Blunt Cardiac Injury

Question 1

What condition is often suspected in patients with blunt thoracic injury and sternal fracture?

Answer 1

Myocardial contusion

Elevated cardiac enzymes/Abnormal ECG

Question 2

In what types of injuries should blunt cardiac injury (BCI) be considered?

Answer 2

High-speed impacts to the thorax
motor-vehicle collisions
bicycle or motorcycle crashes
falls greater than 10 feet
blast injuries, assaults
crush injuries to the chest

Question 3

What mechanisms can cause blunt cardiac injury (BCI)?

Answer 3

Direct precordial impact
compression or crush between the sternum and spine
deceleration/torsion force causing a cardiac tear at a fixed point (e.g., between the right atrium and vena cava).

Question 4

How can an abrupt compression of the abdomen lead to blunt cardiac injury (BCI)?

Answer 4

causing a significant and sudden rise in venous pressure transmitted to the right heart, potentially resulting in cardiac rupture.

Question 5

What combination of tests can rule out significant blunt cardiac injury (BCI)?

Answer 5

normal ECG and troponin I level on admission and 8 hours later

Question 6

How is significant blunt cardiac injury (BCI) defined?

Answer 6

presence of cardiogenic shock
arrhythmias requiring treatment
posttraumatic structural deficits.

Question 7

What does the initial chest radiograph help rule out in diagnosing blunt cardiac injury (BCI)?

Answer 7

Tension pneumothorax and/or hemothorax as sources of blood loss and hypotension

Question 8

How can spinal cord injury be ruled out as a cause of hypotension before intubation?

Answer 8

By confirming movement of the lower extremities and checking for rectal tone during the physical examination

Question 9

How does the FAST examination aid in diagnosing blunt cardiac injury (BCI)?

Answer 9

-determine cardiac activity in patients without vital signs
-identifies fluid in the pericardial sac in patients with vital signs.

Question 10

What imaging is recommended for patients with abnormal ECGs on admission

Answer 10

A transthoracic echocardiogram (TTE) or transesophageal echocardiogram (TEE)

Question 11

What characterizes Grade 1 blunt cardiac injury (BCI)?

Answer 11

ECG abnormalities
nonspecific ST or T-wave changes
premature atrial or ventricular contractions
or persistent sinus tachycardia.

Question 12

What characterizes Grade 2 blunt cardiac injury (BCI)

Answer 12

Heart block or ischemic changes without cardiac failure

Question 13

What characterizes Grade 3 blunt cardiac injury (BCI)?

Answer 13

Sustained arrhythmias
septal rupture
valvular incompetence
papillary muscle dysfunction
distal coronary artery occlusion without heart failure
or blunt pericardial laceration without cardiac herniation.

Question 14

What characterizes Grade 4 blunt cardiac injury (BCI)?

Answer 14

Septal rupture
pulmonary or tricuspid incontinence
papillary muscle dysfunction
distal coronary artery occlusion with cardiac failure, rupture of the atria or right ventricle
or aortic/mitral valvular incompetence

Question 15

What characterizes Grade 5 blunt cardiac injury (BCI)?

Answer 15

Proximal coronary artery occlusion
left ventricular perforation
or rupture of more than one chamber.

Question 16

How should patients with Grade 1 blunt cardiac injury (BCI) be managed?

Answer 16

observed with continued monitoring until the ECG abnormalities have corrected
Within 24 hours.

Question 17

How should patients with Grade 2 blunt cardiac injury (BCI) be managed?

Answer 17

monitored until ischemic changes resolve and the ECG returns to normal.
serial assessment of troponin levels
Within 48 hours Resolve

Question 18

How should patients with Grade 3 blunt cardiac injury (BCI) and ventricular arrhythmias be managed?

Answer 18

monitored closely for progression to cardiac failure.

Question 19

What should be checked in Grade 3 BCI patients with pericardial fluid?

Answer 19

evidence of pericardial tamponade

Question 20

What types of injuries are associated with Grade 4 blunt cardiac injury (BCI)?

Answer 20

Septal rupture, valvular incompetence, or chamber rupture of the right ventricle, either atrium, or the right atrial appendage

Question 21

How are Grade 4 BCI patients with valvular incompetence or papillary muscle dysfunction diagnosed?

Answer 21

reduced ejection fraction or dyskinesis, which can be identified on imaging

Question 22

What evidence might Grade 4 BCI patients with distal coronary artery occlusion exhibit?

Answer 22

Signs of cardiac ischemia and inotropic compromise

Question 23

Do Grade 4 BCI patients always require operative intervention?

