Blunt Cardiac Injury, Screening for

Published 2012
Citation: J Trauma. 73(5):S301-S306, November 2012

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Authors

Clancy, Keith MD; Velopulos, Catherine MD; Bilaniuk, Jaroslaw W. MD; Collier, Bryan DO; Crowley, William MD[†]; Kurek, Stanley DO; Lui, Felix MD; Nayduch, Donna RN; Sangosanya, Ayodele MD; Tucker, Brian DO; Haut, Elliott R. MD

Author Information

From the Department of Surgery (K.C.), York Hospital Trauma Program, York, Pennsylvania; Department of Surgery (C.V., E.H.), Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Surgery (J.B.), Morristown Memorial Hospital, Morristown, New Jersey; Department of Surgery (B.C.), Carilion Roanoke Memorial Hospital, Roanoke, Virginia; Department of Surgery (S.K.), Lawnwood Regional Medical Center, Ft. Pierce, Florida; Department of Surgery (F.L.), Yale University, New Haven, Connecticut; Consultant (D.N.), Evans, Colorado; Department of Surgery (A.S.), University of Rochester Medical Center, Rochester, New York; Department of Surgery (B.T.), University of Kentucky, Lexington, Kentucky.

†Deceased.

Address for reprints: Keith Clancy, MD, York Hospital Trauma Program, 1001 South George St, York, PA 17405; email: kdclancy@yahoo.com.

Statement of the Problem

Diagnosing BCI can be difficult. Many patients with cardiovascular compromise from BCI are already admitted to the critical care setting based on their associated injuries, but much debate surrounds those patients who are hemodynamically stable on initial evaluation and do not otherwise require a higher level of care. It thus becomes crucial to determine what tests and diagnostic studies are required to safely rule out BCI, to allow for safe discharge home or admission to a nonmonitored setting. The decision to screen for BCI is clinician dependent because there are no standard criteria. Attempts have been made to identify specific injuries that might be highly associated with BCI, such as sternal fracture, but no such association has been demonstrated. In general, the literature supports that patients with any significant blunt trauma to the anterior chest should be screened.

Process

A computerized search of the National Library of Medicine MEDLINE database was undertaken using the Entrez interface. English-language citations were queried during the period of March 1997 through December 2011 using the primary search strategy: [((myocardial injury OR myocardial contusion) AND (traumatic OR trauma)) OR (heart injuries)] AND humans NOT (case reports OR letter OR comment OR news).

Review articles, autopsy studies, and investigations of indirect myocardial injury after trauma were excluded. The Related Articles algorithm was also used to identify additional articles similar to the items retrieved by the primary strategy. Of approximately 599 articles identified by these two techniques, those dealing with either prospective or retrospective studies examining BCI were selected, composing of 27 institutional studies evaluating diagnosis and management of adult patients with suspected or proven blunt cardiac trauma. Each article was reviewed by two members of the BCI workgroup. Data were collated, and a consensus was obtained for the final recommendations of this practice management guideline update (Table).

A separate search strategy was used to identify relevant radiology articles using the search ([blunt] AND [cardiac] AND [injury]). Because major changes in imaging technology have been widely adopted in the last 5 years, 2005 was chosen as a starting point. This yielded 13 articles, 3 of which examined radiologic diagnostic studies. The bibliographies of these articles were then hand searched to yield recent literature regarding utility of diagnostic imaging.

Assessment of Scientific Evidence

The scientific evidence assessment methods outlined by the EAST PMG committee should be applied when classifying the articles identified for review.[2] For purposes of practice management guidelines for trauma, the data will be classified as follows:

Class I: Prospective randomized controlled trials—the criterion standard of clinical trials. Some may be poorly designed, have inadequate numbers, or suffer from other methodological inadequacies.

Class II: Clinical studies in which the data were collected prospectively and retrospective analyses that were based on clearly reliable data. Types of studies so classified include observational studies, cohort studies, prevalence studies, and case-control studies.

Class III: Studies based on retrospectively collected data. Evidence used in this class indicates clinical series, database or registry review, large series of case reviews, and expert opinion.

Establishing the Recommendations

Level 1

The recommendation is convincingly justifiable based on the available scientific information alone. This recommendation is usually based on Class I data; however, strong Class II evidence may form the basis for a Level 1 recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, low-quality or contradictory Class I data may not be able to support a Level 1 recommendation.

Level 2

The recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. This recommendation is usually supported by Class II data or a preponderance of Class III evidence.

Level 3

The recommendation is supported by available data, but adequate scientific evidence is lacking. This recommendation is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future clinical research.

Recommendations

We first attempted to address previously determined recommendations and whether there was additional scientific evidence to support each one, move it to a different level, or eliminate it altogether. We then reviewed the literature to assess whether new recommendations could be made. Changes from the original guideline are noted accordingly.

