Accuracy of diagnostic tests in cardiac injury after blunt chest trauma: a systematic review and meta-analysis.

INTRODUCTION: The diagnosis of cardiac contusion, caused by blunt chest trauma, remains a challenge due to the non-specific symptoms it causes and the lack of ideal tests to diagnose myocardial damage. A cardiac contusion can be life-threatening if not diagnosed and treated promptly. Several diagnostic tests have been used to evaluate the risk of cardiac complications, but the challenge of identifying patients with contusions nevertheless remains. AIM OF THE STUDY: To evaluate the accuracy of diagnostic tests for detecting blunt cardiac injury (BCI) and its complications, in patients with severe chest injuries, who are assessed in an emergency department or by any front-line emergency physician. METHODS: A targeted search strategy was performed using Ovid MEDLINE and Embase databases from 1993 up to October 2022. Data on at least one of the following diagnostic tests: electrocardiogram (ECG), serum creatinine phosphokinase-MB level (CPK-MB), echocardiography (Echo), Cardiac troponin I (cTnI) or Cardiac troponin T (cTnT). Diagnostic tests for cardiac contusion were evaluated for their accuracy in meta-analysis. Heterogeneity was assessed using the I2 and the QUADAS-2 tool was used to assess bias of the studies. RESULTS: This systematic review yielded 51 studies (n = 5,359). The weighted mean incidence of myocardial injuries after sustaining a blunt force trauma stood at 18.3% of cases. Overall weighted mean mortality among patients with blunt cardiac injury was 7.6% (1.4-36.4%). Initial ECG, cTnI, cTnT and transthoracic echocardiography TTE all showed high specificity (> 80%), but lower sensitivity (< 70%). TEE had a specificity of 72.1% (range 35.8-98.2%) and sensitivity of 86.7% (range 40-99.2%) in diagnosing cardiac contusion. CK-MB had the lowest diagnostic odds ratio of 3.598 (95% CI: 1.832-7.068). Normal ECG accompanied by normal cTnI showed a high sensitivity of 85% in ruling out cardiac injuries. CONCLUSION: Emergency physicians face great challenges in diagnosing cardiac injuries in patients following blunt trauma. In the majority of cases, joint use of ECG and cTnI was a pragmatic and cost-effective approach to rule out cardiac injuries. In addition, TEE may be highly accurate in identifying cardiac injuries in suspected cases.

Managing blunt cardiac injury.

Blunt cardiac injury (BCI) encompasses a spectrum of pathologies ranging from clinically silent, transient arrhythmias to deadly cardiac wall rupture. Of diagnosed BCIs, cardiac contusion is most common. Suggestive symptoms may be unrelated to BCI, while some injuries may be clinically asymptomatic. Cardiac rupture is the most devastating complication of BCI. Most patients who sustain rupture of a heart chamber do not reach the emergency department alive. The incidence of BCI following blunt thoracic trauma remains variable and no gold standard exists to either diagnose cardiac injury or provide management. Diagnostic tests should be limited to identifying those patients who are at risk of developing cardiac complications as a result of cardiac in jury. Therapeutic interventions should be directed to treat the complications of cardiac injury. Prompt, appropriate and well-orchestrated surgical treatment is invaluable in the management of the unstable patients.

Attention: Cardiac contusion.

