01Approach to the Critical Patient/attcp48

Immediate stabilization

›Airway and breathing priorities

›Airway protection assessment

›Depressed mental status or GCS <13

›Inability to protect airway from hemorrhage or secretions

›Oxygenation targets

›SpO2 >94% on supplemental oxygen

›PaO2 >60 mmHg

›If hemopneumothorax confirmed, chest decompression before intubation

›Tension physiology is immediately life-threatening

›Circulation priorities

›Hemorrhagic shock vs cardiogenic shock differentiation

›Hemorrhagic: tachycardia, flat neck veins, responds to volume

›Cardiogenic: JVD, muffled heart sounds, Beck's triad

›IV access, two large-bore peripheral IVs

›Blood products if hemorrhagic shock

›Fluid cautious if cardiogenic etiology suspected

›Continuous cardiac monitoring from point of contact

›Ventricular fibrillation is the most lethal early arrhythmia

›Defibrillator at bedside

›Cardiac tamponade recognition

›Beck's triad: hypotension, JVD, muffled heart sounds

›May be incomplete or masked by concurrent hemorrhage

›Bedside eFAST for pericardial effusion

›Pericardiocentesis or emergent thoracotomy if tamponade confirmed

›Class I recommendation for emergent decompression

Monitoring and escalation targets

›Monitoring bundle

02History/hx56

Mechanism of injury

›High-risk mechanisms for blunt cardiac injury

›High-speed deceleration

›Motor vehicle collision (leading cause, approximately 48% of cases)

›Motorcycle collision

›Direct anterior chest impact

›Steering wheel deformity or impact

›Airbag deployment

›Other high-risk mechanisms

›Falls from height

›Crush injuries

›Blast injuries

›Sports-related direct chest impact

›Timing and cardiac cycle vulnerability

›End-diastole impact increases rupture risk (ventricles maximally distended)

›Early systole impact increases AV valve injury risk

›Speed of impact and deformity of vehicle or object

Presenting symptoms

›Chest pain characteristics

›Retrosternal or diffuse chest pain

›Angina-like quality

›Pleuritic component

›Pain potentially masked by coexisting injuries

›Rib or sternal fractures

›Pulmonary contusion

›Cardiac symptoms

›Palpitations

›Sense of irregular heartbeat or racing

03Physical Exam/exam40

Vital signs and hemodynamics

›Hemodynamic status

›Tachycardia (most common finding, nonspecific)

›Heart rate >100 suggests sympathetic activation or pain

›Hypotension

›SBP <90 mmHg or MAP <65 mmHg requiring urgent action

›Tachypnea and oxygen desaturation

›May indicate concurrent pulmonary contusion or hemothorax

Inspection

›Chest wall external signs

›Seatbelt sign

›Diagonal or transverse ecchymosis across anterior chest

›Anterior chest wall ecchymosis

›Steering wheel imprint pattern

›Chest wall deformity

›Sternal fracture or flail segment

›Jugular venous distension

›Elevated JVP suggests tamponade or right ventricular failure

Palpation and auscultation

›Chest wall palpation

›Sternal tenderness

›Midline sternal fracture crepitus

›Rib tenderness and crepitus

›Flail chest instability on palpation

›Cardiac auscultation

›Muffled heart sounds

›Beck's triad component for tamponade

›New murmur

04Differential Diagnosis/ddx38

Life-threatening cardiac diagnoses

›Acute myocardial infarction (ICD-10: I21)

›Traumatic coronary artery dissection

›Wall motion abnormality in coronary distribution (differentiating feature from BCI)

›Coronary angiography or CT coronary angiography to confirm

›Cardiac tamponade (ICD-10: I31.9)

›Chamber rupture or pericardial laceration

›Beck's triad: hypotension, JVD, muffled heart sounds

›eFAST confirms pericardial effusion

›Cardiac rupture (ICD-10: S26.0)

›Most commonly pre-hospital fatal

›Right atrium or right ventricle most vulnerable anatomically

›Valvular disruption (ICD-10: S26.8)

