Cardiac injury from blunt trauma
- Eric Legome, MD
Eric Legome, MD
- Professor of Clinical Emergency Medicine
- SUNY Downstate School of Medicine
- Chief of Emergency Medicine
- Kings Count Hospital, Brooklyn
- Howard Kadish, MD, MBA
Howard Kadish, MD, MBA
- Professor of Pediatrics
- Division Chief, Pediatric Emergency Medicine
- University of Utah School of Medicine
- Section Editors
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
- Susan B Torrey, MD
Susan B Torrey, MD
- Section Editor — Pediatric Resuscitation; Pediatric Trauma
- Director, Division of Pediatric Emergency Medicine
- Associate Professor of Emergency Medicine and Pediatrics (Clinical)
- NYU School of Medicine
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Blunt cardiac injury (BCI) encompasses a spectrum of pathology ranging from clinically silent, transient arrhythmias to deadly cardiac wall rupture. The most common form is "cardiac contusion" (ie, injury to the myocardium), which remains the subject of considerable debate. The absence of a clear definition and accepted gold standard for testing makes the diagnosis of cardiac contusion difficult. Important considerations in blunt cardiac trauma include arrhythmia, cardiac wall motion abnormalities, possibly progressing to cardiogenic shock, and rupture of valves, the septum, or a ventricular, atrial, or septal wall [1,2].
The evaluation and management of cardiac injuries sustained in adults from blunt thoracic trauma will be reviewed here. Other injuries from blunt trauma and injuries in children are discussed separately. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and stabilization of children with thoracic trauma".)
EPIDEMIOLOGY, DEFINITIONS, AND SCORING
The incidence of blunt cardiac injury (BCI) is unknown, and estimates vary widely. Of diagnosed BCIs, "myocardial contusion" or "cardiac contusion" is most common. However, each of these terms has been used to refer to a range of cardiac injuries. The absence of clear diagnostic criteria and reliable diagnostic tests makes reporting difficult. Suggestive symptoms may be unrelated to BCI, while some injuries may be clinically asymptomatic. Furthermore, some criteria used to define significant BCI, such as arrhythmias, may be due to the effects of multiple trauma in a susceptible patient (eg, patient with preexisting heart disease). Other diagnostic criteria, such as an elevated troponin, may be seen in major trauma remote from the chest . (See 'Cardiac biomarkers' below.)
Due to the ambiguity surrounding the terms "myocardial contusion" and "cardiac contusion", we prefer to describe BCIs in terms of specific injuries (eg, septal rupture, myocardial infarction) or cardiac dysfunction (eg, diminished contractility in the absence of arrhythmia or hemorrhage). (See 'Types of injury' below.)
Cardiac rupture is the most devastating BCI. Most patients who sustain rupture of a heart chamber do not reach the emergency department alive. Chamber rupture is described primarily in autopsy series [4,5]. (See 'Anatomy and mechanism of injury' below.)
- Mattox KL, Flint LM, Carrico CJ, et al. Blunt cardiac injury. J Trauma 1992; 33:649.
- Elie MC. Blunt cardiac injury. Mt Sinai J Med 2006; 73:542.
- Martin M, Mullenix P, Rhee P, et al. Troponin increases in the critically injured patient: mechanical trauma or physiologic stress? J Trauma 2005; 59:1086.
- Fitzgerald M, Spencer J, Johnson F, et al. Definitive management of acute cardiac tamponade secondary to blunt trauma. Emerg Med Australas 2005; 17:494.
- Türk EE, Tsokos M. Blunt cardiac trauma caused by fatal falls from height: an autopsy-based assessment of the injury pattern. J Trauma 2004; 57:301.
- Moore EE, Malangoni MA, Cogbill TH, et al. Organ injury scaling. IV: Thoracic vascular, lung, cardiac, and diaphragm. J Trauma 1994; 36:299.
- Fulda G, Brathwaite CE, Rodriguez A, et al. Blunt traumatic rupture of the heart and pericardium: a ten-year experience (1979-1989). J Trauma 1991; 31:167.
- Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin 2004; 20:57.
- PARMLEY LF, MANION WC, MATTINGLY TW. Nonpenetrating traumatic injury of the heart. Circulation 1958; 18:371.
- Mandavia DP, Hoffner RJ, Mahaney K, Henderson SO. Bedside echocardiography by emergency physicians. Ann Emerg Med 2001; 38:377.
