Updated: 12/21/2019

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
  • 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
  • Associated conditions
    • head trauma
  • Prognosis
    • survival depends on etiology of blunt cardiac trauma
      • patients with frank cardiac rupture often do not even make it to the emergency room
Presentation
  • Symptoms
    • chest pain
    • difficulty breathing
    • palpitations
    • lightheadedness
  • Physical exam
    • physical exam findings depend on etiology
    • patients may be in 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
  • Making the diagnosis
    • based on clinical presentation, ECG, and imaging
Differential
  • Myocardial infarction-induced cardiogenic shock
    • distinguishing factor
      • no evidence of external trauma
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
 

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