Practice Management Guidelines for Diagnosis and Management of Blunt Cardiac Injury
March 1997 – December 2011
First Author
Sanfa GS
Year
2011
Reference Title
Serum troponin-I as an indicator of clinically
significant myocardial injury in paediatric trauma
patients. Injury. 2011 Nov 25.
Class
3
Conclusions
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 JulAug;31(4):E101-105.
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.
CT imaging of blunt chest trauma. Insights Imaging.
2011 Jun;2(3):281-295.
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.
Case reports. ECG gating is able to identify specific coronary lesions to
differentiate acute myocardial infarction from traumatic cardiac injury.
Malbranque G
2011
Oikonomou A
2011
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
Leibecke T
2008
Posttraumatic and postoperative cardiac luxation:
computed tomography finding in nine patients. J
Trauma 2008;64(3):721-726.
3
Scaglione M
2008
Multi-detector row computed tomography and blunt
chest trauma. Eur J Radiol 65:377-388.
3
Southam S
2006
3
Mirvis SE
2005
Ismailov RM
2005
Contrast-enhance cardiac MRI in blunt chest trauma:
differentiating cardiac contusion from acute peritraumatic myocardial infarction. J Thorac Imaging
2006;21(2):176-178.
Imaging of acute thoracic injury: the advent of
MDCT screening. Semin Ultrasound CT MR
2005;26(5):305-331.
Blunt cardiac injury associated with cardiac valve
3
3
3
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%.
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.
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.
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.
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.
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.
A retrospective review of hospital discharge database. There was an
Practice Management Guidelines for Diagnosis and Management of Blunt Cardiac Injury
March 1997 – December 2011
insufficiency: trauma links to chronic disease?
Injury. 2005;36:1022-8.
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
Incidence and significance of cardiac troponin I
release in severe trauma patients.
Anesthesiology. 2004;101:1262-8.
2
Edouard AR
2004
Lancey RA
2003
Correlation of clinical characteristics and outcomes
with injury scoring in blunt cardiac trauma.
J Trauma. 2003;54:509-15.
Normal electrocardiography and serum troponin I
levels preclude the presence of clinically significant
blunt cardiac injury.
J Trauma. 2003;54:45-51
2/3
Velmahos GC
2003
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
Athanassiadi K
2002
Sternal fractures: retrospective analysis of 100 cases.
World J Surg. 2002;26:1243-6.
2
Collins JN
2001
The usefulness of serum troponin levels in evaluating
cardiac injury.
Am Surg. 2001;67:821-6.
2
2
2
increased association of Limited conclusions based the nature of the
database (discharge) used, there are associations but no ability to
determine cause and effect
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 >1.05g/L should undergo further
cardiac evaluation and monitoring.
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 g/L
Values for cTnI in predicting BCI:
Sensitivity: 63%
Specificity: 98%
PPV: 40%
NPV: 98%
Retrospective review of 47 patients with dx BCI. Higher OIS grades
seem to correlate with severity of injury and survival.
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.
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.
Retrospective study of 100 patients with sternal fracture, one patient had
“cardiac contusion”. Routine screening with echo not warranted for
sternal fractures
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
Practice Management Guidelines for Diagnosis and Management of Blunt Cardiac Injury
March 1997 – December 2011
Wiener Y
2001
Echocardiogram in sternal fracture.
Am J Emerg Med. 2001;19:403-5.
3
Walsh P
2001
2
Vignon P
2001
Rashid MA
2001
Salim A
2001
Nagy KK
2001
Swan KG Jr
2001
Use of V4R in patients who sustain blunt chest
trauma.
J Trauma. 2001;51:60-3.
Comparison of multiplane transesophageal
echocardiography and contrast-enhanced helical CT
in the diagnosis of blunt traumatic cardiovascular
injuries.
Anesthesiology. 2001;94:615-22
Cardiovascular injuries associated with sternal
fractures.
Eur J Surg. 2001;167:243-8.
Clinically significant blunt cardiac trauma: role of
serum troponin levels combined with
electrocardiographic findings.
J Trauma. 2001;50:237-43.
Determining which patients require evaluation for
blunt cardiac injury following blunt chest trauma.
World J Surg. 2001 Jan;25(1):108-11.
Decelerational thoracic injury.
J Trauma. 2001;51:970-4
Sadaba JR
2000
Bertinchant JP
2000
Rashid MA
2000
Tanaka H
1999
1/2
telemetry.
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.
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
Prospective, observational study (n=110)
TEE superior to CT in diagnosis of cardiac injury (eg, valve damage).
CT does not rule out BCI
3
Retrospective chart review (n=418, 29 sternal fractures). Sternal fracture
is not a marker for BCI
2
Prospective, non-randomized (n=115). NPV of normal ECG and
troponin was 100% in combination. Normal ECG did not rule out BCI
2
Patients with an abnormal ECG need monitoring. Patients with normal
ECG, hemodynamics, and cardiac enzymes do not need further
intervention.
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.
Case review (n=37) pts with sternal fracture. Sternal fracture is not a
marker for BCI.
3
Management of isolated sternal fractures:
determining the risk of blunt cardiac injury.
Ann R Coll Surg Engl. 2000;82:162-6.
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.
Cardiac injuries: a ten-year experience.
Eur J Surg. 2000;166:18-21.
2
Pericardial tamponade type injury: a 17-year study in
an urban trauma center in Japan.
3
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.
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.
Retrospective study of pericardial tamponade. Of patients with
tamponade from blunt cause (n=12), five had “myocardial contusion”.
Practice Management Guidelines for Diagnosis and Management of Blunt Cardiac Injury
March 1997 – December 2011
Velmahos GC
1999
Swaanenburg JC
1998
Garcia-Fernandez
MA
1998
Chiu WC
1997
Fulda GJ
1997
Surg Today. 1999;29:1017-23
The "seat belt mark" sign: a call for increased
vigilance among physicians treating victims of motor
vehicle accidents.
Am Surg. 1999;65:181-5.
Troponin I, troponin T, CKMB-activity and CKMBmass as markers for the detection of myocardial
contusion in patients who experienced blunt trauma.
Clin Chim Acta. 1998;272:171-81.
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.
Sternal fractures in blunt chest trauma: a practical
algorithm for management.
Am J Emerg Med. 1997;15:252-5.
An evaluation of serum troponin T and signalaveraged electrocardiography in predicting
electrocardiographic abnormalities after blunt chest
trauma.
J Trauma. 1997;43:304-12.
2
2
2
2
2
Tamponade patients from blunt mechanism had average ISS =54
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.
Review of 89 blunt trauma pts separated by thoracic and non-thoracic
trauma. Examined CK, CK-MB, and relative ratios and troponin. CKMB no useful in diagnosis of BCI. While troponin may be helpful in
diagnosis of BCI, the optimal timing of measurement needs to be
determined.
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.
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.
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.