- Leavitt BJ, Meyer JA, Morton JR, et al. Survival following nonpenetrating traumatic rupture of cardiac chambers. Ann Thorac Surg 1987; 44:532.
- Namai A, Sakurai M, Fujiwara H. Five cases of blunt traumatic cardiac rupture: success and failure in surgical management. Gen Thorac Cardiovasc Surg 2007; 55:200.
- De Maria E, Gaddi O, Navazio A, et al. Right atrial free wall rupture after blunt chest trauma. J Cardiovasc Med (Hagerstown) 2007; 8:946.
- Cordovil A, Fischer CH, Rodrigues AC, et al. Papillary muscle rupture after blunt chest trauma. J Am Soc Echocardiogr 2006; 19:469.e1.
- Pasquier M, Sierro C, Yersin B, et al. Traumatic mitral valve injury after blunt chest trauma: a case report and review of the literature. J Trauma 2010; 68:243.
- Wilke A, Kruse T, Hesse H, et al. Papillary muscle injury after blunt chest trauma. J Trauma 1997; 43:360.
- Schwaitzberg SD, Khalil KG. Isolated traumatic aortic valvular insufficiency with rapid pulmonary deterioration. Report of two cases. Arch Surg 1985; 120:971.
- Ismailov RM, Weiss HB, Ness RB, et al. Blunt cardiac injury associated with cardiac valve insufficiency: trauma links to chronic disease? Injury 2005; 36:1022.
- Bruschi G, Agati S, Iorio F, Vitali E. Papillary muscle rupture and pericardial injuries after blunt chest trauma. Eur J Cardiothorac Surg 2001; 20:200.
- Foussas SG, Athanasopoulos GD, Cokkinos DV. Myocardial infarction caused by blunt chest injury: possible mechanisms involved--case reports. Angiology 1989; 40:313.
- Lee DW, Garnic JD, Barlow GC. Acute anterior wall myocardial infarction secondary to blunt chest trauma--a case report. Angiology 1990; 41:82.
- Jensen S, Kristensen IB, Kristensen BO. Lethal myocardial infarction subsequent to compression of the left anterior descending coronary artery induced by traumatic hematoma. Int J Legal Med 1992; 105:121.
- Fu M, Wu CJ, Hsieh MJ. Coronary dissection and myocardial infarction following blunt chest trauma. J Formos Med Assoc 1999; 98:136.
- Banzo I, Montero A, Uriarte I, et al. Coronary artery occlusion and myocardial infarction: a seldom encountered complication of blunt chest trauma. Clin Nucl Med 1999; 24:94.
- Yoon SJ, Kwon HM, Kim DS, et al. Acute myocardial infarction caused by coronary artery dissection following blunt chest trauma. Yonsei Med J 2003; 44:736.
- Plautz CU, Perron AD, Brady WJ. Electrocardiographic ST-segment elevation in the trauma patient: acute myocardial infarction vs myocardial contusion. Am J Emerg Med 2005; 23:510.
- Ismailov RM, Ness RB, Weiss HB, et al. Trauma associated with acute myocardial infarction in a multi-state hospitalized population. Int J Cardiol 2005; 105:141.
- Patel R, Samaha FF. Right coronary artery occlusion caused by blunt trauma. J Invasive Cardiol 2000; 12:376.
- Liedtke AJ, Allen RP, Nellis SH. Effects of blunt cardiac trauma on coronary vasomotion, perfusion, myocardial mechanics, and metabolism. J Trauma 1980; 20:777.
- Liu B, Wang Z, Yang Z, et al. Experimental studies on the hemodynamic changes after thoracic impact injury. J Trauma 1996; 40:S68.
- Babu GG, Wood A, O'Callaghan P, et al. The complete array of electrocardiogram abnormalities secondary to myocardial contusion in a single case. Europace 2009; 11:1557.
- Cotter G, Moshkovitz Y, Barash P, et al. Ventricular fibrillation in the patient with blunt trauma: not always exsanguination. J Trauma 1996; 41:345.
- Godbe D, Waxman K, Wang FW, et al. Diagnosis of myocardial contusion. Quantitative analysis of single photon emission computed tomographic scans. Arch Surg 1992; 127:888.
- Helling TS, Duke P, Beggs CW, Crouse LJ. A prospective evaluation of 68 patients suffering blunt chest trauma for evidence of cardiac injury. J Trauma 1989; 29:961.
