(See also Overview of Thoracic Trauma Overview of Thoracic Trauma Thoracic trauma causes about 25% of traumatic deaths in the US. Many chest injuries cause death during the first minutes or hours after trauma; they can frequently be treated at the bedside... read more .)
Manifestations vary with the injury.
Myocardial contusion may be minor and asymptomatic, although tachycardia may be present. Some patients develop conduction abnormalities and/or arrhythmias.
Ventricular rupture is usually rapidly fatal, but patients with smaller, particularly right-sided, lesions may survive to present with cardiac tamponade Cardiac Tamponade Cardiac tamponade is accumulation of blood in the pericardial sac of sufficient volume and pressure to impair cardiac filling. Patients typically have hypotension, muffled heart tones, and distended... read more . Tamponade due to atrial rupture may manifest more gradually.
Valve disruption may occur, causing a heart murmur and sometimes manifestations of heart failure (eg, dyspnea, pulmonary crackles, sometimes hypotension), which may develop rapidly.
Septal rupture may not cause symptoms initially, but patients may present later with heart failure.
Commotio cordis is sudden cardiac arrest that follows a blow to the anterior chest wall in patients who do not have pre-existing or traumatic structural heart disease. Typically this blow involves a fast, hard projectile (eg, baseball, hockey puck) with relatively low kinetic energy. Pathophysiology is unclear, but the timing of the blow in relation to the cardiac cycle may be important. Initial rhythm is usually ventricular fibrillation.
Diagnosis of Blunt Cardiac Injury
Cardiac injury should be suspected in patients with significant chest trauma and any palpitations, arrhythmia, new cardiac murmur, or unexplained tachycardia or hypotension.
Most patients with significant blunt chest trauma should have 12-lead ECG. With myocardial contusion, ECG may reveal ST segment changes that mimic cardiac ischemia or infarction. The most common conduction abnormalities include atrial fibrillation, bundle branch block (usually right), unexplained sinus tachycardia, and single or multiple premature ventricular contractions. Echocardiography is sometimes done during the initial resuscitation and may show wall motion abnormalities, pericardial fluid, or chamber or valvular rupture. Patients suspected of having blunt cardiac injury because of clinical or ECG findings should have formal echocardiography to evaluate function and anatomic abnormalities.
Cardiac markers (eg, troponin, creatine phosphokinase muscle band isoenzyme [CPK-MB]) are most useful to screen for and thus help exclude blunt cardiac injury. If cardiac markers and ECG are normal and there are no arrhythmias, blunt cardiac injury can be safely excluded.
Treatment of Blunt Cardiac Injury
Patients with myocardial contusion causing conduction abnormalities require cardiac monitoring for 24 hours because they are at risk for sudden arrhythmias during this time. Treatment is mainly supportive (eg, treatment of symptomatic arrhythmias or heart failure) and is seldom needed. Surgical repair is indicated for rare cases of myocardial or valvular rupture.
Patients with commotio cordis are treated for their arrhythmia (eg, resuscitation with cardiopulmonary resuscitation [CPR] and defibrillation followed by in-hospital observation).
Blunt cardiac injury should be suspected in patients with significant chest trauma and any palpitations, arrhythmia, new cardiac murmur, or unexplained tachycardia or hypotension.
ECG and cardiac markers are useful to screen for injury, and echocardiography is helpful to evaluate function and anatomic abnormalities.
Patients with conduction abnormalities or arrhythmias require cardiac monitoring.