Guideline sources The following summarized guidelines for the evaluation and management of blunt cardiac injury (BCI) are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2020) and the Eastern Association for the Surgery of Trauma (EAST 2012). 1 3 4 4 4 5 Definition BCI refers to an injury sustained due to blunt trauma to the heart, the spectrum of which ranges from a minor bruise to specific post-contusion cardiac conditions such as free-wall rupture. 4 Epidemiology BCI is mostly caused by motor vehicle accidents, falls from heights, direct blow to the chest wall by airbag deployment, crushing incidents, contact sports injuries, acts of violence, or blast trauma. 4 Disease course Clinical manifestations include arrhythmias, myocardial contusion, wall motion abnormalities, myocardial wall rupture, and valve damage. The spectrum of injuries includes commotio cordis, cardiac rupture, coronary artery dissection, indirect cardiac injury, cardiac herniation, pericardial effusion and tamponade, traumatic cardiac arrest, and blunt aortic injury. 4 Prognosis and risk of recurrence https://web.pathway.md/diseases/recdxGUsCMwhmJWIH 1/4 6/29/23, 3:20 AM Blunt cardiac injury Pathway BCI is associated with an overall mortality rate of 13.9%. 5 Calculator NEXUS criteria for chest X-ray in Guidelines 1. Screening and diagnosis Patients at risk: admit patient for continuous ECG monitoring if the admission ECG reveals a new abnormality such as arrhythmias, ST changes, ischemia or heart block. B Indications for testing: avoid implementing cardiac monitoring on the sole basis of a sternal fracture, in patients in whom ECG and troponin I levels are normal. D 2. Diagnostic investigations Electrocardiogram: obtain an admission ECG in all patients in whom BCI is suspected. A Continuous ECG monitoring: admit patients for continuous electrocardiographic monitoring if the admission ECG reveals a new abnormality such as arrhythmia, ST changes, ischemia, heart block, and unexplained ST changes. Compare with a previous ECG to determine need for monitoring in patients with preexisting abnormalities. B Troponin I: measure troponin I routinely for patients with suspected BCI; if elevated, admit patients to a monitored setting and follow troponin I serially, although the optimal timing is unknown. B Creatine kinase: avoid obtaining CK with isoenzyme analysis, because it is not beneficial in predicting which patients have or will have complications related to BCI. D Cardiac imaging: As per ACR 2020 guidelines, obtain a TTE in patients (either hemodynamically stable or unstable) with suspected cardiac injury following blunt chest trauma. B As per EAST 2012 guidelines: Obtain a TTE in patients with hemodynamic instability or persistent new arrhythmia. Obtain a TEE if an optimal TTE cannot be obtained. B Obtain cardiac CT or MRI to help differentiate acute myocardial infarction from BCI in trauma patients with abnormal ECG, cardiac enzymes, and/or abnormal echocardiography. B Chest imaging: https://web.pathway.md/diseases/recdxGUsCMwhmJWIH 2/4 6/29/23, 3:20 AM Blunt cardiac injury Pathway Obtain a CXR and chest CT with IV contrast or chest CT angiography as complementary first- line imaging modalities in hemodynamically stable patients with suspected cardiac injury following blunt chest trauma. B Obtain a CXR, chest CT with IV contrast, chest CT angiography, and cardiac CT with IV contrast as complementary imaging modalities in hemodynamically unstable patients with suspected cardiac injury following blunt chest trauma. B Nuclear medicine studies: avoid routinely obtaining nuclear medicine studies in patients with BCI, as they provide little additional information when compared with echocardiography. D 3. Specific circumstances Patients in need of surgical intervention: consider proceeding with surgery in elderly patients with known cardiac disease, unstable patients, and those with an abnormal admission ECG, provided that they are appropriately monitored. Consider placement of a pulmonary artery catheter in these situations. C Clinical findings Symptoms Past medical history Chest pain DVT Pericardial tamponade Vital signs Traumatic injury Hypotension Vascular exam Cardiac exam Pulse deficit Muffled heart sounds Respiratory exam Murmur Rales ECG findings Imaging findings AF AV block Myocardial rupture Cardiac arrhythmias Pericardial effusion Sinus tachycardia Ventricular septal defect Wall motion abnormality References 1. Clancy K, Velopulos C, Bilaniuk JW et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73 5 Suppl 4 S301 6. Open https://web.pathway.md/diseases/recdxGUsCMwhmJWIH 3/4 6/29/23, 3:20 AM Blunt cardiac injury Pathway 2. Mark J Seamon, Elliott R Haut, Kyle Van Arendonk et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Jul;79 1 159 73. Open 3. Expert Panels on Cardiac Imaging and Thoracic Imaging, Jadranka Stojanovska, Lynne M Hurwitz Koweek et al. ACR Appropriateness Criteria Blunt Chest Trauma-Suspected Cardiac Injury. J Am Coll Radiol. 2020 Nov;17 11S S380 S390. Open 4. Rayyan Fadel, Ayman El-Menyar, Samir ElKafrawy et al. Traumatic blunt cardiac injuries: An updated narrative review. Int J Crit Illn Inj Sci. Jul-Sep 2019;9 3 113 119. Open 5. Marc Hanschen, Karl-Georg Kanz, Chlodwig Kirchhoff et al. Blunt Cardiac Injury in the Severely Injured A Retrospective Multicentre Study. PLoS One. 2015 Jul 2;10 7):e0131362. Open 6. Rayyan Fadel, Ayman El-Menyar, Samir ElKafrawy et al. Traumatic blunt cardiac injuries: An updated narrative review. Int J Crit Illn Inj Sci. Jul-Sep 2019;9 3 113 119.Jul-Sep 2019;9 3 113 119. Open 7. Marc Hanschen, Karl-Georg Kanz, Chlodwig Kirchhoff et al. Blunt Cardiac Injury in the Severely Injured A Retrospective Multicentre Study. PLoS One. 2015 Jul 2;10 7):e0131362.2015 Jul 2;10 7):e0131362. Open 8. Alexander Levitov, Heidi L Frankel, Michael Blaivas et al. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part II Cardiac Ultrasonography. Crit Care Med. 2016 Jun;44 6 1206 27. Open 9. Heidi L Frankel, Andrew W Kirkpatrick, Mahmoud Elbarbary et al. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part I General Ultrasonography. Crit Care Med. 2015 Nov;43 11 2479 502. Open https://web.pathway.md/diseases/recdxGUsCMwhmJWIH 4/4