EMed

Cardiac Contusion

Summary

  • Infrequent, occasionally serious injury seen in blunt chest injuries
  • Clinically significant complications include hypotension and arrhythmias

Prevalence

  • 15% of significant blunt chest injury patients who present to the ED
  • 3 - 56% of significant blunt chest injuries
  • 14% of of blunt chest trauma autopsies

Causes

  • Deceleration force
  • Direct pressure myocardium
  • Increased intrathoracic pressure and shearing force
  • Patchy myocyte necrosis & transmural haemorrhage
  • Right ventricle (60%)
  • LV output falls (up to 40%)
    • Reduced preload
    • Reduced LV compliance
    • May last weeks
  • Histology more haemorrhage than AMI (with distinct boundary)
    • Patchy necrosis, oedema and scar formation
    • "Giant capillary sinusoids" (Epicardial > sub-endocardial perfusion)
    • ⇓ contractility, ⇑ EDP

Complications

  • Ventricular dysfunction and arrhythmia:
    • 24 hours (91% within 48 hours)
  • Associated coronary vessel and valvular injury

Key Clinical Features

  • Significant blunt chest trauma
  • Chest pain, SOB, Palpitations
  • Haemodynamic instability

Algorithm

Treatment and management

  • High index of suspicion
  • Treat hypovolaemia (beware Spinal / Obstructive causes)
  • Suspect cardiac conusion if persistent lhypotension and no clear haemorrhage
  • Early CVP
  • ALS periarrest guidelines
  • Monitor for 24 hours if ECG morphology or rhythm disturbances
  • Biochemical abnormalities should be actively managed
  • Early echocardiography
  • Avoid anaesthesia and DC cardioversion if possible
  • Careful inotrope support

Investigations

  • ECG and TnI in all
  • TTE or TOE if above positive

ECG findings

  • Pericarditis like ST elevation
  • Long QTc
  • RBBB
  • AV nodal abN

Echo findings

  • RV Dilatation
  • Segmental hypokinesis
  • Beware other pathology

Content by Dr Íomhar O' Sullivan 16/08/04. Last updated by Dr Khaled Khalifa, Prof Conor Deasy, Dr ÍOS 22/10/22