High-Risk Cardiovascular Emergencies - Blunt Cardiac Injury
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Course 3: Diagnosis and Management of Blunt Cardiac Injury

The use of direct oral anticoagulants – the direct thrombin inhibitor and the anti-factor Xa inhibitors – has increased greatly since 2010, when the first agent was approved by the FDA. Though DOACs are popular with patients because they don’t require the lab monitoring and dietary changes of warfarin, these patients can present new challenges to emergency clinicians.

When a patient arrives in the ED following blunt force trauma to the anterior chest wall, how can you tell whether they have a life-threatening cardiac injury that requires urgent operative management or just some soreness and can be discharged?

What are the most serious cardiac injuries, and how can the mechanism of injury give you clues to the location?

What vital signs will give you the most information about the nature of the injury?

Are there cautions in providing pain control for patients with BCI?

How can you use ECG and troponin testing together to improve recognition of significant BCI?

What are the particular circumstances when chest x-ray, FAST, eFAST, and echocardiogram are most appropriate?

What is the role for fluids and transfusions in BCI?

When is an ED thoracotomy called for? Pericardiocentesis?

Table of Contents
  1. Abstract
  2. Case Presentation
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Epidemiology
  6. Differential Diagnosis
    1. Cardiac Wall Rupture
    2. Septal Injuries
    3. Valvular Injuries
    4. Coronary Artery Injury
    5. Pericardial Injury
    6. Dysrhythmias
    7. Conduction Blocks
    8. Commotio Cordis
    9. Myocardial Contusion
    10. Aortic Root Injuries
  7. Prehospital Care
    1. Hospital Destination
    2. Level of Care
    3. Providing Comfort and Alleviating Pain During Transport to the Emergency Department
    4. Rapid Identification of Blunt Cardiac Injury With Ultrasound
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
  9. Diagnostic Studies
    1. Laboratory Testing
    2. Electrocardiogram
    3. Electrocardiogram and Troponin Testing
    4. Chest X-Ray
    5. Focused Assessment With Sonography in Trauma (FAST) Examination
    6. Computed Tomography
    7. Echocardiogram
  10. Treatment
    1. Transfusion and Fluids
    2. Operative Management
    3. Dysrhythmia
    4. Myocardial Infarction
    5. Pain Management Strategies
  11. Special Circumstances
    1. Sternal Fractures
  12. Controversies and Cutting Edge
    1. Advanced Cardiac Imaging
  13. Disposition
    1. Emergent Transfer to the Operating Room
    2. Admission for Observation
  14. Discharge
  15. Summary
  16. Risk Management Pitfalls in Blunt Chest Trauma
  17. Time- and Cost-Effective Strategies
  18. Case Conclusions
  19. Clinical Pathway for Management of Emergency Department Patients With Suspected Blunt Cardiac Injury
  20. Tables and Figures
    1. Table 1. Eastern Association for the Surgery of Trauma – Levels of Recommendation
    2. Table 2. Differential Diagnosis of Chest Pain Following Blunt Chest Trauma
    3. Table 3. Physical Examination Findings in Blunt Cardiac Injury
    4. Figure 1. Pericardial Effusion on Chest X-Ray
    5. Figure 2. Pericardial Effusion on Ultrasound and Noncontrast Chest Computed Tomography
    6. Figure 3. Sternal Fracture and Myocardial Contusion on Magnetic Resonance Imaging
  21. References

Abstract

Blunt cardiac injury describes a range of cardiac injury patterns resulting from blunt force trauma to the chest. Due to the multitude of potential anatomical injuries blunt force trauma can cause, the clinical manifestations may range from simple ectopic beats to fulminant cardiac failure and death. Because there is no definitive, gold-standard diagnostic test for cardiac injury, the emergency clinician must utilize an enhanced index of suspicion in the clinical setting combined with an evidence-based diagnostic testing approach in order to arrive at the diagnosis. This review focuses on the clinical cues, diagnostic testing, and clinical manifestations of blunt cardiac injury as well as best-practice management strategies.

 

Case Presentation

You are working a quiet morning shift when 2 patients are brought in after a motor vehicle crash. The first patient is hypotensive, and the FAST exam reveals a pericardial effusion. You know that time is of the essence, so you rapidly assess the options and wonder whether a needle pericardiocentesis is the best option…

The second patient from the MVC has an ecchymosis across his chest. He has normal vital signs and a normal ECG, so you decide to send him for a CT to assess for thoracic and abdominal injuries. Upon returning from CT, he is tachycardic at 115 beats/min, the CT is negative, and he has a troponin of 0.0. Given that he has a seat belt sign and tachycardia, you are still concerned there may be a cardiac injury, and you wonder whether the ECG without ischemic changes and negative troponin are sufficient to exclude blunt cardiac injury. You question whether the patient needs to be admitted or observed . . . and if so, for how long?

 

Introduction

Blunt cardiac injury (BCI) encompasses a spectrum of cardiac conditions resulting from blunt force trauma to the anterior chest wall. In 1992, Mattox used the term blunt cardiac injury to describe the spectrum of disease from a minor “bruise” to the heart to specific postcontusion cardiac conditions such as free wall rupture or myocardial hemorrhage.1 Depending upon the extent and the anatomical location of injury, the manifestations of these injury patterns range from benign ectopic beats to cardiac wall rupture resulting in sudden death. Because there are no universally accepted diagnostic criteria for the diagnosis of BCI, the true incidence is undetermined.

Motor vehicle crashes (MVCs) are the cause of most reported cases of BCI,2,3 accounting for many of the deaths related to these accidents.4-6 Failure to identify and understand the extent of blunt cardiac injuries can result in significant morbidity to the trauma patient. A high index of suspicion, application of current diagnostic protocols, and prompt and appropriate management are fundamental to maximizing good outcomes. This issue of Emergency Medicine Practice describes the most common cardiac injuries resulting from blunt trauma, the most effective diagnostic studies, and the most effective treatments for these life-threatening injuries.

 

Critical Appraisal of the Literature

PubMed was queried using the search term blunt cardiac injury. The search produced 1209 articles; however, most were case reports and reviews; large prospective trials on this topic are lacking. Additionally, this review was informed by guidelines from the Eastern Association for Surgery in Trauma (EAST). (See Table 1.)

Table 1. Eastern Association for the Surgery of Trauma – Levels of Recommendation

 

Risk Management Pitfalls in Blunt Chest Trauma

1. “I always wait 3 hours before obtaining a troponin as part of my BCI workup.”

It would be appropriate to send troponin as part of the initial blood draw, therefore decreasing the duration of workup in the ED. Very few patients with significant BCI will have both a negative initial ECG and troponin. The important concept is to perform both tests initially, and if both are negative, then there is very little value to serial testing.

2. “The chest x-ray was normal, so I felt comfortable ruling out a pericardial effusion.”

A significant amount of fluid may be present in the pericardium despite a normal chest x-ray. If suspicion for a BCI or pericardial effusion remains, both point-of-care ultrasound and CT have high sensitivity and should be considered.

6. “For all patients with BCI, I order a formal echocardiogram and admit them to inpatient telemetry.”

Patients with suspected BCI can be effectively ruled out while in the ED or observation unit. Formal echocardiograms are reserved for patients with hemodynamic instability, persistent new dysrhythmias, and increasing troponin levels, and in symptomatic patients with significant mechanisms of injury. In otherwise stable patients, consideration of discharge home versus observation can avoid an inpatient admission.

 

Tables and Figures

Table 1. Eastern Association for the Surgery of Trauma – Levels of Recommendation

 

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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