Trauma Induced Dysrhythmias

[seekersofthetruth]

I'm trying to get everyone's takes on treatment of Blunt Trauma Induced Cardiac Dysrhythmias. To treat or not to treat? Lets say the pt is in V-tach with a pulse following blunt chest trauma. Suspect SA and AV nodal damage?

 

[Smash]

Suspect commotio cordis, treat as per your usual VF algorithm. It's the only "trauma" arrest where ACLS might be of use. In fact I would say that ACLS should be contraindicated in traumatic arrests (except this)

If you don't get get return to a perfusing rhythm, and depending on the circumstances, look for your usual suspects in trauma arrest, and if that fails, call it.

 

[Smash]

Sorry, I misread your post. I would be very surprised to see conscious VT as a result of blunt trauma to to chest. Not saying it can't happen, just that I don't think it would be common. Most arrhythmias following blunt trauma to the chest will be brady-asystolic PEA. In the setting of commotio cordis it's usually VF.

 

[Hockey]

Common is vf following lets say a baseball to the chest. That is very common and has pretty good success rates I BELIEVE on recovery

 

[Veneficus]

If life was simple...

Trauma patients are not a collection of individual pathologies to attempt treatment in.

As I have mentioned before, multisystem trauma can be some of the most complex medical cases found.

If you have a patient in an arrhythmia, you must first determine why if you want your treatments to help.

In the case of trauma, the most likely cause of an arrhythmia is hypovolemia. If the shock state has progressed to the failure of myocardial oxygenation, it is very late in the game. If you defib this, you might get a nice rythm for a few minutes and it will likely revert or you might convert it directly to asystole. I wouldn't try to play that game unless I had some very specific information that might make it a better decision.

In the event of commotio cordis, which is very rare, as I saw stats with 2-3 cases a year in the US. That in an almost impossible incidence, but is helped with early defibrilation.

Other direct blows to the chest can result in both pulmonary and cardiac contusions. Which wil not be helped by an ACLS algorythm, and can likely be made worse. The treatment for pneumothorax is not ACLS.

For the most part, once you progress to arrest from blunt trauma there is basically nothing to be done. From penetrating you need blood, a surgeon, and a very skilled critical care doc of some sort. Even then, there are some very long odds.

Considering in a shock state the kidneys and brain are usually lost prior to the heart, all of which is lost from lack of blood usually in trauma, the needed treatments are to reduce the loss of and replacement of blood.

Defibrillators and medications designed around heart dysfunction from age related pathology doesn't really affect what is causing the problem.

As for Vtach with a pulse in trauma, best to leave that alone and let the folks at the trauma center ED sort it out.

 

[TomB]

The main point is to leave the antiarrhythmics in the drug box.

 

[18G]

I know there are many different opinions on the treatment of PVC's of an Atraumatic etiology but I have to ask what the opinion is of treating frequent PVC's in a patient with evidence of blunt chest trauma. Say for example, pt. has probable myocardial contusion resulting in very frequent PVC's.

Do we leave these PVC's alone or treat them? What is the risk of not treating PVC's in this scenario? Can the contusion continue to increase in size making the heart more irritable with time? What if ST-T wave abnormalities are also present?

 

[Smash]

I wasn't aware that there were different opinions regarding treatment of PVCs at all. Certainly if they are showing up from an injury significant enough to cause cardiac contusion I would not be giving them any pro-arrythmics. We aren't going to be addressing any underlying pathology, only adding more nastiness to the mix.

 

[18G]

I wasn't aware that there were different opinions regarding treatment of PVCs at all.

Um... yeah there are plenty of differing opinions on treating PVC's. Some claim it's beneficial to treat malignant PVC's as many EMS system protocols take this side, and there are others who advocate not to treat PVC's.

 

[Smash]

Empirical treatment of PVCs was certainly all the rage in the 1980s, but studies showing no benefit, and in some cases, harm meant that the practice fortunately disappeared not long into the 1990s. I'm not aware of any services that advocate the use of anti-arrhythmics for PVCs. Not saying it doesn't happen, but I'd be surprised and somewhat saddened to find it does.