Level 1

  1. An admission electrocardiogram (ECG) should be performed on all patients in whom BCI is suspected (no change).

Level 2

  1. If the admission ECG reveals a new abnormality (arrhythmia, ST changes, ischemia, heart block, and unexplained ST changes), the patient should be admitted for continuous ECG monitoring. For patients with preexisting abnormalities, comparison should be made to a previous ECG to determine need for monitoring (updated).
  2. In patients with a normal ECG result and normal troponin I level, BCI is ruled out. The optimal timing of these measurements, however, has yet to be determined. Conversely, patients with normal ECG results but elevated troponin I level should be admitted to a monitored setting (new).
  3. For patients with hemodynamic instability or persistent new arrhythmia, an echocardiogram should be obtained. If an optimal transthoracic echocardiogram cannot be performed, the patient should have a transesophageal echocardiogram (updated).
  4. The presence of a sternal fracture alone does not predict the presence of BCI and thus should not prompt monitoring in the setting of normal ECG result and troponin I level (moved from Level 3).
  5. Creatinine phosphokinase with isoenzyme analysis should not be performed because it is not useful in predicting which patients have or will have complications related to BCI (modified and moved from Level 3).
  6. Nuclear medicine studies add little when compared with echocardiography and should not be routinely performed (no change).

Level 3

  1. Elderly patients with known cardiac disease, unstable patients, and those with an abnormal admission ECG result can safely undergo surgery provided that they are appropriately monitored. Consideration should be given to placement of a pulmonary artery catheter in such cases (no change).
  2. Troponin I should be measured routinely for patients with suspected BCI; if elevated, patients should be admitted to a monitored setting and troponin I should be followed up serially, although the optimal timing is unknown (new).
  3. Cardiac computed tomography (CT) or magnetic resonance imaging (MRI) can be used to help differentiate acute myocardial infarction (AMI) from BCI in trauma patients with abnormal ECG result, cardiac enzymes, and/or abnormal echo to determine need for cardiac catheterization and/or anticoagulation (new).

Scientific Foundation

Electrocardiogram

Five studies evaluated the utility of ECG in diagnosis of BCI. One study determined that a normal ECG effectively ruled out BCI. This is consistent with the findings of the first BCI guideline.[3] Fulda et al.[4] determined that initial ECG is the best single overall predictor of BCI.

A recent study by Nagy et al.[5] evaluated which patients required evaluation for BCI following blunt chest trauma. They concluded that patients with abnormal ECG result or cardiac failure following blunt chest trauma should be admitted to a monitored bed, as 6 of 22 of the patients with BCI ultimately required treatment.

Four studies determined, however, that a normal ECG alone does not rule out significant BCI.[4][6–8] One study used transesophageal echocardiography to diagnose BCI, which was defined as a wall motion abnormality or dilation of the cardiac chambers.[6] Only 59% of the patients who had significant findings on transesophageal echocardiogram (TEE) presented with an abnormal ECG result. In the study of Fulda et al., 24% of the patients with a mechanism for BCI had a normal ECG result at admission, and 41% of these patients developed a clinically significant abnormality. Salim et al.[8] and Velmahos et al.[7] found that a small but significant number of patients in their studies also presented with normal ECG result, but were later diagnosed with BCI.

There have been attempts to use specialized types of ECG to improve the predictive value of this modality. Because the right ventricle is believed to be the more likely injured cardiac chamber in BCI, Walsh et al.[9] assessed the ability of V4R (right-sided ECG) to aid the diagnosis of BCI. Forty-five patients with blunt chest trauma and 40 unmatched controls were compared with standard 12-lead ECG and right precordial leads. The authors concluded that patients with a significant mechanism and physical findings of blunt chest trauma were more likely than controls to have an abnormal 12-lead ECG result; they were not more likely to have abnormalities in V4R. Right-sided ECG was not helpful in diagnosing BCI. Fulda et al.[4] examined the role of signal-averaged ECG and found it to be of no benefit.

Echocardiogram

In the first BCI guideline, multiple studies showed that routine transthoracic echocardiogram is not useful as a primary screening modality but rather as a diagnostic test for patients who have unexplained hypotension or arrhythmias. Recent studies are consistent with this determination.[4][5][7][10–13]

The literature also supports reserving echocardiogram for symptomatic patients even with significant mechanism of injury. Specifically, patients with isolated sternal fracture do not need screening for BCI.[10][11]

Cardiac Enzymes

Creatinine Phosphokinase

Four studies assessed the utility of creatinine phosphokinase and its isoenzyme CK-MB. They determined that CK-MB was not useful for diagnosing BCI, as was suggested by the original guideline.[4][6][14][15]

Swaanenburg et al.[14] obtained CK, CK-MB, troponin I, and troponin T levels and compared patients based on the presence or absence of thoracic injury. They determined that CK-MB, CK-MB/CK total ratio, CK-MB mass, and CK-MB mass/CK total ratio were not useful in detecting myocardial damage after blunt chest trauma.

Another study of hemodynamically stable patients with BCI after blunt chest trauma evaluated the prognostic value of cardiac troponin I (cTnI), cardiac troponin T (cTnT), CK, CK-MB, and their ratios.[15] Neither CK nor CK-MB was able to differentiate those with BCI from those without.