- Bodin L, Rouby JJ, Viars P. Myocardial contusion in patients with blunt chest trauma as evaluated by thallium 201 myocardial scintigraphy. Chest 1988; 94:72.
- Hanschen M, Kanz KG, Kirchhoff C, et al. Blunt Cardiac Injury in the Severely Injured - A Retrospective Multicentre Study. PLoS One 2015; 10:e0131362.
- Roy-Shapira A, Levi I, Khoda J. Sternal fractures: a red flag or a red herring? J Trauma 1994; 37:59.
- Hills MW, Delprado AM, Deane SA. Sternal fractures: associated injuries and management. J Trauma 1993; 35:55.
- Rashid MA, Ortenwall P, Wikström T. Cardiovascular injuries associated with sternal fractures. Eur J Surg 2001; 167:243.
- Juan CW, Wu FF, Lee TC, et al. Traumatic cardiac injury following sternal fracture: a case report and literature review. Kaohsiung J Med Sci 2002; 18:363.
- Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73:S301.
- Dua A, McMaster J, Desai PJ, et al. The Association between Blunt Cardiac Injury and Isolated Sternal Fracture. Cardiol Res Pract 2014; 2014:629687.
- Perez MR, Rodriguez RM, Baumann BM, et al. Sternal fracture in the age of pan-scan. Injury 2015; 46:1324.
- Milligan J, Potts JE, Human DG, Sanatani S. The protean manifestations of blunt cardiac trauma in children. Pediatr Emerg Care 2005; 21:312.
- Sybrandy KC, Cramer MJ, Burgersdijk C. Diagnosing cardiac contusion: old wisdom and new insights. Heart 2003; 89:485.
- Ismailov RM, Ness RB, Redmond CK, et al. Trauma associated with cardiac dysrhythmias: results from a large matched case-control study. J Trauma 2007; 62:1186.
- Hossack KF, Moreno CA, Vanway CW, Burdick DC. Frequency of cardiac contusion in nonpenetrating chest injury. Am J Cardiol 1988; 61:391.
- Nagy KK, Krosner SM, Roberts RR, et al. Determining which patients require evaluation for blunt cardiac injury following blunt chest trauma. World J Surg 2001; 25:108.
- Karalis DG, Victor MF, Davis GA, et al. The role of echocardiography in blunt chest trauma: a transthoracic and transesophageal echocardiographic study. J Trauma 1994; 36:53.
- van Wijngaarden MH, Karmy-Jones R, Talwar MK, Simonetti V. Blunt cardiac injury: a 10 year institutional review. Injury 1997; 28:51.
- Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr 2010; 23:1225.
- Chirillo F, Totis O, Cavarzerani A, et al. Usefulness of transthoracic and transoesophageal echocardiography in recognition and management of cardiovascular injuries after blunt chest trauma. Heart 1996; 75:301.
- Collins JN, Cole FJ, Weireter LJ, et al. The usefulness of serum troponin levels in evaluating cardiac injury. Am Surg 2001; 67:821.
- Jackson L, Stewart A. Best evidence topic report. Use of troponin for the diagnosis of myocardial contusion after blunt chest trauma. Emerg Med J 2005; 22:193.
- Rajan GP, Zellweger R. Cardiac troponin I as a predictor of arrhythmia and ventricular dysfunction in trauma patients with myocardial contusion. J Trauma 2004; 57:801.
- Guild CS, deShazo M, Geraci SA. Negative predictive value of cardiac troponin for predicting adverse cardiac events following blunt chest trauma. South Med J 2014; 107:52.
- Salim A, Velmahos GC, Jindal A, et al. Clinically significant blunt cardiac trauma: role of serum troponin levels combined with electrocardiographic findings. J Trauma 2001; 50:237.
- Biffl WL, Moore FA, Moore EE, et al. Cardiac enzymes are irrelevant in the patient with suspected myocardial contusion. Am J Surg 1994; 168:523.
- Bertinchant JP, Polge A, Mohty D, et al. Evaluation of incidence, clinical significance, and prognostic value of circulating cardiac troponin I and T elevation in hemodynamically stable patients with suspected myocardial contusion after blunt chest trauma. J Trauma 2000; 48:924.
- Velmahos GC, Karaiskakis M, Salim A, et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma 2003; 54:45.