›Acute aortic or mitral regurgitation

›New murmur and hemodynamic instability

›Ventricular septal rupture (ICD-10: I23.2)

›Traumatic VSD

›Holosystolic murmur, step-up in oxygen saturation on right heart catheterization

Vascular diagnoses

›Aortic injury or transection (ICD-10: S25.0)

›Widened mediastinum on CXR

›CT aortography confirmatory

›Commotio cordis (ICD-10: S26.9)

›Concussive arrhythmia without structural damage

›No troponin elevation

›Typically in young athletes from low-velocity projectile impact

Non-cardiac mimics

›Tension pneumothorax (ICD-10: J93.1)

05Laboratory Tests/lt34

Cardiac biomarkers

›High-sensitivity cardiac troponin I or T (hs-cTn)

›Primary screening biomarker for blunt cardiac injury

›Sensitivity 62-77%, specificity 69-100% depending on assay

›Serial measurements at admission and 4-8 hours (EAST guideline recommendation)

›Elevated troponin mandates admission to monitored setting

›Normal troponin + normal ECG supports safe discharge consideration

›Troponin superior to CK-MB for BCI detection

›CK-MB no longer recommended when troponin available

›High-sensitivity troponin added value

›Earlier detection of myocardial injury

›Lower threshold of detection in low-level BCI

›Optimal serial interval not yet firmly established in BCI literature

Hematological and metabolic workup

›Complete blood count

›Hemorrhage burden assessment

›Baseline hemoglobin for serial comparison

›Thrombocytopenia if disseminated intravascular coagulation concern

›Basic metabolic panel

›Electrolyte disturbances potentiate arrhythmia

›Correct potassium to >4.0 mmol/l in arrhythmia setting

›Correct magnesium to >0.85 mmol/l

›Renal function baseline

›Coagulation studies

›PT/INR, aPTT for anticoagulant reversal planning

›Type and screen for polytrauma resuscitation

Hemodynamic and respiratory markers

›Lactate

06Diagnostic Tests/dt76

Scoring Systems

›Injury Severity Score (ISS)

›No validated scoring system specific to myocardial contusion

›ISS >25 associated with increased dysrhythmia risk

›Clinical judgment with mechanism and biomarkers guides workup

›EAST Practice Management Guidelines (Clancy et al. 2012)

›Recommend ECG as initial screening tool for all blunt chest trauma

›Abnormal ECG or elevated troponin: admit to monitored setting 24-48 hours

›Normal ECG + normal troponin: no further cardiac workup required

›ATLS algorithm for blunt cardiac injury triage

›Hemodynamically stable + normal ECG + normal troponin: observation then discharge

›Hemodynamically unstable or abnormal ECG or elevated troponin: monitored admission

›Hemodynamically unstable with suspected structural injury: emergent surgical consultation

MRI

›Cardiac MRI (CMR) indications

›Subacute setting when diagnosis remains uncertain

›Differentiates myocardial contusion from acute MI when echo inconclusive

›Identifies myocardial edema and hemorrhage via T2 and T1 mapping

›Not first-line in acute trauma (time and access constraints)

›ACR Appropriateness Criteria: usually appropriate for persistent unexplained cardiac dysfunction

›CMR findings in BCI

›Late gadolinium enhancement (LGE) pattern

›Traumatic contusion: non-ischemic pattern, mid-myocardial or epicardial distribution

›Acute MI pattern: subendocardial or transmural in coronary distribution

›Right ventricular involvement most common anatomically

›RV wall motion abnormality or RV LGE on CMR

CT

›CT chest with IV contrast

›First-line imaging for blunt chest trauma

›Identifies sternal fracture, rib fractures, hemopericardium, pneumothorax, hemothorax

›Cannot directly visualize myocardial contusion

›ACR Appropriateness Criteria: usually appropriate in significant blunt chest trauma

›Combined trauma CT (chest-abdomen-pelvis) when polytrauma suspected

›CT coronary angiography or CT aortography

›Indicated when aortic injury suspected (widened mediastinum, mechanism)

