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
- Any blunt trauma to the heart. Ranges from contusion to dysrhythmia to ventricular wall rupture.
- 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.
- 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.
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
- EAST: Screening for Blunt Cardiac injury
- REBEL EM: Blunt Cardiac Injury (BCI)
- EMDocs: Blunt Cardiac Injury
- American Association for the Surgery of Trauma : Blunt Cardiac Injury
Show Notes Written By: Miguel Reyes, MD (Twitter: @Miguel_ReyesMD)
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)