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Cardiac Trauma and Cardiac Tamponade - 2 Nursing CEs Author: Kristi Hudson RN MSN CCRN Course Description: This

course is designed to investigate the care and management of the patient who suffers from acute cardiac trauma and cardiac tamponade. Focus will be placed on etiology, pathophysiology, clinical presentation and collaborative plan of care for both blunt and penetrating cardiac trauma (including nursing diagnosis). Etiology, pathophysiology, clinical presentation and collaborative plan of care for the patient who develops cardiac tamponade secondary to blunt/penetrating cardiac trauma will be the final focus of this course. Course Objectives:

Auto vs. pedestrian injuries Being kicked by a large animal (horse for example) Being assaulted with a blunt instrument Industrial crushing injuries (explosions for example) Rigorous cardiopulmonary resuscitation

Pathophysiology of Blunt Cardiac Trauma: Blunt cardiac trauma causes bruising and often bleeding into the myocardium which in turn causes the red blood cells to extravasate around the myocardial fibers. These fibers then become edematous and fragmented. The right ventricle is usually the site of injury because it rests directly under the sternum. When the right ventricle becomes injured; right ventricular contractility decreases which causes the following cascade of events occurs:

Upon completion of this course the student will be able to: Describe the etiology of both blunt and penetrating cardiac trauma State the clinical manifestations of the patient who presents with blunt and penetrating cardiac trauma Explain the pathophysiology of the both blunt and penetrating cardiac trauma Discuss the collaborative plan of care for both blunt and penetrating cardiac trauma Define and describe the pathophysiology of cardiac tamponade Outline the collaborative plan of care for the patient with cardiac tamponade

Increased right ventricular volume. Decreased right ventricular ejection fraction. A shift of the intraventricular septum towards the left ventricle. Left ventricle loses compliance. Increased pulmonary resistance and increased afterload (both increase the workload of the already injured heart). Damage to the valves can ultimately occur due to high pressure within the ventricles.

Definition of Blunt Cardiac Trauma: Blunt cardiac trauma is defined as a blunt trauma injury to the chest/heart that causes either ecchymosis or petechiae to develop on the myocardium (heart muscle). Etiology of Blunt Cardiac Trauma: Blunt cardiac trauma is most often caused an acceleration/deceleration injury that is sustained during a motor vehicle collision (MVC). Usual mechanism of injury is either the seat belt or from striking an object inside the vehicle (usually the steering wheel or dashboard). Other common mechanisms for sustaining a blunt cardiac trauma include:

Clinical Manifestations of Blunt Cardiac Trauma: Clinical presentation varies with the degree of injury but the following are common subjective and objective findings in patients with blunt cardiac trauma:

Pericardial angina like chest pain (greater on inspiration, cough and movement). Chest pain unrelieved by Nitroglycerin (responsive to 02 and anti-inflammatory medication). Sternal tenderness Shortness of breath Palpitations Abdominal pain Tachycardia

Evidence of RV failure (jugular vein distention, peripheral edema). Ecchymosis at site of anterior chest

Possible Complications of Blunt Cardiac Trauma Include: Cardiac rupture Air embolus traumatic aortic injury Cardiac tamponade (discussed later) Heart failure Tracheal tear Pneumothorax Hemothorax Pulmonary contusion Acute Respiratory Distress Syndrome (ARDS) Rib fractures Flail chest Sternal fractures Esophageal injuries

Altered tissue perfusion (cerebral, cardiac or peripheral) Impaired gas exchange secondary to pulmonary edema Activity intolerance Pain Knowledge deficit

Definition of Penetrating Cardiac Trauma: Penetrating Cardiac Trauma is defined as anything that causes the myocardium to sustain a puncture wound from a sharp object. Etiology of Penetrating Cardiac Trauma: Any of the following can be the cause of a penetrating cardiac trauma:

Collaborative Plan of Care for Patient with Blunt Cardiac Trauma: Priority number one for the patient with blunt cardiac trauma is to assure that the patient is receiving adequate oxygenation and in doing so to make sure that myocardial oxygen tissue demands are at a minimum. This can be accomplished by all of the following interventions:

Fractures (rib most commonly) Force inflicted injuries (knife, gunshot, ice pick) Industrial injury (usually falling on a sharp object) Motor vehicle collision that causes some sort of impalement Sports injuries Crushing injuries

Bed rest Supplemental Oxygen Maintain SaO2 greater the 95% Sedatives and pain medication as necessary If tolerable it is preferred to use antiinflammatory medication before narcotics to avoid respiratory complications.