Troponin

Initial studies indicated that troponin was not helpful in the diagnosis of BCI, and thus, it was not recommended in the first set of EAST BCI recommendations. Swaanenburg et al.[14] obtained troponin I and troponin T at admission and 24 hours later and compared patients based on the presence or absence of thoracic injury. The study found that cTnI and cTnT were more reliable than the CK biomarkers, but if initial values were negative, the repeat analysis at 24 hours was necessary to help diagnose myocardial damage. Of the patients with blunt thoracic trauma, only three were determined to have BCI, and this subgroup was not further clarified. This study did not determine to evaluate patients with BCI but rather evaluated patients with blunt thoracic trauma and compared them with patients without blunt thoracic trauma.

Another study of hemodynamically stable patients with BCI after blunt chest trauma evaluated the prognostic value of cTnI, cTnT, CK, CK-MB, and their ratios.[15] Because of the low sensitivity of cTnT (12%) and cTnI (23%), neither provided an improved method of diagnosis of BCI.

One study of severe trauma patients evaluated patients with BCI diagnosed by abnormal ECG result and subcategorized patients based on magnitude of troponin I elevation (greater or less than 2 µg/L) and duration of elevation (very transient, ≤12 hours; transient, ≤36 hours; and sustained, ≥36 hours). This study determined that patients with sustained elevations had a greater likelihood of coronary injury, but elevated troponin levels had no prognostic value for BCI. Of note, the level of elevated troponin I for this study was greater than that for other studies.[7][8]

Collins et al.[3] conducted a prospective study that evaluated the usefulness of serum troponin (cTnI) levels to evaluate cardiac injury. This study found that positive cTnI had a low positive predictive value. Furthermore, they found that a negative ECG result alone ruled out BCI. In this study, they also found that if the ECG result was abnormal but the cTnI level was normal, a BCI was ruled out. Patients with both abnormal ECG result and abnormal cTnI level should be admitted with telemetry monitoring.

In a study by Rajan et al.[16] a cTnI less than 1.05 µg/L drawn immediately upon evaluation or at 6 hours in the asymptomatic patient ruled out BCI. The authors concluded that a cTnI greater than 1.05 µg/L necessitated further workup. Neither CK total or CK-MB were helpful in predicting BCI.

Further studies specifically targeting BCI rather than all comers for thoracic injury seem to show that a small, but important, group of patients may present with a normal ECG result and clinically significant cardiac injury that is identified early only with the addition of troponin. In a 2001 prospective study by Salim et al.,[8] patients with significant blunt thoracic trauma were evaluated with ECG at admission and 8 hours as well as cTnI at admission, 4 hours, and 8 hours. Of the 19 patients (16.5%) with significant BCI, all were admitted to the intensive care unit for associated injuries. The negative predictive value (NPV) for BCI improved from 95% with ECG alone to 100% for ECG and cTnI combined. The authors concluded that patients with both a normal ECG result and normal cTnI level at admission and no other injuries requiring admission could be safely discharged home without further monitoring.

When the same population was combined with more patients by Velmahos et al.,[7] their prospective study determined that a negative troponin and normal ECG results ruled out BCI, but a normal ECG result alone could not rule out BCI. The incidence of significant BCI in their study was 13%, which they defined as cardiogenic shock, arrhythmia requiring treatment, posttraumatic structural defects, or unexplained hypotension. Importantly, 5 of 67 patients with normal initial ECG result had a positive result for troponin and clinically significant BCI defined by hypotension, arrhythmia, decreased cardiac index, and/or need for treatment. An abnormal cTnI level was defined as greater than 1.5 ng/mL. All patients with significant BCI required admission to the intensive care unit for associated injuries. Forty-one patients with normal ECG result and troponin level at admission and 8 hours, but significant mechanism, were admitted for 1 day to 3 days of observation. None of these patients developed clinically significant BCI. The authors determined that the NPV of normal ECG result and normal cTnI level was 100%. They concluded that patients with normal ECG result and normal cTnI level at admission were at no risk of developing subsequent cardiac instability requiring intervention and could be safely discharged without further monitoring.

An additional study evaluating the role of troponin T and signal-averaged ECG prospectively evaluated patients with chest wall injuries; patients received daily ECG, signal-averaged ECG, and serial troponin T levels as well as creatinine phosphokinase (CK-MB).[4] A troponin T level of 0.02 µg/L or greater was considered elevated. Patients with preexisting cardiac disease were excluded from the study, as were patients discharged in less than 48 hours. This study determined that, while ECG is the single best predictor of BCI, the best combined predictors of the development of clinically significant disease are ECG and troponin.

These more recent studies show that ECG alone is not sufficient to definitively rule out BCI, which is a major change from the previous EAST PMG. This recommendation is based on data from four studies representing more than 500 prospectively studied patients, taking into account the overlap from the studies of Salim et al. and Velmahos et al. and not counting them twice. Most of the studies show that the addition of troponin I increases the NPV to 100%. When looking at a 5% difference combining ECG and troponin, the effect may seem relatively small; however, this represents an inexpensive way (certainly less expensive than a day in the hospital) to allow safe discharge, as well as being a way to identify patients who potentially need further workup to prevent harm. When the risk is low (a blood test) and the benefit is relatively high (no missed diagnosis and decreased length of stay), the potential effect is more significant and thus represents a stronger recommendation.

