May 1, 2019

REBEL Core Cast 10.0 – Blunt Cardiac Injury

Take Home Points on Blunt Cardiac Injury

  • No single test can be used to exclude BCI. However a thorough physical exam combined with a 12-lead EKG, troponin measurement, and echocardiography can be used to characterize BCI and direct care
  • Obtain a 12-lead EKG in all thoracic trauma patients 
  • A chest x-ray may help to identify associated injuries. However, isolated musculoskeletal injuries such as sternal fractures do not correlate with a risk of BCI
  • Bedside TTE can quickly evaluate for life-threats such as cardiac tamponade; A TEE is both sensitive and specific across the spectrum of BCI pathology and is part of a comprehensive evaluation
  • BCI can be excluded in a patient without EKG abnormalities and a negative troponin I

REBEL Core Cast 10.0 – Blunt Cardiac Injury

Definition

  • Any blunt trauma to the heart. Ranges from contusion to dysrhythmia to ventricular wall rupture.

Anatomy

  • Right ventricle and right atrium most commonly injured (most anterior portion of heart)
  • Suspect this pathology with any significant thoracic trauma ( mvc / crush injury / deceleration injury / blast injuries)

Signs of Injury

  • Dysrhythmia / ecchymosis / hypotension / chest wall deformity / pulse deficit / new heart failure / new murmur
  • Pediatric patients may not present with outward signs of cardiac injury. Think of it with significant chest wall trauma.
  • Treatment
  • Stabilize: A-B-C-D-E
  • E-FAST after primary survey – rule out life threatening injuries
  • If tachycardia after initial resuscitation + elimination of other injuries – consider cardiac injury
  • Testing for blunt cardiac injury in the not obvious group
  • ECG will most commonly find tachycardia. Make sure to look for dysrhythmias.
  • CXR / CT Chest – if finding of multiple rib fractures or sternal fracture then raise your suspicion for cardiac injury. Get an echo!
  • Echo may show wall motion abnormality / abnormal flow / turbulent flow / intraventricular clots
  • Get a troponin, they have 100% negative predictive value. Good to rule out disease. May need two trops.

Eastern Association for the Surgery Trauma – 2012 guideline.

Level 1 Recommendation

  • ECG for all patients suspected of blunt cardiac injury

Level 2 Recommendation 

  • ECG with new dysrhythmia means admission for cardiac monitoring.
  • Normal ECG and negative troponin, BCI ruled out.
  • Hemodynamically unstable patient or persistent new arrhythmia then need Echo
  • Sternal fracture alone does not predict BCI

Links:

Show Notes Written By: Miguel Reyes, MD (Twitter: @Miguel_ReyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 10.0 – Blunt Cardiac Injury", REBEL EM blog, May 1, 2019. Available at: https://rebelem.com/rebel-core-cast-10-0-blunt-cardiac-injury/.
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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author
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