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Blunt cardiac injury

Background

Overview

Definition
BCI refers to an injury sustained due to blunt trauma to the heart, the spectrum of which ranges from a minor bruise to specific post-contusion cardiac conditions such as free-wall rupture.
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Pathophysiology
BCI is mostly caused by motor vehicle accidents, falls from heights, direct blow to the chest wall by airbag deployment, crushing incidents, contact sports injuries, acts of violence, or blast trauma.
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Disease course
Clinical manifestations include arrhythmias, myocardial contusion, wall motion abnormalities, myocardial wall rupture, and valve damage. The spectrum of injuries includes commotio cordis, cardiac rupture, coronary artery dissection, indirect cardiac injury, cardiac herniation, pericardial effusion and tamponade, traumatic cardiac arrest, and blunt aortic injury.
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Prognosis and risk of recurrence
BCI is associated with an overall mortality rate of 13.9%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of blunt cardiac injury are prepared by our editorial team based on guidelines from the American College of Emergency Physicians (ACEP 2024), the Eastern Association for the Surgery of Trauma (EAST/WTA/PTS 2023), the American College of Radiology (ACR 2020), and the Eastern Association for the Surgery of Trauma (EAST 2015,2012).
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Screening and diagnosis

Indications for testing: as per EAST 2012 guidelines, avoid implementing cardiac monitoring on the sole basis of a sternal fracture, in patients in whom ECG and troponin I levels are normal.
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Classification and risk stratification

Risk stratification
As per ACEP 2024 guidelines:
Use clinical judgment and hospital-specific protocols to decide between selective CT and whole-body CT in hemodynamically stable adult patients with blunt trauma.
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Take into account age (> 65 years) for triage of older adult patients with trauma, as they have increased morbidity and mortality compared with similarly injured adults.
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Diagnostic investigations

ECG: as per EAST 2012 guidelines, obtain an admission ECG in all patients in whom BCI is suspected.
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More topics in this section

  • Continuous ECG monitoring

  • Troponin I

  • CK

  • Cardiac imaging

  • Chest imaging

  • Nuclear medicine studies

Therapeutic procedures

Blood product transfusion: as per ACEP 2024 guidelines, use a FFP:platelet:packed RBCs ratio from 1:1:1 to 1:1:1.5 in adult patients presenting to the emergency department with blunt trauma to reduce 24-hour mortality without increasing morbidity.
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Surgical interventions

Resuscitative thoracotomy, adult patients
As per EAST 2015 guidelines:
Consider performing emergency department thoracotomy in patients presenting pulseless to the emergency department after blunt injury with signs of life.
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Avoid performing emergency department thoracotomy in patients presenting pulseless to the emergency department after blunt injury without signs of life.
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More topics in this section

  • Resuscitative thoracotomy (pediatric patients)

  • REBOA

Specific circumstances

Patients requiring surgical interventions: as per EAST 2012 guidelines, consider proceeding with surgery in elderly patients with known cardiac disease, unstable patients, and those with an abnormal admission ECG, provided that they are appropriately monitored. Consider placing a pulmonary artery catheter in these situations.
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