Cardiac contusion: Difference between revisions

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==Background==
==Background==
*Cardiac contusion is on the spectrum of [[Blunt cardiac injury]] (BCI), which ranges from mild contusion to cardiac rupture.<ref name="El-Menyar">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.</ref>
*Contusion is the most common type of [[blunt cardiac injury]] (60-100%) (Other sources cite lower figures of 8-76%<ref name="Emet" /><ref name="El-Chami">El-Chami MF, Nicholson W, Helmy T. Blunt cardiac trauma. J Emerg Med. 2008 Aug;35(2):127-33.</ref>)
**Contusion is the most common of these, found in 60-100% of all blunt cardiac injury. (Other sources cite lower figures of 8-76%<ref name="El-Chami">El-Chami MF, Nicholson W, Helmy T. Blunt cardiac trauma. J Emerg Med. 2008 Aug;35(2):127-33.</ref>)
*Range is due to lack of standardized diagnostic criteria.
**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<ref name="Emet">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.</ref>
*Mechanism of injury
 
**MVC is common, but crush injuries, CPR and others have also been described.
===Mechanism of injury===
**Can occur with decelerations from as little as less than 20mph<ref name="El-Chami" />
*MVC is common, but [[crush injuries]], [[CPR]] and others have also been described.
*Autopsy shows patchy necrosis and hemorrhage of damaged areas of myocardium.
*Can occur with decelerations from as little as less than 20mph<ref name="El-Chami" />
 
{{Background BCI}}


==Clinical Features==
==Clinical Features==
*Chest pain
*[[Chest pain]]
*Palpitations
*[[Palpitations]]
*Tachycardia
*[[Tachycardia]]
*Dyspnea/SOB
*[[Dyspnea]]/[[shortness of breath]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Thoracic trauma DDX}}
{{Thoracic trauma DDX}}


==Diagnosis==
==Evaluation==
*Physical
''Diagnosis is difficult due to spectrum of clinical disease and lack of adequate test in the ED''
**New murmur
*Physical exam
*EKG
**Majority (75%) of patients will have evidence of chest wall trauma<ref name="Sybrandy">Sybrandy KC, Cramer MJM, Burgersdijk C. Diagnosing cardiac contusion: old wisdom and new insights. Heart. 2003;89(5):485-489.</ref>
**most common abnormality in order
*Imaging<ref name="Sybrandy" />
***Sinus tachy
**[[CXR]] and CT Chest are neither sensitive nor specific for cardiac contusion, but may show other blunt cardiac injury
***PVCs
**Echocardiography may be useful - contusion will show localized wall motion abnormality
***A. fib
*[[ECG]] - may be normal or show non-specific abnormalities<ref name="Sybrandy" />
**Dysrythmia can be delayed for up to 12 hours
**most common abnormality in order (sinus tachycardia, PVCs, atrial fibrillation)
*Do NOT need enzymes but can help dx
**81–95% of life threatening ventricular arrhythmias and acute cardiac failures occur within the first 24–48 hrs
**Positive Trop
*[[Cardiac enzymes]] (Troponin, CK-MB)<ref name="Sybrandy" />
*Echo
**CK-MB is neither sensitive nor specific
**Can aid in further determining the extent of damage
**[[Troponin]] is specific for cardiac injury, but not sensitive for cardiac contusion


==Treatment==
==Management==
*Treat arrhythmia prn
*Treatment is generally supportive and based on clinical presentation<ref name="Sybrandy" />
**Do NOT treat prophylactically (increased mortality!)
*Do NOT treat arrhythmias prophylactically (increased mortality!)
*NO thrombolytics for AMI (increased mortality)
*Do NOT give thrombolytics for signs of [[myocardial infarction]] (increased mortality)


==Disposition==
==Disposition==
Observation for 6 hours
*Patients with mild injury, normal ECG, and negative Troponin can likely be discharged after period of observation<ref name="Sybrandy" />
*Admit to telemetry bed for:
**Hemodynamic instability
**Abnormal [[ECG]]
**Elevated troponin


*Admit to telemetry bed for:
===Prognosis===
**Abnormal physical exam
*Generally favorable prognosis
**Abnormal [[EKG]]
*Even if patient has minor wall motion abnormality, mild arrhythmia, etc, these usually resolve within 1 day<ref>Bock JS, Benitez RM. Blunt cardiac injury. Cardiol Clin. 2012 Nov;30(4):545-55. doi: 10.1016/j.ccl.2012.07.001.</ref>
**Hypotension
**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<ref>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.</ref>


==See Also==
==See Also==
[[Thoracic Trauma]]
*[[Blunt cardiac injury]]
*[[Thoracic Trauma]]


==References==
==References==
<References/>
<References/>


[[Category:Cards]]
[[Category:Cardiology]]
[[Category:Trauma]]
[[Category:Trauma]]

Latest revision as of 20:58, 17 August 2019

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

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. ↑ 1.0 1.1 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. ↑ 2.0 2.1 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. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 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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