“The heart was made to be broken.” ― Oscar Wilde
Blunt thoracic trauma accounts for 25% of all traumatic fatalities. Blunt Cardiac Injury (BCI) has been quoted to be present in up to 76% of blunt thoracic trauma patients. BCI encompasses a spectrum of injuries from myocardial contusion to myocardial rupture. These injuries can be a challenge for trauma professionals to diagnose. Often, they are diagnosed in patients with other traumatic injuries and are already admitted to a monitored setting, making the disposition easy. The difficulty in disposition arises when one considers the patient in whom a BCI is present in the absence of other injuries. Who should be screened? What screening modalities should be used? Currently there are no recommendations on who to screen for BCI. Attempts to associate BCI with other injuries (sternal fracture, etc.) have been inconclusive. However, the literature-supported general rule is to screen anyone with significant blunt trauma to the anterior chest wall. Keep in mind—the term “significant” can be difficult to define, seeing that myocardial contusions can occur with minimal force and are seen even in relatively low velocity injuries (20 miles/hr).
In case anyone missed them, here are the updated recommendations from EAST that came out last year:
Level 1
1. An admission electrocardiogram (ECG) should be performed on all patients in whom BCI is suspected (no change).
Level 2
1. If the admission ECG reveals a new abnormality (arrhythmia, ST changes, ischemia, heart block, and unexplained ST changes), the patient should be admitted for continuous ECG monitoring. For patients with preexisting abnormalities, comparison should be made to a previous ECG to determine need for monitoring (updated).
2. In patients with a normal ECG result and normal troponin I level, BCI is ruled out. The optimal timing of these measurements, however, has yet to be determined. Conversely, patients with normal ECG results but elevated troponin I level should be admitted to a monitored setting (new).
3. For patients with hemodynamic instability or persistent new arrhythmia, an echocardiogram should be obtained. If an optimal transthoracic echocardiogram cannot be performed, the patient should have a transesophageal echocardiogram (updated).
4. The presence of a sternal fracture alone does not predict the presence of BCI and thus should not prompt monitoring in the setting of normal ECG result and troponin I level (moved from Level 3).
5. Creatinine phosphokinase with isoenzyme analysis should not be performed because it is not useful in predicting which patients have or will have complications related to BCI (modified and moved from Level 3).
6. Nuclear medicine studies add little when compared with echocardiography and should not be routinely performed (no change).
Level 3
1. Elderly patients with known cardiac disease, unstable patients, and those with an abnormal admission ECG result can safely undergo surgery provided that they are appropriately monitored. Consideration should be given to placement of a pulmonary artery catheter in such cases (no change).
2. Troponin I should be measured routinely for patients with suspected BCI; if elevated, patients should be admitted to a monitored setting and troponin I should be followed up serially, although the optimal timing is unknown (new).
3. Cardiac computed tomography (CT) or magnetic resonance imaging (MRI) can be used to help differentiate acute myocardial infarction (AMI) from BCI in trauma patients with abnormal ECG result, cardiac enzymes, and/or abnormal echo to determine need for cardiac catheterization and/or anticoagulation (new).
1. Bansal, MK. Myocardial Contusion Injury: Redefining the Diagnostic Algorithm. Emerg Med J 2005;22:465-469
2. Clancy, K. et al. Screening for Blunt Cardiac Injury. J Trauma. November 2012 73 (5): S301-S306.
sadia.hussain
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1 Comment
jkhadpe · January 14, 2014 at 10:36 am
Great topic as it can be difficult to decide how far you should go to work up possible BCI. I’m a little surprised that they are recommending routine troponin’s. I didn’t check out the referenced articles yet but I have never seen any evidence showing that troponin is useful as a screening tool in this situation. It is only level 3 so maybe this is just “expert opinion.” Any thoughts?