Cardiac contusion: Difference between revisions
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==Background==
==Background==
*MVC with chest striking the steering wheel
*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 of these, found in 60-100% of all blunt cardiac injury. (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>)
**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.
*Can occur with decelerations from as little as less than 20mph<ref name="El-Chami" />


==Clinical Features==
==Clinical Features==
*Chest pain
*[[Chest pain]]
*Palpitations
*[[Palpitations]]
*Tachy
*[[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==
#Treat arrhythmia prn
#*Do NOT treat prophylacticly (increased mortality!)
#NO thrombolitics for AMI here (increased mortality)


severity depends on underlying CAD because of inflammatory changes= redistribute coronary flow that may= ischemic cp.
==Management==
*Treatment is generally supportive and based on clinical presentation<ref name="Sybrandy" />
*Do NOT treat arrhythmias prophylactically (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 (tele) for:
===Prognosis===
#abnl physical
*Generally favorable prognosis
#abnl 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]]

Revision as of 07:55, 23 July 2016

Background

  • Cardiac contusion is on the spectrum of Blunt cardiac injury (BCI), which ranges from mild contusion to cardiac rupture.[1]
    • Contusion is the most common of these, found in 60-100% of all blunt cardiac injury. (Other sources cite lower figures of 8-76%[2][3])
    • 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[2]

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[3]

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[4]
  • Imaging[4]
    • 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[4]
    • 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)[4]
    • 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[4]
  • 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[4]
  • 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[5]
    • 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[6]

See Also

References

  1. ↑ 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.
  2. ↑ 2.0 2.1 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.
  3. ↑ 3.0 3.1 El-Chami MF, Nicholson W, Helmy T. Blunt cardiac trauma. J Emerg Med. 2008 Aug;35(2):127-33.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Sybrandy KC, Cramer MJM, Burgersdijk C. Diagnosing cardiac contusion: old wisdom and new insights. Heart. 2003;89(5):485-489.
  5. ↑ Bock JS, Benitez RM. Blunt cardiac injury. Cardiol Clin. 2012 Nov;30(4):545-55. doi: 10.1016/j.ccl.2012.07.001.
  6. ↑ 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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