›CT angiography for aorta: sensitivity approaching 100%, specificity approaching 100%

›Cardiac CT coronary angiography when traumatic coronary dissection suspected

›Distinguishes coronary territory wall motion abnormality from global contusion

›CT findings associated with BCI risk

›Sternal fracture on CT

›Not independently predictive of significant BCI alone

›Use in context with ECG and troponin

Ultrasound

›eFAST (extended Focused Assessment with Sonography in Trauma)

›Bedside first-line cardiac assessment

›Subxiphoid view: pericardial effusion detection

›Cardiac tamponade physiology: right ventricular diastolic collapse

›Performed on all hemodynamically unstable blunt trauma patients

›Class I recommendation for pericardial effusion evaluation (ACEP)

›Transthoracic echocardiography (TTE)

›First-line cardiac imaging when ECG or troponin is abnormal

›Pooled sensitivity approximately 45%, specificity approximately 88%

›Limited value as screening tool; reserve for abnormal ECG, elevated troponin, hemodynamic instability, or new arrhythmia

›Findings evaluated on TTE

›Wall motion abnormalities (regional suggests coronary, global suggests contusion)

›Pericardial effusion

›Valvular regurgitation or structural disruption

›Right and left ventricular function (ejection fraction)

›Transesophageal echocardiography (TEE)

›Superior to TTE when acoustic windows are poor

›Intubated patients with chest wall injuries limiting TTE

›Intraoperative monitoring during cardiac or thoracic surgery

›Detects valvular injury, septal defects, aortic injury

›Higher sensitivity and specificity than TTE for structural lesions

›ECG (12-lead)

›Cornerstone screening tool for all blunt chest trauma patients

›Pooled sensitivity 62-71%, specificity approximately 80%

›Normal ECG negative predictive value approximately 95%

›Normal ECG + normal troponin negative predictive value approaches 100%

›Common findings in BCI

›Sinus tachycardia (most common, nonspecific)

›ST-segment elevation or depression

›T-wave inversions

›New right bundle branch block (RV most commonly injured chamber)

›Premature ventricular contractions

›Atrial fibrillation or flutter

›Ventricular tachycardia or fibrillation (life-threatening)

›AV conduction block

›Right-sided leads (V4R) consideration

›RV is the most commonly injured chamber due to anterior position

07Disposition/dispo44

Discharge criteria

›Safe discharge criteria (all must be met)

›Hemodynamically stable throughout observation

›No hypotension, no tachycardia requiring treatment

›Normal 12-lead ECG on presentation

›No arrhythmia, no new bundle branch block, no ST changes

›Normal serial troponin measurements

›Admission and 4-8 hour repeat both within normal range

›No other injuries requiring admission

›No significant rib fractures requiring pain management admission

›Discharge follow-up instructions

›PCP or cardiologist within 1-2 weeks

›Repeat ECG at follow-up if initial was borderline

›Restrict strenuous activity and contact sports until cleared

Telemetry admission criteria

›Admit to monitored bed for 24-48 hours

›Abnormal 12-lead ECG (any finding)

›New bundle branch block, ST changes, T-wave inversions

›Elevated troponin on any measurement

›Serial troponin monitoring q4-8 hours

›New arrhythmia detected

›Treat per ACLS protocols

›Age >55 with pre-existing cardiac disease

›Lower threshold for monitored admission

›Requirement for general anesthesia within 24 hours for other injuries

›Perioperative arrhythmia risk elevated

ICU admission criteria

›Intensive care unit indications

08Treatment/t68

Immediate resuscitation

›ATLS primary survey resuscitation

›Airway management

›Supplemental oxygen for SpO2 >94%

›Endotracheal intubation if airway protection lost

›Hemorrhagic shock management

›Massive transfusion protocol if hemorrhagic shock

›Permissive hypotension until hemorrhage controlled (MAP 50-65 mmHg in penetrating)

