It is important to first identify the trauma patient with blunt chest injury by the mechanism of force. For instance, patients involved in an MVC should be queried on whether there was a steering wheel impact. In one study, 54% of patients with a history of a fall greater than 20 feet had BCI.[6]

The most common complaint is chest pain or shortness of breath[1][2], but some may report palpitations or even present with typical symptoms of angina.[2][14] It is also important to assess cardiac risk factors such as a history of myocardial infarction, cardiovascular disease, and other commonly associated comorbidities. Medication assessment is important, especially in the patient taking cardiac drugs which can alter the patient presentation. For example, beta-blockers and calcium channel blockers may mask tachycardia.

The physical exam should be thorough. Patients can present with cardiac tamponade, and suspicion should be high in the presence of jugular venous distention and hypotension. The focused assessment with sonography for trauma (FAST exam) will help in the assessment for pericardial fluid and cardiac tamponade. Tachypnea, irregular lung sounds, chest wall tenderness, chest abrasion or ecchymosis, rib or sternal fractures, and seatbelt sign across the chest are some of the physical findings that should raise suspicion for BCI[10] although they are non-specific.[1][2][10][14] Furthermore, patients with severe BCI are more likely to have other significant traumatic injuries that may mask or distract from some of its physical sequelae.[10][14]

No consensus has been established to diagnose blunt cardiac injuries. However, in 2012, the Eastern Association of Trauma (EAST) published BCI practice guidelines that supported obtaining an ECG in all patients with suspected BCI.[6][7] Patients with abnormal findings should be admitted for continuous cardiac monitoring; however, a normal ECG does not entirely exclude BCI as it has been reported that a significant number of patients with an initial normal ECG were noted to have a possible cardiac injury 24 hours later as measured by elevated cardiac troponin I (cTnI) levels.[3][6] Nevertheless, patients with a normal ECG in conjunction with normal levels of cTnI can be safely discharged home.[3][6][7] Furthermore, it should be noted that a normal ECG and cTnI levels do not rule out all BCI as some may have a delayed presentation (e.g., septal injury). Following an abnormal ECG and cTnI level, echocardiography is usually obtained to further characterize the injury. Computerized tomography (CT) and magnetic resonance imaging (MRI) do not play a role in the initial diagnostic evaluation of BCI; however, these modalities can be complementary or useful in the patient with symptoms without a clear clinical etiology and can be considered on a case-by-case basis.[3][6]

Patients with abnormal ECG and/or cTnI levels should be admitted for cardiac monitoring for 24 to 48 hours because life-threatening arrhythmias or cardiac failure will most likely present during this time.[3][14] Patients can be admitted to the intensive care unit or placed under telemetry, depending on concurrent injuries, type of ECG change, and the grade of hemodynamic imbalance. It is not necessary to admit all sternal fractures with a normal ECG to rule out BCI. The most prevalent of the BCIs are the subset of patients with isolated abnormal ECG and/or cTnI elevations which usually have a benign course with the rare occurrence of long-term functional impairment.[1]   

Management of dysrhythmias should be approached and treated as in the non-BCI patient. Replete electrolytes accordingly, avoid hypoxia and acidosis, and when clinically indicated utilize antidysrhythmics and advanced life support algorithms. Although rare with isolated BCI, complete heart block may necessitate a pacemaker. ST segment elevations can be due to either a contused heart or a traumatic myocardial infarction, necessitating coronary angiography.[3]

Patients with severe clinically diagnosed or imaged structural cardiac injury require emergent cardiology evaluation for further management. Temporizing measures such as fluid resuscitation, inotropes, or vasopressors may be indicated in the interim based on the specific clinical findings and associated injuries. Patients presenting with cardiac tamponade, most frequently seen in cardiac rupture, require emergent surgical intervention.[1][3] Cardiothoracic intervention is required and time is of the essence in the majority of those cases. Refractory cardiogenic shock can benefit from intra-aortic balloon pump (IABP) to help increase coronary blood flow, allowing the stunned heart to recover in days to weeks.[1]

• Arrhythmia
• Cardiac tamponade
• Cardiac wall motion abnormality
• Cardiogenic pulmonary edema
• Cardiogenic shock
• Hemorrhagic shock
• Myocardial infarction
• Valvular regurgitation

Prognosis in blunt cardiac injury (BCI) is highly dependent on the specified injury, its association with concomitant injuries, and any history of previous cardiac disease or injury.[14] The patient with isolated BCI that is presented by way of an abnormal ECG or cTnI level tends to have a more favorable outcome than the patient who is hemodynamically compromised with a cardiac structural injury with an associated high trauma injury score.[7][14] Given that the former represents the largest pool of BCI patients, BCI generally has a favorable prognosis overall.

Overall, complications from blunt cardiac trauma are rare.[7][14] Acute complications from severe cardiac injuries usually necessitate immediate management, and those that survive may have long-term complications related to their specific injury. Most BCI patients do not have long-term sequelae, but a few, late complications have been reported including delayed cardiac rupture, complete atrioventricular block, heart failure, pericardial effusion, and constrictive pericarditis.[7] Therefore, good practice entails reevaluating these patients in 3 to 6 months.[7]

The diagnosis of blunt cardiac injury (BCI) remains challenging due to its variable presentation and range of injury. Furthermore, there is a lack of consensus on definition and diagnostic criteria. However, the crucial factor in caring for these patients is to have a high suspicion in trauma patients. ECG and cTnI levels can be used as screening tools, followed by admission and echocardiography for any resultant abnormalities with the understanding that BCI can take up to 48 hours to manifest. An interprofessional consensus should be employed to identify BCI based on the specific injury.

While the majority of cases diagnosed as BCI may be inconsequential, the true significance of the diagnosis remains controversial due to inadequate assessment of long-term outcomes. Those suspected of having BCI who are hemodynamically stable without dysrhythmia should at least have a short period of observation. Further consensus and research among providers are warranted to better define the management and long-term significance of BCI.