BACKGROUND: The objective of the study is to investigate diagnostic and clinical processes performed for cardiac contusion in patients with blunt thoracic trauma. METHODS: This study was conducted retrospectively on 65 patients admitted with isolated blunt thoracic trauma to the Emergency Medicine Department. The CT images, the cardiac enzyme levels, the periodic 4-h follow-up electrocardiography (ECGs) in the emer-gency department, and the results of echocardiography, performed at admission and when required according to the clinical status, were investigated. The 1-h and 4-h high-sensitivity troponin I levels were studied, and values above 0.04 ng/ml were considered as positive. RESULTS: Sixty-five patients with isolated thoracic trauma were included in the study, 23 (35.38%) had pulmonary and cardiac contu-sions both. In 23 (35.38%) patients, pulmonary contusion had been present, and cardiac contusion had not been identified at the initial evaluation. However, during clinical follow-up, troponin became positive, dysrhythmia developed, and the trauma affected the heart in four of these patients. In six (9.24%) patients, cardiac contusion was identified without pulmonary contusion. In 13 (20%) patients, no cardiac or pulmonary contusion was identified. troponin elevation was detected in 10 patients without a diagnosis of cardiac contusion who had a pulmonary contusion, hemothorax, and/or pneumothorax at the time of hospital admission and then with normal troponin levels at 4-h control. We found that there was a statistical agreement between cardiac contusion and troponin-ECG results at 4th h. CONCLUSION: We advise that all blunt thoracic trauma patients should be screened for cardiac contusion by continuous ECG monitoring and troponin levels.

Diagnostic approach for myocardial contusion: a retrospective evaluation of patient data and review of the literature.

PURPOSE: Myocardial contusion can be a life-threatening condition in patients who sustained blunt thoracic trauma. The diagnostic approach remains a subject of debate. The aim of this study was to determine the sensitivity and specificity of echocardiography, electrocardiography, troponins T and I (TnT and TnI), and creatine kinase muscle/brain (CK-MB) for identifying patients with a myocardial contusion following blunt thoracic trauma. METHODS: Sensitivity and specificity were first determined in a 10-year retrospective cohort study and second by a systematic literature review with meta-analysis. RESULTS: Of the 117 patients in the retrospective study, 44 (38%) were considered positive for myocardial contusion. Chest X-ray, chest CT scan, electrocardiograph, and echocardiography had poor sensitivity (< 15%) but good specificity (≥ 90%). Sensitivity to cardiac biomarkers measured at presentation ranged from 59% for TnT to 77% for hs-TnT, specificity ranged from 63% for CK-MB to 100% for TnT. The systematic literature review yielded 28 studies, with 14.5% out of 7242 patients reported as positive for myocardial contusion. The pooled sensitivity of electrocardiography, troponin I, and CK-MB was between 62 and 71%, versus only 45% for echocardiography and 38% for troponin T. The pooled specificity ranged from 63% for CK-MB to 85% for troponin T and 88% for echocardiography. CONCLUSION: The best diagnostic approach for myocardial contusion is a combination of electrocardiography and measurement of cardiac biomarkers. If abnormalities are found, telemonitoring is necessary for the early detection of life-threatening arrhythmias. Chest X-ray and CT scan may show other thoracic injuries but provide no information on myocardial contusion.

Points & Pearls: Blunt cardiac injury: emergency department diagnosis and management

Blunt cardiac injury describes a range of cardiac injury patterns resulting from blunt force trauma to the chest. Due to the multitude of potential anatomical injuries blunt force trauma can cause, the clinical manifestations may range from simple ectopic beats to fulminant cardiac failure and death. Because there is no definitive, gold-standard diagnostic test for cardiac injury, the emergency clinician must utilize an enhanced index of suspicion in the clinical setting combined with an evidence-based diagnostic testing approach in order to arrive at the diagnosis. This review focuses on the clinical cues, diagnostic testing, and clinical manifestations of blunt cardiac injury as well as best-practice management strategies. [Points & Pearls is a digest of Emergency Medicine Practice.]

Blunt cardiac injury: emergency department diagnosis and management.

Blunt cardiac injury describes a range of cardiac injury patterns resulting from blunt force trauma to the chest. Due to the multitude of potential anatomical injuries blunt force trauma can cause, the clinical manifestations may range from simple ectopic beats to fulminant cardiac failure and death. Because there is no definitive, gold-standard diagnostic test for cardiac injury, the emergency clinician must utilize an enhanced index of suspicion in the clinical setting combined with an evidence-based diagnostic testing approach in order to arrive at the diagnosis. This review focuses on the clinical cues, diagnostic testing, and clinical manifestations of blunt cardiac injury as well as best-practice management strategies.

[Myocardial contusion following trauma]. / Hartcontusie na een trauma.

BACKGROUND: Myocardial contusion is a potentially life threatening condition, which should be considered in patients with a compatible thoracic trauma. Guidelines for diagnosis and determination of management are non-existent. CASE DESCRIPTION: A 51-year-old man arrived at the accident and emergency department with thoracic trauma after being knocked down by a bus. A myocardial contusion was diagnosed based on the ECG and elevated high-sensitivity (hs) troponin levels. Cardiac ultrasound revealed no abnormalities. No complications occurred during 48 hours of cardiac monitoring. CONCLUSION: In patients with thoracic trauma, a combination of ECG abnormalities and raised hs troponin levels indicates myocardial contusion. Cardiac ultrasound is required in these patients if they are haemodynamically instable or suffer clinical deterioration. Observation using cardiac rhythm monitoring is necessary in all patients with myocardial contusion, because of the risk of complications such as life-threatening cardiac arrhythmias.

ST-segment elevation after blunt chest trauma: myocardial contusion with normal coronary arteries or myocardial infarction following coronary lesions.

Cardiac lesions secondary to blunt chest trauma vary from insignificant arrhythmias to fatal cardiac rupture. Of these, a distinction remains difficult; face to ST-segment elevation on ECG with positive cardiac biomarkers, is it a myocardial contusion or a genuine myocardial infarction (MI) secondary to coronary lesions? We report the case of a patient admitted for multiple trauma. Initial assessment showed an ST segment elevation on ECG, along with multiple fractures and abdominal injuries. We would like to discuss, through this case, the similarities and the differences between myocardial infarction due to coronary lesions and myocardial contusion in a traumatic context, but also emphasize the difficulty of striking the right balance between thrombotic and bleeding risks in this situation, and insist on the importance of a multidisciplinary and collegial reflexion so we can offer these patients the best care there is.

Clinical Significance and Prognostic Implications of Quantifying Pulmonary Contusion Volume in Patients with Blunt Chest Trauma.

BACKGROUND Pulmonary contusion (PC) is the most frequent blunt chest injury which could be used to identify patients at high-risk of clinical deterioration. We aimed to investigate the clinical correlation between PC volume and outcome in patients with blunt chest trauma (BCT). MATERIAL AND METHODS BCT patients with PC were identified retrospectively from the prospectively collected trauma registry database over a 2-year period. Contusion volume was measured and expressed as percentage of total lung (CTCV) volume using three-dimensional reconstruction of thoracic CT images on admission. Data included patients' demographics, mechanism of injury (MOI) and injury severity, associated injuries, CTCV, mechanical ventilation, complications, and mortality. RESULTS A total of 226 BCT patients were identified to have PC with a mean age of 35.2 years. Motor vehicle crash (54.4%) and falls (16.4%) were the most frequent MOIs. Bilateral PC (61.5%) was more prevalent than right-sided (19.5%) and left-sided PC (19%). CTCV had a significant positive correlation with ISS; whereas, age and PaO2/FiO2 ratio showed a negative correlation (p<0.05 for all). The median CTCV was significantly higher in patients who developed in-hospital complications (p=0.02). A CTCV >20% was associated with increasedrisk of acute respiratory distress syndrome (ARDS), blood transfusion and prolonged mechanical ventilation. However, multiple linear regression analysis showed that CTCV alone was not an independent predictor of in-hospital outcomes. Presence of chest infection, CTCV, and Injury Severity Scores were predictors of ARDS. CONCLUSIONS Quantifying pulmonary contusion volume could allow identification of patients at high-risk of ARDS. CTCV has a significant correlation with injury severity in patients with BCT. Further prospective studies are needed to address the validity of CTCV in the patients care.

Paediatric chest wall trauma causing delayed presentation of ventricular arrhythmia.

This report describes a paediatric patient presenting with haemodynamically stable non-sustained ventricular tachycardia 1 day after minor blunt chest trauma. Initial laboratory studies, chest X-ray and echocardiography were normal; however, cardiac MRI revealed precordial haematoma, myocardial contusion and small pericardial effusion. Throughout her hospital course, she remained asymptomatic aside from frequent couplets and triplets of premature ventricular contractions. Ectopy was controlled with oral verapamil. This case highlights how significant cardiac injury may be missed with standard diagnostic algorithms.

Detection of toluene in a body buried for years with a fatal cardiac contusion.

This report aimed to present the postmortem finding of toluene in a homicide victim buried under the ground for six years. The bones of the skull and limbs were exposed, and the remainder of the subcutaneous tissues, brain and heart had formed into adipocere. There were numerous fractures in the skull and the anterior side of the ribs. A cardiac contusion extending into the cavity of the right ventricle was also observed. No other obvious injuries were identified on the body. The concentration of toluene in the bone marrow within the head of the humerus was 58.4 µg/g. The cause of death was suspected as heart rupture, possibly from a forceful impact or compression of the anterior chest under toluene intoxication. This report presents a rare case where toluene intake by a human was disclosed by autopsy even after several years of death.

Identifying the broken heart: predictors of mortality and morbidity in suspected blunt cardiac injury.

BACKGROUND: Blunt cardiac injury (BCI) is an infrequent but potentially fatal finding in thoracic trauma. Its clinical presentation is highly variable and patient characteristics and injury pattern have never been described in trauma patients. The aim of this study was to identify predictors of mortality in BCI patients. METHODS: We performed an 8-year retrospective analysis of all trauma patients diagnosed with BCI at our Level 1 trauma center. Patients older than 18 years, blunt chest trauma, and a suspected diagnosis of BCI were included. BCI was diagnosed based on the presence of electrocardiography (EKG), echocardiography, biochemical cardiac markers, and/or radionuclide imaging studies. Elevated troponin I was defined as more than 2 recordings of greater than or equal to .2. Abnormal EKG findings were defined as the presence of bundle branch block, ST segment, and t-wave abnormalities. Univariate and multivariate regression analyses were performed. RESULTS: A total of 117 patients with BCI were identified. The mean age was 51 ± 22 years, 65% were male, mean systolic blood pressure was 93 ± 65, and overall mortality rate was 44%. Patients who died were more likely to have a lactate greater than 2.5 (68% vs 31%, P = .02), hypotension (systolic blood pressure < 90) (86% vs 14%, P = .001), and elevated troponin I (86% vs 11%, P = .01). There was no difference in the rib fracture (58% vs 56%, P = .8), sternal fracture (11% vs 21%, P = .2), and abnormal EKG (89% vs 90%, P = .6) findings. Hypotension and lactate greater than 2.5 were the strongest predictors of mortality in BCI. CONCLUSIONS: BCI remains an important diagnostic and management challenge. However, once diagnosed resuscitative therapy focused on correction of hypotension and lactate may prove beneficial. Although the role of troponin in diagnosing BCI remains controversial, elevated troponin may have prognostic significance.

Janela pericárdica: história e seu uso nos dias atuais / Pericardial window: history and its use nowadays

O traumatismo cardíaco penetrante constitui-se em evento que pode evoluir para o óbito rapidamente e por isso demanda diagnóstico e tratamento imediatos. Apesar da evolução dos métodos de imagem, às vezes não é possível identificá-lo de maneira não invasiva. Assim, o emprego da janela pericárdica constitui-se um método de fácil realização, com elevada sensibilidade e baixa morbidade, especialmente útil em pequenos centros com recursos escassos e limitados. (AU)

The penetrating cardiac trauma is into event that can lead to death quickly and therefore demands immediate diagnosis and treatment. Despite the evolution of the imaging methods, sometimes it is not possible to identify it using a non-invasive method. Thus, the use of pericardial window is an easy to accomplish method, wich has high sensibility and low morbity, specially useful in small centers with few and limited resourses. (AU)