Pathophysiology of Penetrating Cardiac Trauma: Penetrating cardiac trauma usually afflicts the right ventricle and causes cardiac contusions and or myocardium lacerations. Blood leaks into the pericardium or into the mediastinum which leads to cardiac tamponade or cardiogenic shock. Clinical Presentation for the Patient with a Penetrating Cardiac Trauma: As with blunt cardiac trauma clinical manifestations of penetrating cardiac trauma vary with the degree of injury, but most commonly patients present with the following subjective and/or objective findings:

Nursing Diagnosis for the Patient with Blunt Cardiac Trauma: Decreased cardiac output related to heart failure Potential for cardiac tamponade secondary to bleeding Complaints of chest pain (depending on level of consciousness) A visual wound Visual bleeding Hypotension Hypoperfusion-tachycardia Narrowed pulse pressure

Tachypnea Cool and clammy skin Oliguria Restlessness/Anxiety/Agitation Decreased right atrial pressure Decreased pulmonary artery pressure (PAWP)

Possible Complications with Penetrating Cardiac Trauma:

Decreased cardiac output secondary to decreased contractility or hypovolemia Fluid volume deficit secondary to hemorrhage Impaired gas exchange Activity intolerance Risk of infection related to foreign body Pain Anxiety Knowledge Deficit

Hemorrhagic shock Pulmonary Embolism Cardiogenic Shock Pneumothorax Hemothorax Cardiac Tamponade

Definition of Cardiac Tamponade: Cardiac tamponade is defined as the accumulation of blood, effusion fluid and or pus into the pericardial space. This fluid accumulation compromises cardiac filling and cardiac output as a result of increasing pressure on the myocardium. Etiology for Cardiac Tamponade: Any of the following can be considered to be causes of acute or chronic cardiac tamponade:

Collaborative Plan of Care for the Patient with a Penetrating Cardiac Trauma: Initial management should be aimed at avoiding or managing cardiopulmonary arrest. Other interventions include:

Control hemorrhage (apply direct pressure if bleeding from the wound). DO NOT REMOVE the impaled object (controlled surgical intervention will be required). Stabilize impaled object with IV bags and dressings Chest tube for hemothorax or pneumothorax will more then likely be required. Pericardiocentesis for cardiac tamponade Improve oxygen delivery with supplemental O2 (patient will likely require intubation). Keep SaO2 greater the 95% Insert at least 2 large bore IVs for fluid resuscitation Type and cross match for blood transfusion Prepare patient for surgical intervention (thoracotomy)

Blunt or penetrating trauma Pericarditis Cardiac rupture Post CPR Rupture of the great vessels Electrical cardioversion Malignancy Radiation therapy Connective tissue disease Metabolic disorders Renal failure Hepatic failure Infections (viral, bacterial or fungal) Drugs (Procainamide, Methyldopa, Hydralazine for example) Post op mediastinal chest tube occlusion or removal Invasive catheters Cardiac needle biopsy

Nursing Diagnosis for the Patient with Penetrating Cardiac Trauma:

Pathophysiology of Cardiac Tamponade: The accumulation of blood or fluid into the pericardial space (as little as 100ml) can cause cardiac tamponade. As pressure in the pericardium increases the following occurs within the heart:

When pericardial pressures equal atrial and ventricular pressures a fall in transmural cardiac pressure occurs. This leads to the inability of the heart to pump and fill. End-diastolic pressure then decreases. When end-diastolic pressure decreases so does cardiac contractility. This causes a decrease in cardiac output and stroke volume and ultimately leads to shock.

Place patient in semi-Fowlers position ECG pads should be placed on limbs and away from the chest wall if possible Monitoring of ST-segment elevation is required and will be seen when the needle touches the epicardium. Pain medication and sedation should be given when possible. Monitoring for other complications (pneumothorax, cardiac rupture or cardiac laceration).

Clinical Presentation of the Patient with Cardiac Tamponade: The following are all common subjective and objective clinical manifestations surrounding cardiac tamponade:

Nursing Diagnosis for the Patient with Cardiac Tamponade:

Complaints of pericardial fullness Complaints regarding feelings of doom Pain Dyspnea Tachycardia Pulseless Electrical Activity (PEA) in severe cases Becks Triad (hypotension, distended neck veins and muffled heart sounds) Increased right atrial pressure Increased Pulmonary artery diastolic pressure Decreased cardiac output and cardiac index

Decreased cardiac output secondary to decreased contractility or hypovolemia Fluid volume deficit secondary to hemorrhage Pain Anxiety Knowledge Deficit

Collaborative Plan of Care for the Patient with Cardiac Tamponade: First priority is to maintain airway, ventilation oxygen and perfusion. Other interventions include:

Intubation and mechanical ventilation (in most cases) Replacement of circulating volume (Normal Saline or Albumin) Inotropes as necessary

Pericardiocentesis: Performing a Pericardiocentesis is often a life saving measure for the patient who has developed cardiac tamponade. If Pericardiocentesis is required, the nurse can assist with the following preparations: