The Eastern Association for the Surgery of Trauma recently released an update of their practice guideline for screening for blunt cardiac injury. Although the bulk of the guideline remains the same, a few areas have been updated to reflect advances since its original 1998 release.
Here is a quick summary of the new guidelines. Level 1 (best data):
- If blunt cardiac injury is suspected, an EKG should be obtained (no change)
Level 2 (okay data):
- If a new arrhythmia is seen on EKG, admit for monitoring. If not new, compare with an old EKG to determine need for admission. (updated)
- If the EKG is normal and troponin I is normal, BCI is ruled out. If the EKG is normal and troponin I is abnormal, admit for monitoring. (new)
- If the patient is unstable or the arrhythmia persists, obtain a cardiac echo. (updated)
- Sternal fracture is not predictive of BCI (moved from level 3)
- CPK should not be obtained (modified and moved from level 3)
- Nuclear medicine studies should not be obtained (no change)
Level 3 (data not so good):
- Elderly patients with known cardiac disease, unstable patients, and those with abnormal EKG can safely undergo surgery with appropriate monitoring (no change)
- Troponin I should be measured routinely in suspected BCI, and if elevated should prompt monitoring and serial testing (new)
- Cardiac CT or MRI may help differentiate acute MI from BCI to determine need for catheterization and/or anti-coagulation (new)
The EAST guidelines are just that, guidelines. They are not a complete management algorithm. I have combined this new information with an existing algorithm based on the old EAST guidelines. Feel free to download this algorithm using the link below. As always, I welcome any comments.
Click here to download the blunt cardiac injury algorithm
Reference: Screening for by cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma 73:(5) Supplement 4, S301-S306, 2012.
Blunt cardiac injury (BCI), better known as cardiac contusion, has been poorly understood for decades. There has always been confusion about the best way to detect, monitor, and treat this condition. The Eastern Association for the Surgery of Trauma developed a set of practice guidelines in 1998 that provided solid, evidence-based principles to act upon. At that time, CPK was the only cardiac enzyme available. It was useless because it had no correlation with presence or absence of contusion, or even severity of injury.
With the arrival of troponin assays, a new tool for looking at cardiac injury became available. However, initial evaluations indicated that it was also not very reliable when used in the diagnosis of cardiac contusion. For years, I’ve been teaching that these enzymes are useless. However, additional work has been done that does show some limited usefulness.
A prospective study by Collins looked at the usefulness of troponin I (TnI) in patients with cardiac injury. As in previous retrospective studies, this test had a very low positive predictive value. In addition, they determined that a negative EKG alone ruled out blunt cardiac injury. So what good is it?
The new piece of information here is that if the EKG is abnormal and the troponin I is normal, then a cardiac contusion can be ruled out. This changes the overall algorithm by allowing us to eliminate some patients who have abnormal EKGs.
On Monday, I’ll provide my take on a comprehensive algorithm for evaluating and managing cardiac injury. Stay tuned.
Reference: The usefulness of serum troponin levels in evaluating cardiac injury. Am Surg 67:821-826, 2001.
This is a brief trauma nursing inservice on cardiac contusion.
Cardiac contusion is an uncommon condition that is too-commonly worried about. It requires extreme blunt force with a significant head-on component. The most common mechanisms are car crashes (steering wheel) and sports injuries.
A true cardiac contusion is very rare. If a patient did not strike their chest hard enough to cause significant and lasting anterior chest pain, they probably do not have one. If the force was enough to cause a sternal fracture, there is some possibility they may have sustained a cardiac contusion. During ED evaluation, if a patient with a significant mechanism does not exhibit any arrhythmias, they do not have a contusion.
Diagnosis is relatively simple: any trauma patient with a likely mechanism who has chest wall pain and a new arrhythmia or cardiac pump failure has a cardiac contusion. Atrial or ventricular arrhythmias are significant, but a ventricular one is significant because it can degenerate into v-tach or worse.Enzyme measurements do not indicate severity of injury or outcome and should not be obtained.
From a nursing standpoint, you should monitor for and report the following:
- A new arrhythmia, especially a ventricular one. Medications or cardioversion may be ordered to treat.
- Hypotension, pulmonary congestion, or other signs or heart failure. An echocardiogram or vasoactive medications may be ordered.
Remember, true cardiac contusion is rare! If suspected, telemetry is indicated, along with frequent vital signs. Cardiac enzymes should not be ordered, and any indication of cardiac problems (arrhythmia or failure) should be reported and treated promptly.