Review Question - QID 106388

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Blunt Cardiac Injury QID: 106388 (M2.CV.14.59)

QID 106388 (Type "106388" in App Search)

A 62-year-old lady is brought to the emergency department by ambulance following a high speed motor vehicle accident. On arrival, she is alert and responsive and complains of non-radiating chest pain. She also reports shortness of breath and nausea. Her past medical history is significant for hypertension and hyperlipidemia, for which she takes hydrochlorothiazide and simvastatin. Her temperature is 37 C, heart rate 98/min, blood pressure 86/52 mm Hg, respiratory rate 16/min, and SpO2 98% on room air. On physical exam, she has multiple bruises over the chest, and there is exquisite tenderness over the sternum. Upon palpation of the sternum, you feel crunching and crepitation. Cardiac auscultation reveals a regular rate and rhythm with no murmurs, rubs, or gallops. Jugular venous pressure is slightly elevated. An electocardiogram (ECG) (Figure A) and chest radiograph (Figure B) are performed. An ECG from a prior visit is shown in Figure C. Her blood pressure does not improve following a one-liter bolus of lactated Ringer's solution. What is the most likely diagnosis?

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ST-elevation myocardial infarction

10%

8/83

Non-ST-elevation myocardial infarction

0/83

Myocardial contusion

48%

40/83

Pericardial tamponade

33%

27/83

Tension pneumothorax

7/83

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This patient has most likely suffered blunt cardiac injury (BCI), such as myocardial contusion, following a sternal fracture, resulting in ECG changes mimicking a myocardial infarction.

Blunt cardiac injury (BCI) is a poorly characterized disease with varied presentations and no clear diagnostic criteria. Injuries may include rupture of the ventricular or atrial wall, septum, or a valve; cardiac dysfunction; arrhythmia; or, rarely, myocardial infarction.
Standard ACLS protocols are used to manage severe arrhythmia; immediate surgical consultation is required for severe structural cardiac injury. Echocardiography and cardiology consultation are necessary for any patient with a complex arrhythmia, cardiac dysfunction, diastolic murmur (not known to be old), or signs of heart failure. Screening with serial ECGs, cardiac monitoring, and observation for 4-6 hours is sufficient in hemodynamically stable patients.

Figure A shows the ECG of a patient with blunt cardiac injury showing ST-segment changes. Figure B shows a lateral chest radiograph showing a fracture of the body of the sternum. Figure C shows a normal ECG.

Incorrect Answers:
Answers 1 and 2: While this patient's ECG does show ST-segment changes, the diagnosis of myocardial contusion is more likely in a patient with a sternal fracture.
Answer 4: Pericardial tamponade would not result in ST-segment changes and would cause muffled heart sounds, jugular venous distension, and low-voltage QRS complexes on EKG.
Answer 5: Tension pneumothorax would cause unilaterally absent breath sounds and jugular venous distension.

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