Tag Archives: cardiac contusion

What You Need To Know About Blunt Cardiac Injury

Blunt cardiac injury can be an enigma. Significant injuries are uncommon, and the literature on it consists of case reports and small series. The group at Scripps La Jolla has an excellent review article on the topic that is currently in press. This post will relate some of the key points in this nicely prepared article.

  • Use the correct nomenclature. For years, many have called this condition “cardiac contusion” or “myocardial contusion.” Unfortunately, these descriptors are too specific. The proper term is “blunt cardiac injury (BCI),” which encompasses the entire gamut of injury from asymptomatic contusion to pericardial injury to cardiac rupture.
  • BCI occurs more commonly than you think. If one defines BCI as any arrhythmia or cardiac enzyme elevation, it is fairly common. However, if the definition is limited to clinically significant sequelae such as potentially malignant arrhythmia or cardiac failure, the incidence is easily less than 1% in blunt trauma patients.
  • Be aware of the usual mechanisms of injury. This is a condition caused by blunt trauma, with motor vehicle crashes causing half and pedestrians struck by them another one-third. Motorcycle crashes and falls caused the remaining 12%.
  • Diagnosis can be challenging.
    • Physical examination is usually of little help. New onset of a heart murmur may indicate a serious cardiac injury but is exceedingly rare.
    • EKG evidence of a new onset arrhythmia is important, particularly bundle branch blocks, PVCs, and ST segment / T wave changes, which require further investigation.
    • CPK-MB enzyme measurements are useless. Please don’t get them.
    • Troponin T and Troponin I are frequently used but do not reliably predict BCI. Testing in asymptomatic patients is not helpful and may result in additional asymptomatic testing.
    • Echocardiography is not indicated in asymptomatic patients with isolated enzyme elevations.
    • Cardiac CT may be used to differentiate acute MI from BCI. Frequently, patients at risk are having a chest CT with contrast performed anyway.

Here is the recommended treatment algorithm:

  1. If BCI is possible based on mechanism of injury, follow the ATLS protocols and perform a physical exam, E-FAST, and place on EKG monitoring.
  2. If the patient is hemodynamically unstable, quickly identify and treat tamponade or tension pneumothorax if present. If significant arrhythmias are present, treat with appropriate medications. If heart failure is present, treat medically and evaluate for surgical problems such as valve, septum, or coronary artery injury.
  3. If the patient is hemodynamically stable, obtain a 12 lead EKG. If significant arrythmias are present, treat with appropriate medications. If there is organ hypoperfusion, obtain an echocardiogram. If this study reveals an effusion, a pericardial window is indicated. If the echo shows hypokinesis or structural injury, appropriate medical or surgical management should be carried out.
  4. Patients who have only significant arrhythmias should be admitted to a monitored bed for 24 hours. Once arrhythmias have resolved, the patent can be discharged.
  5. Patients with nonspecific EKG changes should have troponin levels drawn after 8 hours of observation in the ED. If elevated, admit to a monitored bed for 24 hours. Once EKG and troponin have normalized, the patent can be discharged.
  6. If EKG and labs are normal, may discharge home from the ED if there are no other indications for admission.

Reference: Diagnosis and Management of Blunt Cardiac Injury: What You Need to Know. J Trauma, accepted for publication. DOI: 10.1097/TA.0000000000004216

Practice Guideline – Blunt Cardiac Injury (BCI)

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.

Cardiac Enzymes And Blunt Cardiac Injury

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.

Related posts:

Reference: The usefulness of serum troponin levels in evaluating cardiac injury. Am Surg 67:821-826, 2001.

Cardiac Contusion (for Nurses)

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:

  • 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.