›Cardiogenic shock fluid strategy

›Cautious fluid resuscitation to avoid worsening RV overload

›Fluid bolus 250-500 mL then reassess

Arrhythmia management

›Ventricular fibrillation

›Immediate defibrillation per ACLS protocol

›200 J biphasic initial shock

›Epinephrine 1 mg IV/IO every 3-5 minutes if refractory

›Amiodarone 300 mg IV/IO bolus for refractory VF

›Ventricular tachycardia with pulse

›Hemodynamically unstable: synchronized cardioversion

›100-200 J biphasic

›Hemodynamically stable: amiodarone IV

›Amiodarone 150 mg IV over 10 minutes loading dose

›Followed by 1 mg/min continuous infusion for 6 hours

›Then 0.5 mg/min for 18 hours

›Maximum 2.2 g per 24 hours

›Atrial fibrillation with rapid ventricular response

›Rate control preferred over rhythm control acutely

›Metoprolol tartrate 2.5-5 mg IV every 5 minutes, maximum 3 doses

›Diltiazem 0.25 mg/kg IV over 2 minutes, then 5-15 mg/hour infusion

›Avoid anticoagulation acutely unless thrombosis confirmed

›Hemorrhagic pericardial effusion risk

›Symptomatic bradycardia or AV block

›Atropine 0.5 mg IV, may repeat to 3 mg total

›Transcutaneous pacing if atropine fails

›Transvenous pacing for complete heart block unresponsive to atropine

Hemodynamic support

›Vasopressor therapy for cardiogenic shock

›Norepinephrine: first-line vasopressor for mixed shock

›Start 0.05-0.1 mcg/kg/min IV infusion

›Titrate to MAP >65 mmHg

›Maximum 0.5-1.0 mcg/kg/min

›Dopamine: alternative when norepinephrine unavailable

›5-20 mcg/kg/min IV infusion

›Higher arrhythmogenic potential than norepinephrine

›Inotropic support for reduced cardiac output

›Dobutamine for reduced EF with adequate MAP

›Start 2-3 mcg/kg/min IV infusion

›Titrate by 2-3 mcg/kg/min every 10-15 minutes

›Target cardiac index >2.2 L/min/m2

›Maximum 20 mcg/kg/min

Structural injury management

›Cardiac tamponade

›Emergent pericardiocentesis

›Subxiphoid approach under ultrasound guidance

›Immediate aspiration of as little as 50-100 mL may restore hemodynamics

›Operative decompression (pericardiostomy)

›Preferred over repeat pericardiocentesis for traumatic effusion

›Valvular disruption or septal defect

›Hemodynamically unstable: emergent operative repair

›Cardiothoracic surgery consultation immediately

›Hemodynamically stable: medical optimization then semi-elective repair

›Intra-aortic balloon pump bridge for aortic or mitral regurgitation

Analgesics and supportive care

›Pain management

›Opioids for severe pain (fentanyl 1-2 mcg/kg IV PRN)

›Avoid NSAIDs if pericardial hemorrhage suspected

›Adequate analgesia prevents sympathetic activation worsening arrhythmia

›Anticoagulation

›Avoid anticoagulation unless clearly indicated

›Risk of hemorrhagic pericardial effusion

›If anticoagulation required, differentiate BCI from acute MI first with cardiac CT or MRI

›NPO status

›Maintain NPO if hemodynamically unstable or surgical intervention anticipated

09Special Populations/sp54

Pregnancy

›Physiological considerations in pregnant trauma patients

›Cardiac output increases 30-50% above baseline

›Physiological tachycardia at baseline can mask contusion-related tachycardia

›Uterine displacement: left lateral decubitus during resuscitation

›Relieves aortocaval compression after 20 weeks gestation

›Radiation exposure minimization

›CT chest justified when clinical indication present; fetal dose acceptable vs maternal risk

›Troponin interpretation in pregnancy

›hs-cTn levels may be mildly elevated at baseline near delivery

›Serial trending and clinical context essential

›Echo preferred to reduce radiation

›Treatment modifications

›Amiodarone: avoid if possible (fetal thyroid toxicity, class D)

