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