One recent study looked at the use of troponin I in the pediatric trauma population, finding that it was elevated in 27%. Elevation was associated with higher injury severity and interventions, although the degree of elevation was not indicative of the degree of injury. Furthermore, peak troponin I did not correlate with abnormalities on cardiac echo and was not useful in detecting cardiac injury. No recommendations can be made for this population.[17]

Sternal Fracture

Five studies evaluated the relationship of sternal fracture to BCI. Four of those studies concluded that sternal fracture was not a marker for BCI.

Sadaba et al.[18] evaluated 37 patients with isolated sternal fracture. Of those patients with a normal chest radiograph and normal ECG results, none exhibited any signs or symptoms of BCI. They concluded that isolated sternal fracture is not a marker for BCI and these patients could be safely discharged if they had a normal chest radiograph and normal ECG results.

In a retrospective review of 100 patients, 67 of whom had isolated sternal fractures, the incidence of BCI was 4%, which was diagnosed by ECG.[10] Echocardiography did not add to the ability to diagnose BCI and was not recommended as a screening tool in the evaluation of patients with isolated sternal fractures.

In a second retrospective review of 50 patients with diagnosis of sternal fracture, of the 30 patients with isolated sternal fracture, only 1 patient (3%) had a BCI.[11] This patient had a normal echocardiogram result, with myocardial contusion diagnosed by ECG. No clinical intervention was needed. Because this was a retrospective study, no information was available regarding any hemodynamic instability as a result of the BCI. While the authors recommended that an echocardiogram be used for patients with sternal fracture and moderate (Injury Severity Score [ISS], 6–15) or severe (ISS > 16) injury, no clinically actionable abnormalities were identified on any of the abnormal echocardiography results. Thus, in a patient with isolated sternal fracture, the diagnostic algorithm should remain the same as in other patients with suspected BCI.

In a study that assessed cardiovascular injury associated with sternal fracture, the authors found that sternal fracture either with or without a retrosternal hematoma was not a marker for BCI.[19]

A final study retrospectively examining the relationship between sternal fractures and BCI determined that patients with isolated sternal fractures, in the absence of hemodynamic instability, could be safely discharged without further workup.[20] Management of patients with sternal fracture should be directed at the management of associated injuries.

Multidetector CT/MRI

Previously, the utility of helical CT was compared with TEE for diagnosis of blunt cardiac injuries and associated injuries such as valvular damage.[12] Both modalities had similar ability to identify surgically acute thoracic aortic injury. In a select group of ninety-five patients in this prospective study, multiplane TEE was compared with helical chest CT for the diagnosis of traumatic cardiovascular injury. Of the four patients with “myocardial contusion,” all were diagnosed by TEE, and none were diagnosed by helical chest CT. Helical chest CT at that time (2001) was considered unreliable in identifying BCI and its associated cardiac injuries.

MRI has been used in the past to diagnose significant cardiac disease, including impending cardiac rupture and valvular compromise. Most studies involve case reports and anecdotal evidence. The potential benefit is in being able to distinguish direct traumatic cardiac disease from ischemic peritraumatic disease arising from coronary artery disease that would warrant further interrogation with cardiac catheterization, thus sparing the former group an unnecessary intervention. This modality requires a stable patient and is associated with a relatively greater cost than other imaging modalities. The quality of MRI is also more variable from institution to institution.[21][22]

CT technology has changed markedly since the first EAST BCI guideline. Multidetector CT (MDCT) became available around 2002, becoming widely adopted by 2005. The advent of MDCT with ECG-gated capabilities promises to give new sensitivity and specificity to the diagnosis of BCI. The ability to accurately distinguish types of injury to the myocardium seems to be approaching that of MRI, in a much faster and less expensive way. Formerly hampered in resolution by patient motion and increased cardiac activity via tachycardia, current scanners are much faster and can be gated to take images only in diastole, with immediate reconstruction of the combined images.[22–25] CT can identify very small pericardial effusions, pericardial tears, and rarer entities such as cardiac luxation, characterized by displacement of the heart to the left, entrapment of the left atrium and ventricle, and pneumopericardium. A combined modality with MDCT Angiography shows coronary anatomy and can gauge myocardial function and perfusion.[26–28]Differentiation between BCI and AMI must be established to determine whether to proceed with cardiac catheterization or anticoagulation that would be helpful in AMI but potentially harmful in BCI, especially in the setting of associated traumatic injury.

Future Investigation

To advance our understanding of BCI diagnosis, future studies should address the role of troponin in ruling out BCI. Specifically, questions remain as to whether troponin I or troponin T is the more appropriate test, the timing of the test, if the test needs to be repeated, or whether a single value is adequate. Furthermore, the literature still has ambiguity as to what value constitutes a positive troponin. This information will advance our ability to provide cost-efficient workup for BCI and allow us to safely discharge patients without the danger that they will subsequently develop clinically significant sequelae of BCI that requires treatment.

