Definition: Refers to any blunt trauma to the heart. Ranges from mild to severe.
Includes the following:
o Comotio Cordis: a sudden death due to an ill-timed force during a period of electrical vulnerability
o Cardiac Rupture: traumatic rupture of the myocardium due to compression of a full chamber during early systole or raid deceleration forces shearing the atria from the vena cava or pulmonary veins
o Cardiac Contusions: edema and necrosis of cardiac myocytes due to blunt traumatic injury
o Dysrhythmias after trauma
o Ventricular wall rupture
o Coronary artery dissection/thrombosis: less common
o Septal tear: traumatic ASD or VSD less common
o Valvular Injury: laceration of aortic cusps can cause aortic insufficiency. Compression of heart during systole can lead to tearing of mitral valves and/or papillary muscle rupture
o Pericardial rupture and cardiac herniation
Epidemiology:
o Incidence ranges from 9 to 71% mostly because of lack of clear definition and diagnostic criteria
o Most commonly the right ventricle or right atrium are involved
o Most severe BCI result in wall rupture in any of the chambers and these patients typically die in the field
o Pediatric patients have increased thoracic cavity compliance and there may be no signs of trauma on exam which makes it even important that we consider this in our trauma patients
Causes:
o Significant amount of force is normally required for a BCI to occur
o Suspect BCI in any patient with significant thoracic trauma or direct precordial impact including all of the following
o MVA (most common)
o Pedestrians struck
o Crush injuries
o Blast injuries
o Deceleration injuries
o Commonly occurs in patients with sternal fracture or rib fractures
Presentation:
o Symptoms: most commonly patients complain of chest pain
o Signs:
Dysrhythmias (most commonly sinus tachycardia or atrial fibrillation)
Chest wall deformities or ecchymosis
Pulse deficits
Hypotension
New murmur
New onset HF (rales, muffled heart sounds or JVD on exam)
Pericardial effusion or tamponade on FAST
Work up:
o First and foremost follow ATLS guidelines
o Hypotension in trauma patients should be initially approached as due to hemorrhage rather than a purely cardiac cause
o Persistent tachycardia after volume resuscitation, adequate pain control, and exclusion of intrathoracic or intrabdominal hemorrhage should raise suspicion of possible BCI
o Obtain an EKG and look for the following (important to trend EKG)
o Dysrhytmias
o New conduction delays (bundle branch blocks)
o ST segment elevations or depressions
o Look for signs of sternal fracture or rib fracture on CXR
o ECHO
o TTE look for overall cardiac contractility (EF), wall motion abnormalities, turbulent blood flow, intraventricular or intraatrial thrombi
o TEE is most sensitive in detecting cardiac injuries that may require intervention
o Cardiac Biomarkers
o Significance of troponin remains unclear. Presence of single elevated troponin does little to help further management and increases the likelihood of admission and cardiology consult
o CK-MB is not a recommended biomarker in BCI
EAST (Eastern Association for the Surgery of Trauma) Guidelines:
o Level 1 Evidence
o Obtain EKG on all patients with suspected BCI
o Level 2 Evidence
o If the EKG reveals a new abnormality admit the patient for telemetry monitoring
o BCI can be ruled out in patients with a normal EKG and negative troponin (although appropriate timing of troponin remains unclear)
o Obtain an optimal TTE or TEE on patients who are hemodynamically unstable or with persistent new arrythmias
o Sternal fracture alone does not predict BCI
References:
o https://rebelem.com/blunt-cardiac-injury-bci/
o https://www.nuemblog.com/blog/blunt-cardiac-injury
Bruised and broken hearts: diagnosis and management of blunt cardiac injury — NUEM Blog
o https://rebelem.com/rebel-core-cast-10-0-blunt-cardiac-injury/
o https://emcrit.org/emcrit/blunt-cardiac-injuries/