- Pasquale MD, Nagy K, Clarke J. Practice Management Guidelines for Screening of Blunt Cardiac Injury. Eastern Association for the Surgery of Trauma. 1998.
- Asensio JA, Garcia-Nunez LM, Petrone P. Trauma to the Heart. In: Trauma, 6th, Feliciano DV, Mattox KL, Moore EE. (Eds), McGraw Hill, New York 2008.
- Conn A. Chest Trauma. In: Trauma: A Comprehensive Emergency Medicine Approach, Legome E, Shockley LW. (Eds), Cambridge University Press, Cambridge 2011.
- Dahle TG, Berger A, Tuna N, Das G. Coronary artery stenting for acute myocardial infarction secondary to mild, blunt chest trauma in a soccer player. J Invasive Cardiol 2005; 17:163.
- Thorban S, Ungeheuer A, Blasini R, Siewert JR. Emergent interventional transcatheter revascularization in acute right coronary artery dissection after blunt chest trauma. J Trauma 1997; 43:365.
- Calvo Orbe L, Garcia Gallego F, Sobrino N, et al. Acute myocardial infarction after blunt chest trauma in young people: need for prompt intervention. Cathet Cardiovasc Diagn 1991; 24:182.
- Ledley GS, Yazdanfar S, Friedman O, Kotler MN. Acute thrombotic coronary occlusion secondary to chest trauma treated with intracoronary thrombolysis. Am Heart J 1992; 123:518.
- Conn A. Chest trauma. In: Trauma: A Comprehensive Emergency Medicine Approach, 1st, Legome E, Shockley LW. (Eds), Cambridge University Press, New York 2011. p.190.
- Asensio JA, Garcia-Nunez LM, Patrizio P. Trauma to the heart. In: Trauma, 6th, Feliciano D, Mattox K, Moore E. (Eds), McGraw Hill Medical, New York 2008. p.569.
- Dowd MD, Krug S. Pediatric blunt cardiac injury: epidemiology, clinical features, and diagnosis. Pediatric Emergency Medicine Collaborative Research Committee: Working Group on Blunt Cardiac Injury. J Trauma 1996; 40:61.
- Scorpio RJ, Wesson DE, Smith CR, et al. Blunt cardiac injuries in children: a postmortem study. J Trauma 1996; 41:306.
- Bromberg BI, Mazziotti MV, Canter CE, et al. Recognition and management of nonpenetrating cardiac trauma in children. J Pediatr 1996; 128:536.
- Cooper A, Barlow B, DiScala C, String D. Mortality and truncal injury: the pediatric perspective. J Pediatr Surg 1994; 29:33.
- Tiao GM, Griffith PM, Szmuszkovicz JR, Mahour GH. Cardiac and great vessel injuries in children after blunt trauma: an institutional review. J Pediatr Surg 2000; 35:1656.
- Sartorelli KH, Vane DW. The diagnosis and management of children with blunt injury of the chest. Semin Pediatr Surg 2004; 13:98.
- Hirsch R, Landt Y, Porter S, et al. Cardiac troponin I in pediatrics: normal values and potential use in the assessment of cardiac injury. J Pediatr 1997; 130:872.
- Lancey RA, Monahan TS. Correlation of clinical characteristics and outcomes with injury scoring in blunt cardiac trauma. J Trauma 2003; 54:509.
- Lindstaedt M, Germing A, Lawo T, et al. Acute and long-term clinical significance of myocardial contusion following blunt thoracic trauma: results of a prospective study. J Trauma 2002; 52:479.
- Sturaitis M, McCallum D, Sutherland G, et al. Lack of significant long-term sequelae following traumatic myocardial contusion. Arch Intern Med 1986; 146:1765.
- EPIDEMIOLOGY, DEFINITIONS, AND SCORING
- ANATOMY AND MECHANISM OF INJURY
- PREHOSPITAL MANAGEMENT
- CLINICAL FEATURES
- Types of injury
- Initial stabilization
- Diagnostic tests
- - Electrocardiogram
- - Echocardiogram
- - Cardiac biomarkers
- DIAGNOSTIC APPROACH
- Myocardial or cardiac contusion
- Valve, septum, or ventricular wall injury
- Acute coronary syndrome
- Cardiac dysfunction
- PEDIATRIC CONSIDERATIONS
- Presentation, diagnosis, and management
- SUMMARY AND RECOMMENDATIONS