›Lidocaine or procainamide as antiarrhythmic alternatives

›Metoprolol considered relatively safe for rate control

›Fetal growth restriction and bradycardia monitoring required

›Perimortem cesarean delivery at 4 minutes if maternal cardiac arrest

›Delivery improves maternal CPR effectiveness after 23 weeks gestation

Geriatric

›Age-related risk modifications

›Age >55 is independent risk factor for post-traumatic dysrhythmia

›Reduced cardiac reserve and diastolic dysfunction increase vulnerability

›Pre-existing conduction system disease lowers arrhythmia threshold

›Medication interactions

›Beta-blockers and calcium channel blockers mask tachycardia

›Digoxin and antiarrhythmics alter baseline ECG

›Review full medication list before interpreting ECG and vitals

10Background/b62

Epidemiology

›Incidence and prevalence

›Blunt cardiac injury (BCI) accounts for 14.5-38% of patients with blunt thoracic trauma

›Wide range reflects heterogeneous diagnostic criteria across studies

›Most common cardiac manifestation of trauma overall

›Motor vehicle collisions are the leading cause (approximately 48% of cases)

›Motorcycle collisions, falls, blast injuries, and sports as additional causes

›Mortality and morbidity

›Overall mortality for myocardial contusion managed nonoperatively approximately 6.9%

›Dysrhythmia incidence 19.5% in one large series after blunt thoracic trauma

›17.4% of those with dysrhythmia required new antiarrhythmic at discharge

›Delayed arrhythmias documented up to 4-6 days post-injury in case series

›Fatal ventricular arrhythmia possible even with initial normal ECG (rare)

›Population at risk

›Age >55 is independent risk factor for post-traumatic dysrhythmia

›Pre-existing cardiac disease increases complication risk

›ISS >25 and need for >5 units blood products are additional risk factors

Pathophysiology

›Mechanism of myocardial injury

›Blunt force transmitted to the heart causes patchy myocardial necrosis and hemorrhagic infiltrate

›Spectrum ranges from focal bruising to full-thickness necrosis

›Differs from ischemic MI: no coronary occlusion, patchy rather than territorial distribution

›Anatomical vulnerability

›Right ventricle most commonly injured due to anterior position behind sternum

›Right atrium less common; left ventricle less common due to posterior position and thicker wall

›Timing and cardiac cycle

›End-diastole impact (ventricles maximally distended) increases risk of rupture

›Early systole impact increases AV valve injury risk

›Mid-systole when valves are all closed provides some protection

›Cellular mechanisms

›Contusion disrupts myocyte architecture, mitochondria, and intercalated discs

›Calcium overload from direct membrane disruption triggers dysrhythmia

›Catecholamine surge from trauma amplifies arrhythmogenesis

›Inflammatory cascade

›Myocardial edema and pericardial inflammation develop over hours

›Troponin release reflects irreversible myocyte injury

›Structural complications

›Cardiac rupture: usually fatal before hospital arrival

›Chamber rupture occurs when hydraulic force exceeds tensile strength

›Valvular injury: aortic and mitral most common; mechanism is direct force on open valve

›Septal rupture: shear forces cause VSD (ventricular more common than atrial)

Therapeutic Considerations

›Diagnostic strategy evidence base

›Normal ECG + normal serial troponin combination

›Negative predictive value approaches 100% for clinically significant BCI

›EAST guidelines support discharge without further cardiac workup if both normal

›Troponin alone is insufficient screening

›ECG abnormalities may precede troponin elevation

›Both must be assessed and combined

›Monitoring duration evidence

›24-48 hours continuous telemetry for abnormal ECG or elevated troponin

›Delayed arrhythmias beyond 48 hours are rare but documented

›No high-quality evidence for monitoring beyond 48 hours in isolated BCI

›Serial troponin interval: admission and 4-8 hours is standard practice

›High-sensitivity assays may allow shorter intervals (0-2 hour protocols under investigation)