Answer 23

No, they usually do not require surgery unless there is a chamber rupture.

Question 24

How should pericardial tamponade be detected and confirmed?

Answer 24

Detected by initial FAST examination and confirmed by CT scan

Question 25

What is the definitive care for pericardial tamponade in this context?

Answer 25

Transthoracic pericardiocentesis followed by a prompt left anterior thoracotomy

Question 26

What caused the engorged purple liver in this patient with pericardial tamponade?

Answer 26

Impaired hepatic venous return due to the tamponade.

Question 27

Which heart chambers are most commonly ruptured in BCI?

Answer 27

The right atrium or ventricle (65%), followed by the left ventricle

Question 28

What is commotio cordis?

Answer 28

Sudden death from cardiac arrest without any anatomic structural damage to the heart, typically after a blunt blow to the chest
In young people during competitive sporting
blunt impact induces ventricular fibrillation during a vulnerable phase of ventricular excitability, such as cardiac repolarization.
often refractory to CPR and defibrillation

Question 29

What is the next step if a patient with blunt thoracic trauma presents without vital signs?

Answer 29

A FAST examination should be done to determine if there is cardiac activity. If absent, no further action is taken

Question 30

What should be done for a normotensive patient after blunt thoracic trauma?

Answer 30

A FAST examination should be performed as part of the secondary survey
followed by ECG and troponin measurements if no pericardial fluid is detected

Question 31

What is the next step if the ECG and troponin are normal in a patient after blunt thoracic trauma

Answer 31

No further tests or monitoring for BCI is indicated

Question 32

What should be done if the ECG and/or troponin are abnormal with findings such as tachycardia, arrhythmia, or ST elevation?

Answer 32

The patient should be admitted to the ICU, and the ECG and troponin levels should be repeated in 6 hours. An echocardiogram should be done within the first 24 hours

Question 33

How are patients with BCI typically managed if their echocardiogram is abnormal?

Answer 33

The echocardiogram should be repeated in 48 to 72 hours, and treatment is supportive, including β-blockers for tachycardia and ventilatory support for pulmonary injury.

Question 34

What should be excluded first when a patient with blunt thoracic trauma presents with hypotension?

Answer 34

Spinal cord injury
tension pneumothorax
or other sites of hemorrhage, including the chest or fractures.

Question 35

How does a FAST examination help in hypotensive patients with blunt thoracic trauma

Answer 35

determine if there is fluid in the pericardial sac.

Question 36

What should be done if pericardial fluid is present and the patient is stable?

Answer 36

A CT of the chest is recommended to distinguish between serous fluid (e.g., from renal failure) and blood.

Question 37

What is the recommended action if pericardial fluid appears to be blood and the patient is stable?

Answer 37

Immediate surgery is indicated.

Question 38

What is the next step if a hypotensive patient with pericardial fluid is unstable?

Answer 38

Pericardiocentesis should be performed on the way to the operating room

Question 39

What is the recommended surgical approach for blunt cardiac injury (BCI) requiring repair?

Answer 39

left anterolateral thoracotomy for rapid access and pericardiotomy.

Question 40

What is the recommended surgical repair for atrial or atrial appendage injuries in BCI?

Answer 40

A simple primary repair using 2-0 silk sutures on a noncutting needle, with digital pressure to control bleeding.

Question 41

What surgical option is available if a left thoracotomy limits access to the heart?

Answer 41

The incision can be extended across the sternum into the right chest, creating a clamshell thoracotomy.

Question 42

What might cause blood in the pericardial sac without heart rupture in blunt cardiac injury (BCI)?

Answer 42

Bleeding from the pericardial sac itself.

Question 43

How should the pericardium be managed postoperatively if there is bleeding from the pericardial sac?

Answer 43

The pericardium should be approximated, leaving a 3-4 cm opening in the nonapical part to allow egress of postoperative pericardial blood.

Question 44

What other injuries often accompany BCI and require definitive management?

Answer 44

Severe pulmonary injuries.

Question 45

What type of injuries may require cardiopulmonary bypass for repair in BCI?

Answer 45

Rupture of a heart valve or papillary muscle, which may be detected on echocardiogram

cardiopulmonary bypass > repair of any chamber rupture

Question 46

What surgical approaches are recommended for blunt cardiac injury (BCI) that requires repair?

Answer 46

definitive median sternotomy or a left thoracotomy.

Question 47

How is the pericardium opened during surgery for BCI?

Answer 47

opened parallel to the phrenic nerve.

Question 48

What is the next step after opening the pericardium in BCI surgery?

Answer 48

blood is evacuated, and the heart is examined for injury