Changes in our ability to detect and differentiate myocardial injury, particularly in our aging population, offers a potential for change in practice as well. Further studies are needed to assess the sensitivity and specificity of MDCT in the trauma population and to identify those patients who might benefit from cardiac CT.

Summary

The diagnosis of BCI remains challenging but should be considered in those patients with significant mechanism of injury and in those who respond poorly to resuscitative efforts. To date, no single test is able to rule in or rule out BCI. The challenge remains to identify those with clinically significant BCI while limiting costly workup for patients with low risk of hemodynamic instability from BCI. Many of the patients in the articles reviewed who were diagnosed with BCI requiring intervention were admitted to the intensive care unit for associated injuries. What is still not clear from the literature is how much testing needs to be completed to determine that a patient can be safely discharged without further monitoring.

ECG remains the most commonly recommended tool for initial diagnosis of BCI. Less clear is the role that troponin should play in addition to ECG in the diagnostic workup, although it seems that this may allow for safe discharge or admission to a regular ward. A normal ECG result has an excellent NPV, in most studies being greater than 95%. Some studies, however, indicate that the addition of troponin I will increase the NPV to 100%, which could potentially decrease overall costs should that allow for more discharges and avoidance of intensive care unit stay.

The marked advancements in CT technology in the last decade will likely change our ability to differentiate traumatic from ischemic injury in our patients, particularly in a high-risk, aging population. Because traumatic injury is superimposed on preexisting morbidities, this distinction becomes increasingly important as the treatment algorithm is markedly divergent between AMI and BCI.

Authorship

All authors collected, analyzed, and interpreted the data. K.C., C.V., J.B., B.C., S.K., F.L., D.N., A.S., B.T., and E.H. critically revised the manuscript. K.C. and E.H. designed the study. K.C., C.V., and E.H. conducted the literature search and wrote the manuscript.

Disclosure

E.R.H. is the PI of a Mentored Clinical Scientist Development Award K08 1K08HS017952-01 from the AHRQ entitled “Does Screening Variability Make DVT an Unreliable Quality Measure of Trauma Care?” E.R.H. receives royalties from Lippincott, Williams, Wilkins for a book he coauthored, Avoiding Common ICU Errors. E.R.H. has given expert witness testimony in various medical malpractice cases. The authors declare no conflicts of interest.

References

  1. Pasquale M, Nagy K, Clarke J. Practice management guideline for screening of blunt cardiac injury. J Trauma. 1998; 44: 941–956.
  2. Eastern Association for the Surgery of Trauma (EAST) Ad Hoc Committee on Practice Management Guideline Development. Utilizing evidence based outcome measures to develop practice management guidelines: a primer. EAST; 2000. Available at: http://www.east.org/tpg/primer.pdf.
  3. Collins J, Cole F, Weireter L, et al.. The usefulness of serum troponin levels in evaluating cardiac injury. Am Surg. 2001; 67: 821–826.
  4. Fulda G, Giberson F, Hailstone D, et al.. An evaluation of serum troponin T and signal-averaged electrocardiography in predicting electrocardiographic abnormalities after blunt chest trauma. J Trauma. 1997; 43: 304–312.
  5. Nagy K, Krosner S, Roberts R, et al.. Determining which patients require evaluation for blunt cardiac injury following blunt chest trauma. World J Surg. 2001; 25: 108–111.
  6. Garcia-Fernandez M, Lopez-Perez J, Perez-Castellano N, et al.. Role of transesophageal echocardiography in the assessment of patients with blunt chest trauma: correlation of echocardiographic findings with the electrocardiogram and creatine kinase monoclonal antibody measurements. Am Heart J. 1998; 135: 476–481.
  7. Velmahos G, Karaiskakis M, Salim A, et al.. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma. 2003; 54: 45–51.
  8. Salim A, Velmahos G, Jindal A, et al.. Clinically significant blunt cardiac trauma: role of serum troponin levels combined with electrocardiographic findings. J Trauma. 2001; 50: 237–243.
  9. Walsh P, Marks G, Aranguri C, et al.. Use of V4R in patients who sustain blunt chest trauma. J Trauma. 2001; 51: 60–63.
  10. Athanassiadi K, Gerazounis M, Moustardas M, et al.. Sternal fractures: retrospective analysis of 100 cases. World J Surg. 2002; 26: 1243–1246.
  11. Wiener Y, Achildiev B, Karni T, et al.. Echocardiogram in sternal fracture. Am J Emerg Med. 2001; 19: 403–405.
  12. Vignon P, Boncoeur M, Francois B, et al.. Comparison of multiplane transesophageal echocardiography and contrast-enhanced helical CT in the diagnosis of blunt traumatic cardiovascular injuries. Anesthesiology. 2001; 94: 615–622.
  13. Velmahos G, Tatevossian R, Demetriades D. The “seat belt mark” sign: a call for increased vigilance among physicians treating victims of motor vehicle accidents. Am Surg. 1999; 65: 181–185.
  14. Swaanenburg J, Klaase J, DeJongste M, et al.. Troponin I, troponin T, CKMB-activity and CKMB-mass as markers for the detection of myocardial contusion in patients who experienced blunt trauma. Clin Chim Acta. 1998; 272: 171–181.
  15. Bertinchant J, Polge A, Mohty D, et al.. Evaluation of incidence, clinical significance, and prognostic value of circulating cardiac troponin I and T elevation in hemodynamically stable patients with suspected myocardial contusion after blunt chest trauma. J Trauma. 2000; 48: 924–931.
  16. Rajan G, Zellweger R. Cardiac troponin I as a predictor of arrhythmia and ventricular dysfunction in trauma patients with myocardial contusion. J Trauma. 2004; 57: 801–808.
  17. Sangha GS, Pepelassis D, Buffo-Sequeira I, et al.. Serum troponin-I as an indicator of clinically significant myocardial injury in paediatric trauma patients. Injury. 2011. [Epub ahead of print].
  18. Sadaba J, Oswal D, Munsch C. Management of isolated sternal fractures: determining the risk of blunt cardiac injury. Ann R Coll Surg Engl. 2000; 82: 162–166.
  19. Rashid M, Ortenwall P, Wikstrom T. Cardiovascular injuries associated with sternal fractures. Eur J Surg. 2001; 167: 243–248.
  20. Chiu W. Sternal fractures in blunt chest trauma: a practical algorithm for management. Am J Emerg Med. 1997; 15: 252–255.
  21. Southam S, Jutila C, Ketai L. Contrast-enhance cardiac MRI in blunt chest trauma: differentiating cardiac contusion from acute peri-traumatic myocardial infarction. J Thorac Imaging. 2006; 21: 176–178.
  22. Malbranque G, Serfaty JM, Himbert D, et al.. Myocardial infarction after blunt chest trauma: usefulness of cardiac ECG-gated CT and MRI for positive and aetiologic diagnosis. Emerg Radiol. 2011; 18: 271–274.
  23. Co SJ, Yong-Hing CJ, Galea-Soler S, et al.. Role of imaging in penetrating and blunt traumatic injury to the heart. Radiographics. 2011; 31: E101–E105.
  24. Leibecke T, Stoeckelhuber BM, Gellisen J, et al.. Posttraumatic and postoperative cardiac luxation: computed tomography finding in nine patients. J Trauma. 2008; 64: 721–726.
  25. Scaglione M, Pinto A, Pedrosa I, et al.. Multi-detector row computed tomography and blunt chest trauma. Eur J Radiol. 65: 377–388.
  26. Oikonomou A, Prassopoulos P. CT imaging of blunt chest trauma. Insights Imaging. 2011; 2: 281–295.
  27. Mirvis SE. Imaging of acute thoracic injury: the advent of MDCT screening. Semin Ultrasound CT MR. 2005; 26: 305–331.
  28. Sheikh M, Ben-Nakhi A, Shukkur AM, et al.. Accuracy of 64-multidetector-row computed tomography in the diagnosis of coronary artery disease. Med Princ Pract. 2009; 18: 323–328.

