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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Injuries may range from minor myocardial bruise to cardiac rupture

  • Chest pain not responding to nitrates may suggest contusion

  • There may be evidence of other injuries, such as rib or sternal fracture

  • Clinically significant myocardial injury with intact pericardium can present as cardiac tamponade

  • When the pericardium is not intact, extrapericardial bleeding causes hypovolemic shock

  • Valvular dysfunction secondary to tear or rupture may not cause acute symptoms, but later may present as heart failure

  • ECG abnormalities, most commonly nonspecific repolarization changes, consistently accompany contusion

  • Myocardial biomarkers may be elevated but do not have prognostic value

GENERAL CONSIDERATIONS

  • Blunt cardiac trauma most frequently results from motor vehicle accidents, followed by sporting activities and use of mechanical chest compression devices

  • Significant blunt chest trauma results in cardiac injury in 15% of cases

  • Almost any structure in the heart may be injured, but myocardial contusion, valve disruption, and aortic disruption are the most common injuries

  • Abnormal ECG is the best predictor of complications

  • Hemodynamically stable patients with normal ECG require no additional testing

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Angina-like pain not responding to nitrates

  • Dyspnea

PHYSICAL EXAM FINDINGS

  • Evidence of chest wall trauma

  • Hypotension, especially if unresponsive to resuscitative measures

  • Elevated jugular veins with tamponade

  • Pulsus paradoxus with tamponade

  • Signs of heart failure

  • Hypovolemic shock

  • Murmurs of valvular dysfunction, usually regurgitation

DIFFERENTIAL DIAGNOSIS

  • ECG changes secondary to coronary artery disease

  • Noncardiac intrathoracic trauma

  • Myocardial biomarker elevation secondary to noncardiac trauma

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC

  • Cardiac biomarkers, such as troponins, creatine kinase MB

ELECTROCARDIOGRAPHY

  • Nonspecific repolarization abnormalities

  • Sinus tachycardia, atrial tachyarrhythmias, and ventricular premature beats are common

IMAGING STUDIES

  • Echocardiography is useful for identifying left ventricular, valvular, or pericardial abnormalities

  • Gated equilibrium scintigraphy can identify ventricular wall motion abnormalities and reduced function

    • – Especially useful for the right ventricle

DIAGNOSTIC PROCEDURES

  • Transesophageal echocardiography is especially useful if great vessel involvement is suspected

TREATMENT

CARDIOLOGY REFERRAL

  • Suspected cardiac trauma, such as abnormal ECG

  • Unresolved hypotension or shock

HOSPITALIZATION CRITERIA

  • Suspected significant cardiac trauma

  • Hypotension/shock

  • Heart failure

MEDICATIONS

  • Drugs to control heart rate in atrial tachyarrhythmias

  • Pharmacologic agents to suppress ventricular arrhythmias

  • Appropriate treatment for heart failure

  • Fluid resuscitation when appropriate

  • Pressor support if necessary

THERAPEUTIC PROCEDURES

  • Pericardiocentesis for patients with cardiac tamponade

  • Intra-aortic balloon pump in selected cases, such as acute mitral regurgitation

SURGERY

  • Definitive ...

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