 

[firetender]

I got my experience in this department while covering auto races in and around Daytona Beach in the 70's. Whipsawing around while hitting a wall at high speed sometimes tweaked the shoulder harnesses of the time into the chest, compressing the tissues surrounding the heart and mashing it.

The driver would be anxious, note pain, but more like a funny feeling in his chest, have an irregular pulse, and to me, it looked a bit like an anxiety attack. Today, I'd look back and suggest like it was a thump that, in the midst of the accident, produced a huge adrenaline rush.

In the absence of loss of consciousness, blood pressure, breathing or anything vital, we just watched and waited, IV TKO, then maybe a little O2 while transporting if the pt. felt it calmed him. We'd witness weird arrhythmias, notably PVCs, but were instructed not to treat aggressively. Dr. wanted to do more extensive testing due to probable traumatic origin. Which is probably good because then it was all about almost ODing the pt. on Lidocaine!

What I'd say is treat what is sure to bring the patient down, NOT just what you think MIGHT.

 

[jrm818]

Empirical treatment of PVCs was certainly all the rage in the 1980s, but studies showing no benefit, and in some cases, harm meant that the practice fortunately disappeared not long into the 1990s. I'm not aware of any services that advocate the use of anti-arrhythmics for PVCs. Not saying it doesn't happen, but I'd be surprised and somewhat saddened to find it does.

Well shoot, if I'm understanding properly, prepare to be saddened.

Just the other day, I was instructed to attempt to pharmacologically suppress extremely frequent or multifocal PVC's.

I don't know if that's practice where I am, but its at least being taught as truth.

Could you elaborate a bit: is there any clinical scenario where PVC's need to be treated? Is this yet another outdated/useless lesson that needs revising? I try to keep up with backing up (or debunking) the assertions of instructors with evidence, but it can be pretty hard to keep up, especially when nonsense is presented with the same unqualified certainty as good information.

 

[Veneficus]

Say for example, pt. has probable myocardial contusion resulting in very frequent PVC's. Do we leave these PVC's alone or treat them?

Leave them. In this event the PVC is most likely a compensatory mechanism.

What is the risk of not treating PVC's in this scenario?

Nothing that I can see changing the outcome

Can the contusion continue to increase in size making the heart more irritable with time? What if ST-T wave abnormalities are also present?

If the cardiac dysfunction is increasing because the area of contusion is increasing, medication is not going to help that. About the only think that it might do is suppress the excitability left in the still functioning tissue.

ST-T abnormalities would simply be demonstrating the depth of the tissue damage. While the cellular level pathology is the same, the gross cause of it is different from a thomboembolic event.

There is no way I can think of to restore electrophysiology to tissue damaged from compression or disrupted by force short of relieving the pressure when possible or reconstructing tissue when possible. The medications usually have some action based on membrane permiability, which assumes the cell structure is largely intact.

 

[Simusid]

I googled for myocardial contusion to try and learn more. I found this http://health.nytimes.com/health/guides/disease/myocardial-contusion/overview.html (which probably isn't the most authoritative) and under "Exams And Tests" they list RBBB but not LBBB?

Why would LBBB be excluded?

 

[systemet]

Case report here of an LBBB:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726743/pdf/v022p00300.pdf

Another case report here (RBBB)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC484937/pdf/heart00010-0129.pdf

Range of arrhythmias here:

http://europace.oxfordjournals.org/content/11/11/1557.long

Quick review here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726836/pdf/v022p00465.pdf

So, just from some quick reading (all available as free full text at www.pubmed.com), it seems that:

(1) the ECG is relatively insensitive in the detection of myocardial contusion, i.e. just because the ECG is normal, doesn't mean there's no contusion.

(2) pretty much any arrhythmia can be indicative of a myocardial contusion.

(3) one source suggests that RBBB might be more common than other arrhythmias, and suggests this may be because the right ventricle is closer to the sternum / anterior chest. [It helps to remember the heart is rotated a little counterclockwise in the chest --- the RV is also commonly injured with anterior stab wounds.]