Table

March 1997 – December 2011

First Author

Year

Reference Title

Class

Conclusions

Sanfa GS

2011

Serum troponin-I as an indicator of clinically significant myocardial injury in paediatric trauma patients. Injury. 2011 Nov 25.

 

3

Observational study.  Prevalence of elevated TnI in pediatric trauma patients is 27%.  While this correlates with overall severity of injury, it does not correlate with myocardial injury.

Co SJ

2011

Role of imaging in penetrating and blunt traumatic injury to the heart.  Radiographics. 2011 Jul-Aug;31(4):E101-105.

3

Review.  Multidetector CT has increased the diagnosis of cardiac injury, and is the most important diagnostic tool in initial evaluation of patients who have sustained blunt cardiac injury.

Malbranque G

2011

Myocardial infarction after blunt chest trauma: usefulness of cardiac ECG-gated CT and MRI for positive and aetiologic diagnosis. Emerg Radiol. 2011 Jun;18(3):271-4.

3

Case reports.  ECG gating is able to identify specific coronary lesions to differentiate acute myocardial infarction from traumatic cardiac injury.

Oikonomou A

2011

CT imaging of blunt chest trauma. Insights Imaging. 2011 Jun;2(3):281-295.

3

Review.  The advent of MDCT has decreased time required to scan trauma patients and allowed for improved detection of injuries.  It is now the gold standard for diagnosis of many injuries, such as aortic injury.  When mediastinal hematoma is excluded as an indirect sign of aortic injury, sensitivity and specificity are 98% and 100%.

Sheikh M

2009

Accuracy of 64-multidetector-row computed tomotgraphy in the diagnosis of coronary artery disease. Med Princ Pract 2009;18(4):323-328.

3

Prospective study comparing MDCT to coronary angiography.  Patients with suspected CAD who were scheduled to have cardiac catheterization first underwent MDCT, with blinding of the radiographers and those performing the catheterizations to the respective results.  Sensitivity and specificity were high for CTA of the main vessels.  Sensitivity was lower for segmental arteries, but specificity was still good, making it a useful tool for ruling out significant disease.

Leibecke T

2008

Posttraumatic and postoperative cardiac luxation: computed tomography finding in nine patients. J Trauma 2008;64(3):721-726.