›Antiarrhythmic considerations

›Treat arrhythmias per standard ACLS protocols

›No specific antiarrhythmic protocol unique to BCI

›Electrolyte correction (K+ and Mg2+) is important adjunct

›Avoid prophylactic antiarrhythmic therapy without confirmed arrhythmia

›No evidence benefit in the absence of active dysrhythmia

›Prognosis and recovery

›Most clinically significant contusions resolve within days to weeks

›Patchy myocardial scarring may persist on CMR

›Long-term sequelae rare: ventricular aneurysm, constrictive pericarditis, arrhythmia

11Patient Discharge Instructions/pdi23

copy discharge instructions

›Diagnosis and injury explanation

›You have been diagnosed with a myocardial contusion (bruise to the heart muscle) following chest trauma

›The heart muscle was injured by the force of the impact

›Most patients recover fully without lasting problems

›Activity restrictions

›No strenuous exercise, heavy lifting, or contact sports until cleared by your doctor

›Avoid driving if you experience palpitations, dizziness, or chest pain

›Gradually return to normal activities as symptoms improve

›Medications

›Take all prescribed medications as directed

›Do not take ibuprofen (Advil, Motrin) or naproxen (Aleve) without physician approval

›Acetaminophen (Tylenol) is acceptable for pain management

›Follow-up appointments

›Follow up with your family doctor or cardiologist within 1-2 weeks

›Bring a list of all current medications to your follow-up appointment

›A repeat ECG may be required at your follow-up visit

›Return to emergency department immediately for

›Chest pain or pressure

›Palpitations or sensation of irregular heartbeat

›Fainting or near-fainting

›Shortness of breath at rest or with minimal activity

›Lightheadedness or dizziness

›Worsening or new symptoms

12References/r26

Guidelines and key sources

›Eastern Association for the Surgery of Trauma (EAST) guidelines

›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

›Recommends ECG as initial screening for all blunt chest trauma

›Normal ECG + normal troponin: no further cardiac workup required

›ACR Appropriateness Criteria

›Stojanovska J, Hurwitz Koweek LM, Chung JH, et al. ACR Appropriateness Criteria Blunt Chest Trauma-Suspected Cardiac Injury. J Am Coll Radiol. 2020

›CT chest with contrast: usually appropriate in blunt thoracic trauma

›Cardiac MRI: usually appropriate for persistent unexplained cardiac dysfunction

›Landmark reviews

›Pretre R, Chilcott M. Blunt Trauma to the Heart and Great Vessels. N Engl J Med. 1997

›Comprehensive anatomical and pathophysiological review

›Patel KM, Kumar NS, Desai RG, et al. Blunt Trauma to the Heart: A Review of Pathophysiology and Current Management. J Cardiothorac Vasc Anesth. 2022

›Current management algorithms including troponin and echo protocols

›Van Lieshout EMM, Verhofstad MHJ, et al. Diagnostic Approach for Myocardial Contusion. Eur J Trauma Emerg Surg. 2021

›Retrospective evaluation and literature review of diagnostic strategies

›Supporting studies

›Gao JM, Li H, Wei GB, et al. Blunt Cardiac Injury: A Single-Center 15-Year Experience. Am Surg. 2020

›Overall mortality 6.9%; arrhythmia data and structural injury distribution

›Jowers J, Van Derveer K, Moore K, et al. Incidence and Risk Factors of Developing a Dysrhythmia After Blunt Thoracic Trauma. J Clin Med. 2025

›19.5% dysrhythmia incidence; age >55 and ISS >25 as risk factors

›Eghbalzadeh K, Sabashnikov A, Zeriouh M, et al. Blunt Chest Trauma: A Clinical Chameleon. Heart. 2018

›Arrhythmia risk factors and need for >5 units blood products as predictor

›Nathwani JN, Baucom MR, Salvator A, et al. Evaluating the Utility of High Sensitivity Troponin in Blunt Cardiac Injury. J Surg Res. 2023

›High-sensitivity troponin performance characteristics in BCI

›Scagliola R, Seitun S, Balbi M. Cardiac Contusions in the Acute Care Setting. Am J Emerg Med. 2022

›Historical background, evaluation, and management update

Evidence & Review

Evidence & Review