12.2 Cardiac and Great Vessel Trauma
Key Takeaways
- Blunt cardiac injury is a monitor-and-troponin diagnosis; a negative pericardial eFAST does not clear the myocardium.
- Commotio cordis is impact-triggered ventricular fibrillation in a structurally normal heart—defibrillate, do not chase a surgical sac.
- Penetrating cardiac tamponade with a surgeon minutes away goes to the operating room; pericardiocentesis is a bridge, not a substitute.
- Traumatic aortic injury is sudden-deceleration shear: unequal pulses, anti-impulse therapy (beta-blocker first), and a hybrid operating-room destination.
- Medical aortic dissection is Chapter 15 physiology with a similar anti-impulse idea but a different mechanism and workup.
The heart and the aorta fail in different ways after a crash, and Domain 3.D of the August 2026 Certified Flight Registered Nurse (CFRN) outline expects you to tell them apart in a cabin where you cannot auscultate muffled tones. Blunt cardiac injury, commotio cordis, penetrating cardiac wound, and traumatic aortic injury are not one protocol. Burns stay in Chapter 13. Medical aortic dissection is Chapter 15—same anti-impulse idea, different mechanism.
Blunt cardiac injury is a monitor problem
Blunt cardiac injury (BCI) is the modern name for what older notes called cardiac contusion. The sternum hits the wheel, the myocardium bruises, and the exam can look almost normal until a run of premature ventricular complexes (PVCs), new bundle-branch block, unexplained sinus tachycardia, atrial fibrillation, or ST-segment change appears. Troponin rises when myocytes leak. Treatment is monitoring and support, not a specific antidote. Hypotension from pump failure is cardiogenic shock (Chapter 9) layered on trauma, not an invitation to stack unneeded crystalloid.
A negative pericardial view on extended focused assessment with sonography for trauma (eFAST) does not clear BCI. eFAST looks for fluid in the sac, not a bruised wall. If the patient is unstable, a formal echocardiogram at the receiving trauma center is the structural test. In flight you own the defibrillator pads, a readable electrocardiogram (ECG) strip, and a plan for ventricular tachycardia or fibrillation.
Commotio cordis is not a bruise
Commotio cordis is a blow to the precordium during the vulnerable upstroke of the T wave that triggers ventricular fibrillation (VF) in a structurally normal heart. It is the baseball, the elbow, the unrestrained chest against a hub. Immediate cardiopulmonary resuscitation (CPR) and defibrillation are the care. Do not waste the first minutes hunting a surgical tamponade if the story is a single impact and a sudden collapse into VF. After return of circulation, still fly to a trauma-capable hospital—the same blow can hide a sternal fracture or BCI—but the first action is electricity, not a needle in the xiphoid.
Penetrating cardiac injury: Beck, then the operating room
A wound in the cardiac box (sternal notch to xiphoid, nipple to nipple) can fill the pericardium. Beck's triad is hypotension, jugular venous distention (JVD), and muffled heart sounds. Muffled tones are a rumor in a helicopter. Use JVD, a narrow pulse pressure, electrical alternans if you catch it, and a pericardial stripe on eFAST. That is obstructive shock from tamponade.
If a capable operating room (OR) is minutes away, do not delay transport for pericardiocentesis. The needle is a bridge when a surgeon is not. A partial tap can clot, miss, or lacerate a coronary artery. Move. Resuscitative thoracotomy is a separate, protocol-bound last-ditch for selected penetrating arrest—not a ramp improvisation and not the same as a planned pericardial window.
| Problem | Mechanism | Flight move |
|---|---|---|
| Blunt cardiac injury | Myocardial bruise, dysrhythmia, troponin leak | Monitor, treat rhythm and pump failure, do not clear the heart with eFAST alone |
| Commotio cordis | Impact during T-wave vulnerability → VF | Immediate defibrillation |
| Penetrating tamponade | Blood in a closed sac (Beck physiology) | OR if minutes away; pericardiocentesis only as a long-transport bridge |
| Traumatic aortic injury | Sudden deceleration shear at the ligamentum arteriosum | Anti-impulse therapy; hybrid OR / endovascular destination |
Traumatic aortic injury is not Chapter 15 dissection
Traumatic aortic injury (TAI) is a sudden-deceleration shear—high-speed crash, ejection, fall from height—classically just distal to the left subclavian artery at the ligamentum arteriosum. Survivors who reach you often have a partial tear and a contained hematoma. Clues include:
- Unequal upper-extremity blood pressures (BP) or a pulse deficit
- Tearing interscapular pain
- A wide mediastinum on the sending film or a left hemothorax
- High-energy stamps from section 12.1 (first rib, scapula)
Hypotension may mean the hematoma is no longer contained, or it may mean a second bleed (pelvis, abdomen). Do not assume one injury.
Anti-impulse therapy and destination
While the aorta is still contained, the flight job is to lower wall stress without dropping coronary or brain perfusion. Program anti-impulse protocols typically start a short-acting beta-blocker (often esmolol) to cut heart rate and the rate of pressure rise (dP/dt), then add a vasodilator such as nicardipine if BP remains high. Do not open with a vasodilator: reflex tachycardia increases shear. Exact heart-rate and systolic targets are protocol numbers, not Board of Certification for Emergency Nursing (BCEN) cutoffs; many trauma services aim for a quieter pulse and a controlled systolic in the low-normal range. Destination is a trauma center with a hybrid OR and thoracic endovascular aortic repair (TEVAR) or open thoracic capability—not the nearest clinic for serial troponins.
Medical aortic dissection (Chapter 15) is a hypertensive, connective-tissue, or aneurysmal tear without a crash. The anti-impulse concept overlaps. The mechanism, associated injuries, and destination rules do not. Do not treat a deceleration chest as a medical dissection workup that can wait for an outpatient computed tomography (CT) slot.
What eFAST can and cannot say
eFAST adds pleural views to the classic focused assessment with sonography for trauma (FAST) windows: pericardium, right upper quadrant, left upper quadrant, and pelvis. Use it for pericardial fluid, a large hemothorax, and absent lung sliding when you are trained. It does not grade an aortic tear, exclude BCI, or replace a surgeon. A negative scan with a penetrating precordial wound and shock is still an OR patient.
A restrained driver in a sudden-deceleration crash has unequal upper-extremity blood pressures, a wide mediastinum on the sending film, and tearing interscapular pain. What is the flight destination and pressure strategy?
A penetrating precordial wound patient is hypotensive with jugular venous distention and a pericardial stripe on eFAST. The receiving trauma operating room is six minutes away. What is the preferred next step?
After a sternal impact, the patient has frequent premature ventricular complexes, a rising troponin, and a normal eFAST pericardial view. What is the blunt-cardiac-injury plan?