3

Case series.  Traumatic cardiac luxation represents a serious complication of pericardial rupture.  CT is useful in identifying this early so the intervention can be instituted in a timely fashion and delay morbidity and mortality.

Scaglione M

2008

Multi-detector row computed tomography and blunt chest trauma. Eur J Radiol 65:377-388.

3

Review.  MDCT is highly sensitive for blunt chest trauma and should be used as an important adjunct in the evaluation of patients who have sustained blunt chest trauma.

Southam S

2006

Contrast-enhance cardiac MRI in blunt chest trauma: differentiating cardiac contusion from acute peri-traumatic myocardial infarction.  J Thorac Imaging 2006;21(2):176-178.

3

Case report.  Myocardial contusion and myocardial infarction have distinct findings on cardiac MRI that allow for differentiation between the two, which aids in therapeutic decision making. 

Mirvis SE

2005

Imaging of acute thoracic injury: the advent of MDCT screening. Semin Ultrasound CT MR 2005;26(5):305-331.

3

Review.  The increased sensitivity of MDCT aids in not only the diagnosis, but the characterization of blunt thoracic injury.  Routine use is practical and efficient.

Ismailov RM

 

 

2005

Blunt cardiac injury associated with cardiac valve insufficiency: trauma links to chronic disease?

Injury. 2005;36:1022-8. 

3

A retrospective review of hospital discharge database. There was an increased association of Limited conclusions based the nature of the database (discharge) used, there are associations but no ability to determine cause and effect

Rajan GP

 

2004

Cardiac troponin I as a predictor of arrhythmia and ventricular dysfunction in trauma patients with myocardial contusion.

J Trauma. 2004;57:801-8 

2

Prospective observational study of 187 multiply injured patients with blunt chest trauma and suspected BCI. Troponin I <1.05 ruled out BCI. Authors recommended that for cTnI >1.05mg/L should undergo further cardiac evaluation and monitoring.

Edouard AR

 

2004

Incidence and significance of cardiac troponin I release in severe trauma patients.

Anesthesiology. 2004;101:1262-8. 

2

Observational study. Elevated troponin had no prognostic value for stable patients, but authors recommend that positive values need further work up

Myocardial contusion was diagnosed by ECG criteria.

Significant elevation of cTnI >2.0 mg/L

Values for cTnI in predicting BCI:

Sensitivity: 63%

Specificity: 98%

PPV: 40%

NPV: 98%

Lancey RA

 

2003

Correlation of clinical characteristics and outcomes with injury scoring in blunt cardiac trauma.

J Trauma. 2003;54:509-15. 

2/3

Retrospective review of 47 patients with dx BCI. Higher OIS grades seem to correlate with severity of injury and survival.

 

Velmahos GC

 

2003

Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury.

J Trauma. 2003;54:45-51 

2

Prospective observational study (n=333) pts with chest trauma followed with cTnI, serial ECGs, and selective use of echo. The combination of normal ECG and enzymes at 8h post trauma rules out significant injury (NPV=100%).  If both enzymes and ECG are abnormal, PPV of 34% of significant blunt cardiac injury. 5/67 patients with normal ECG had positive troponin and had “significant BCI” (significant defined as hypotension, arrhythmia, decreased cardiac index, treatment required).

This study suggests that a normal ECG by itself, cannot rule out significant BCI.

Lindstaedt M

 

 

2002

Acute and long-term clinical significance of myocardial contusion following blunt thoracic trauma: results of a prospective study.

J Trauma. 2002;52:479-85.

2

Prospective observational study (n=118) with 3 and 12 month follow up. BCI dx by ECG changes and CK-MB>7%. Patients who are hemodynamically stable on admission do not deteriorate. Routine work up for patients with thoracic trauma is not necessary for patients to rule in or out BCI.

Athanassiadi K

 

2002

Sternal fractures: retrospective analysis of 100 cases.

World J Surg. 2002;26:1243-6. 

2

Retrospective study of 100 patients with sternal fracture, one patient had “cardiac contusion”. Routine screening with echo not warranted for sternal fractures

Collins JN

 

2001

The usefulness of serum troponin levels in evaluating cardiac injury.

Am Surg. 2001;67:821-6. 

2

Prospective (n=66) Positive troponin values have a low PPV. Normal ECG rules out BCI. Abnormal ECG with normal troponin rules out BCI. Patients with abnormal ECG and troponin should be admitted with telemetry.

Wiener Y

 

2001

Echocardiogram in sternal fracture.

Am J Emerg Med. 2001;19:403-5. 

3

Incidence of BCI with sternal fracture was 8% (4/50). None of these patients required intervention for their BCI. Patients with isolated sternal fracture do not require echocardiogram.

Walsh P

 

2001

Use of V4R in patients who sustain blunt chest trauma.

J Trauma. 2001;51:60-3. 

2

45 blunt chest trauma pts vs 40 unmatched control subjects. Left sided ECGs were distinguishable from between chest trauma pts and controls. Right sided ECG does not add to the diagnosis of BCI

Vignon P

2001

Comparison of multiplane transesophageal echocardiography and contrast-enhanced helical CT in the diagnosis of blunt traumatic cardiovascular injuries.

