Cardiac contusion

Background
  • Contusion is the most common type of blunt cardiac injury (60-100%) (Other sources cite lower figures of 8-76%[1][2])
  • Range is due to lack of standardized diagnostic criteria.
  • Autopsy shows patchy necrosis and hemorrhage of damaged areas of myocardium and is the "gold standard" for research[1]

Mechanism of injury
  • MVC is common, but crush injuries, CPR and others have also been described.
  • Can occur with decelerations from as little as less than 20mph[2]

Blunt cardiac injury
Spectrum of Blunt Cardiac Injury
  • A spectrum of disease due to blunt trauma to the chest wall
  • Ranges from cardiac contusion to infarction to cardiac rupture and death.[3]
    • Commotio cordis is sudden cardiac arrest resulting from blunt chest trauma, in absence of underlying cardiac disease[4]
    • Up to 20% of all MVC deaths are due to blunt cardiac injury

Clinical Features
  • Chest pain
  • Palpitations
  • Tachycardia
  • Dyspnea/shortness of breath

Differential Diagnosis

Thoracic Trauma

Evaluation

Diagnosis is difficult due to spectrum of clinical disease and lack of adequate test in the ED

  • Physical exam
    • Majority (75%) of patients will have evidence of chest wall trauma[5]
  • Imaging[5]
    • CXR and CT Chest are neither sensitive nor specific for cardiac contusion, but may show other blunt cardiac injury
    • Echocardiography may be useful - contusion will show localized wall motion abnormality
  • ECG - may be normal or show non-specific abnormalities[5]
    • most common abnormality in order (sinus tachycardia, PVCs, atrial fibrillation)
    • 81–95% of life threatening ventricular arrhythmias and acute cardiac failures occur within the first 24–48 hrs
  • Cardiac enzymes (Troponin, CK-MB)[5]
    • CK-MB is neither sensitive nor specific
    • Troponin is specific for cardiac injury, but not sensitive for cardiac contusion

Management
  • Treatment is generally supportive and based on clinical presentation[5]
  • Do NOT treat arrhythmias prophylactically (increased mortality!)
  • Do NOT give thrombolytics for signs of myocardial infarction (increased mortality)

Disposition
  • Patients with mild injury, normal ECG, and negative Troponin can likely be discharged after period of observation[5]
  • Admit to telemetry bed for:
    • Hemodynamic instability
    • Abnormal ECG
    • Elevated troponin

Prognosis
  • Generally favorable prognosis
  • Even if patient has minor wall motion abnormality, mild arrhythmia, etc, these usually resolve within 1 day[6]
    • Long-term sequelae are rare in hemodynamically stable patient without significant ECG abnormality
    • Severe cardiac contusion may rarely lead to ventricular remodeling and aneurysm
  • Short tele admit as 81-95% of ventricular dysrhythmias and cardiac failure within 1-2 days after trauma[7]

See Also

References
  1. Emet M, Saritemur M, Altuntas B, et al. Dual-source computed tomography may define cardiac contusion in patients with blunt chest trauma in ED. Am J Emerg Med. 2015 Jun;33(6):865.e1-3. doi: 10.1016/j.ajem.2014.12.059.
  2. El-Chami MF, Nicholson W, Helmy T. Blunt cardiac trauma. J Emerg Med. 2008 Aug;35(2):127-33.
  3. El-Menyar A, Al Thani H, Zarour A, Latifi R. Understanding traumatic blunt cardiac injury. Ann Card Anaesth. 2012 Oct-Dec;15(4):287-95. doi: 10.4103/0971-9784.101875.
  4. Yousef R, Carr JA. Blunt cardiac trauma: a review of the current knowledge and management. Ann Thorac Surg. 2014 Sep;98(3):1134-40. doi: 10.1016/j.athoracsur.2014.04.043.
  5. Sybrandy KC, Cramer MJM, Burgersdijk C. Diagnosing cardiac contusion: old wisdom and new insights. Heart. 2003;89(5):485-489.
  6. Bock JS, Benitez RM. Blunt cardiac injury. Cardiol Clin. 2012 Nov;30(4):545-55. doi: 10.1016/j.ccl.2012.07.001.
  7. K C Sybrandy, M J M Cramer, and C Burgersdijk. Diagnosing cardiac contusion: old wisdom and new insights. Heart. 2003 May; 89(5): 485–489.
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