Updated: 12/8/2021

Blunt Cardiac Injury

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  • Snapshot
    • A 30-year-old man presents after a motor vehicle collision to the emergency room. Although he is conscious and responsive, he reports severe chest pain. His blood pressure is 83/55 mmHg, pulse is 120/min, and respirations are 24/min. On physical exam, he has extensive ecchymosis over his anterior chest wall. He has jugular venous distention and muffled heart sounds. An electrocardiogram reveals diffused ST elevations and sinus tachycardia. A focused assessment with sonography in trauma (FAST) exam reveals pericardial fluid.
  • Introduction
    • Clinical definition
      • trauma to the thoracic cage, resulting in cardiac injury
    • Associated conditions
      • head trauma
  • Epidemiology
    • Location
      • right ventricle is most commonly injured
        • it is right below the sternum
      • aortic valve is the most common valve to be injured
    • Risk factors
      • motor vehicle collisions
      • crush injuries
  • Etiology
    • Myocardial contusion
    • Arrhythmias
    • Injury to valves or vessels
    • Cardiac rupture
    • Sudden cardiac arrest from sternal blow
    • Pathogenesis
      • blunt cardiac trauma, such as myocardial contusion, disrupts normal heart function, causing pump failure or tamponade
  • Presentation
    • Symptoms
      • chest pain
      • difficulty breathing
      • palpitations
      • lightheadedness
    • Physical exam
      • physical exam findings depend on etiology
      • patients may be in cardiogenic shock
        • hypotension
      • anterior chest wall
        • ecchymosis
        • tenderness to palpation
        • step-off indicating rib or sternal fracture
        • subcutaneous crepitus
          • likely has pneumothorax as well
      • new heart murmur
      • jugular venous distention
  • Imaging
    • Focused assessment with sonography in trauma (FAST) exam
      • indication
        • for all patients with trauma
      • findings
        • cardiac motion abnormalities
        • pericardial blood
        • free fluid in peritoneum
    • Chest radiography
      • indication
        • if rib fracture is suspected
      • findings
        • rib fracture
        • pneumopericardium
    • Echocardiography
      • indication
        • for all patients
      • findings
        • detect structural abnormalities
        • detect pericardial effusion or tamponade
  • Studies
    • Labs
      • cardiac enzyme troponin-I
        • 93-94% negative predictive value
    • Electrocardiogram (ECG)
      • indication
        • best initial test
      • findings
        • sinus tachycardia
        • arrhythmias
        • conduction abnormalities (e.g., bundle branch blocks)
        • prolonged QT intervals
        • ST segment changes
  • Differential
    • Myocardial infarction-induced cardiogenic shock
      • distinguishing factor
        • no evidence of external trauma
  • DIAGNOSIS
    • Making the diagnosis
      • based on clinical presentation, ECG, and imaging
  • Treatment
    • Management approach
      • treat with Advanced Trauma Life Support protocol
      • treat underlying cause of blunt cardiac trauma
    • Medical
      • intravenous fluid resuscitation
        • indication
          • patients with hypotension
      • amiodarone
        • indication
          • patients with ventricular dysrhythmias
    • Operative
      • pericardiocentesis or pericardial window
        • indication
          • patients with pericardial tamponade
  • Complications
    • Heart failure
    • Emboli
    • Cardiopulmonary arrest
  • Prognosis
    • Survival depends on etiology of blunt cardiac trauma
      • patients with frank cardiac rupture often do not even make it to the emergency room
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