Anesthesiology. 2001;94:615-22

1/2

Prospective, observational study (n=110)

TEE superior to CT in diagnosis of cardiac injury (eg, valve damage). CT does not rule out BCI

Rashid MA

 

2001

Cardiovascular injuries associated with sternal fractures.

Eur J Surg. 2001;167:243-8. 

3

Retrospective chart review (n=418, 29 sternal fractures). Sternal fracture is not a marker for BCI

Salim A

 

2001

Clinically significant blunt cardiac trauma: role of serum troponin levels combined with electrocardiographic findings.

J Trauma. 2001;50:237-43. 

2

Prospective, non-randomized (n=115). NPV of normal ECG and troponin was 100% in combination. Normal ECG did not rule out BCI

 

 

Nagy KK

 

2001

Determining which patients require evaluation for blunt cardiac injury following blunt chest trauma.

World J Surg. 2001 Jan;25(1):108-11. 

2

Patients with an abnormal ECG need monitoring. Patients with normal ECG, hemodynamics, and cardiac enzymes do not need further intervention.

Swan KG Jr

 

2001

Decelerational thoracic injury.

J Trauma. 2001;51:970-4

3

Single institution retrospective review of decelerational thoracic injuries. Of the 171 patients with ICD-9 codes for myocardial contusion, only 38 (22%) had that diagnosis supported on review of the medical record.

Sadaba JR

 

2000

Management of isolated sternal fractures: determining the risk of blunt cardiac injury.

Ann R Coll Surg Engl. 2000;82:162-6. 

2

Case review (n=37) pts with sternal fracture. Sternal fracture is not a marker for BCI.

Bertinchant JP

 

2000

Evaluation of incidence, clinical significance, and prognostic value of circulating cardiac troponin I and T elevation in hemodynamically stable patients with suspected myocardial contusion after blunt chest trauma.

J Trauma. 2000;48:924-31. 

2

Prospectively collected data (n=94, 26 with “myocardial contusion” diagnosed by ECG, echo). There was no diff in CK, CK-MB between those with BCI and those without. The low sensitivity (23%, 12%) and low predictive values of troponin-I and troponin-T do not provide an improved method of dx of BCI in hemodynamically stable patient.

 

Rashid MA

 

 

2000

Cardiac injuries: a ten-year experience.

Eur J Surg. 2000;166:18-21.

2

Retrospective case review of 11 cardiac injury pts 4 with blunt mechanism. BCI diagnosis consumes considerable resources, but the disease often has little clinical relevance.

Tanaka H

1999

Pericardial tamponade type injury: a 17-year study in an urban trauma center in Japan.

Surg Today. 1999;29:1017-23

3

Retrospective study of pericardial tamponade. Of patients with tamponade from blunt cause (n=12), five had “myocardial contusion”. Tamponade patients from blunt mechanism had average ISS =54

Velmahos GC

 

1999

The "seat belt mark" sign: a call for increased vigilance among physicians treating victims of motor vehicle accidents.

Am Surg. 1999;65:181-5. 

2

Retrospective review of pts with seatbelt mark. 7.5% of patients with seatbelt mark had a BCI, if abnormal ECG, got an echo, none of the patients with BCI required intervention or treatment.

Swaanenburg JC

 

1998

Troponin I, troponin T, CKMB-activity and CKMB-mass as markers for the detection of myocardial contusion in patients who experienced blunt trauma.

Clin Chim Acta. 1998;272:171-81. 

2

Review of 89 blunt trauma pts separated by thoracic and non-thoracic trauma. Examined CK, CK-MB, and relative ratios and troponin. CK-MB no useful in diagnosis of BCI. While troponin may be helpful in diagnosis of BCI, the optimal timing of measurement needs to be determined.

Garcia-Fernandez MA

 

1998

Role of transesophageal echocardiography in the assessment of patients with blunt chest trauma: correlation of echocardiographic findings with the electrocardiogram and creatine kinase monoclonal antibody measurements.

Am Heart J. 1998;135:476-81. 

2

Multicenter, prospective, non-randomized (n=117) CK-MB not useful in diagnosis of BCI. Normal ECG does not rule out BCI.

TEE is a valuable tool to identify patients needing surgery.

Chiu WC

 

1997

Sternal fractures in blunt chest trauma: a practical algorithm for management.

Am J Emerg Med. 1997;15:252-5. 

2

Retrospective study (n=33) of sternal fracture and relationship to BCI. Sternal fracture is not a marker for BCI. Management of sternal fracture should be directed at management of associated injuries.

Fulda GJ

 

1997

An evaluation of serum troponin T and signal-averaged electrocardiography in predicting electrocardiographic abnormalities after blunt chest trauma.

J Trauma. 1997;43:304-12. 

2

Prospective study (n=71). Signal averaged ECG is not helpful in the diagnosis of BCI. Initial ECG is the best overall predictor of BCI. Troponin T may have a role in the evaluation of patients with normal ECG.

Previous version of this guideline

Blunt Cardiac Blunt Injury, Screening for (1998)

« Back to guidelines

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