must be rapid and often focused on damage control to ensure patient survival. Not infrequently, these patients require specialized evaluation and management for the treatment of injuries.
The case presented by Karagodin et al. (1) in this issue of JACC: Case Reports is an excellent example of how focused cardiovascular ultrasound and, subsequently, three-dimensional echocardiography were decisive in patient care and the resolution of cardiac injuries. From the present case we can learn some valuable lessons: 1) a focused ultrasound examination should be part of the initial assessment of every patient with chest trauma; 2) after initial management, a complete echocardiographic examination is strongly recommended to exclude injuries that might have gone unnoticed; 3) in the presence of traumatic anatomic injuries, the 3-dimensional echocardiogram has an essential role in the decision-making process; and 4) percutaneous interventions are also a feasible alternative in trauma patients.
Currently, the initial assessment of the patient with suspected chest trauma consists of information about the event and the assessment of the B (ABC of the trauma), complemented by a simple chest radiograph searching for thoracic wall, pleuropulmonary, cardiac, and aortic abnormalities. The diagnosis of the thoracic injury and the treatment planning often depend on complementing the diagnosis with the use of focused ultrasound or computed tomography imaging. According to the Advanced Trauma Life Support Program guideline, eFAST (extended focused assessment with sonography for trauma) is usually performed in the primary examination, during the assessment of circulation and bleeding control (letter “C” of the ABC of trauma). It starts with a subxiphoid view to exclude the presence of cardiac tamponade and gross heart injuries, considered to be the most life-threatening lesions (Figure 1).
The diagnosis of cardiac trauma is usually not easy, and ultrasound evaluation, through the eFAST, is the method of choice to provide initial information about the presence of pericardial effusion (sensitivity of 100% and specificity of 97%) and gross changes in the function and structure of the heart (2). Subsequently, a comprehensive transthoracic echocardiogram (TTE) should be performed in all patients with blunt chest trauma or refractory shock without a clear etiology, with the goal of identifying changes that may require immediate intervention (3–6).
In penetrating chest trauma, physical examination alone is not sufficient for the detection and evaluation of the extent of the cardiac injury. The size, shape, and direction of the entrance of the object give an approximate idea of the potential lesions. Lesions located in the precordial topography (cardiac box) should raise awareness of a possible cardiac injury (Figure 1). In these cases, TTE must be used to rule out cardiac involvement (7–10). Due to the concomitance of associated thoracic injuries, the TTE may present suboptimal images due to an unfavorable acoustic window and, therefore, a transesophageal approach may be necessary. A prospective study showed that the transesophageal echocardiogram is superior to the transthoracic modality for investigating persistent hemodynamic instability or trauma-related cardiac injuries, providing excellent quality images in 98% of cases compared with 60% by using the transthoracic approach (6). Moreover, multiple serious injuries, including wall and valvular ruptures, were often not visible on TTE.
In the case by Karagodin et al. (1), echocardiography was an essential tool in diagnosing the presence of the ventricular septal defect, as well as in categorizing the morphology, type, location, and degree of severity. As a final message, it is essential to notice that the complementary 3-dimensional evaluation was the cherry on top. Throughout multiple cropping reconstructions, it allowed a precise recognition of the intact surrounding myocardium and anatomic structures for the percutaneous closure planning and guidance.
↵∗ Editorials published in JACC: Case Reports reflect the views of the authors and do not necessarily represent the views of JACC: Case Reports or the American College of Cardiology.
Dr. Miglioranza has received a post-graduate grant from CAPES, Brazilian governmental agency for post-graduate support; and has received a research grant from CNPq, the Brazilian governmental agency for research support and from FAPERGS, Rio Grande do Sul State governmental agency for research support. Dr. Crespo has reported that he has no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reports author instructions page.
- 2020 The Authors
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