Blunt Cardiac Injury Guidelines — Maimonides Emergency Medicine Residency

To trop or not to trop? Here's a brief review of the 2012 EAST trauma guidelines for BCI.

What is BCI, anyway?

Describes a range of injuries due to blunt thoracic trauma: wall motion abnormalities, myocardial contusion, valve injuries, focal wall dilation, coronary injury, pericardial rupture, wall rupture

Right heart most commonly affected as it is most anterior.

Who to work up?

According to 2012 East guidelines: “patients with any significant blunt trauma toanterior chest should be screened.”

Also consider BCI in patients with persistent unexplained tachycardia, cardiogenic shock, or hypotension not explained by other injuries.

Now that I suspect BCI, what should I do?

Screening:

Screening consists of an EKG (Level 1 evidence) and a troponin (Level 3 evidence). Early studies suggested that EKG alone is sufficient to diagnose BCI, however multiple studies since then show that such an approach does not capture the small percentage of BCI patients that present with normal initial EKG and positive troponin.

A normal EKG and troponin rules out BCI (even in the setting of a sternal fracture, which is not predictive of BCI). Several studies show that the addition of troponin raises the NPV to 100%. Same screening approach is supported for pediatric pts.

Management & Disposition:

Management is supportive; severe trauma may require surgical repair.

Patients who have a new abnormality on EKG (arrhythmias, ST changes, heart block, PACs or PVCs, ischemic changes, etc) must be admitted to a telemetry floor for continuous monitoring.

A new dysrhythmia or hemodynamic instability warrants an echo, preferably TEE over TTE.

Note that degree or persistence of elevation of troponin does not correlate with prognosis.

The chicken or the egg…did an MI precede the MVA or is it BCI?

It is important to differentiate which patients need cath with anticoagulation and which patients would be harmed from it. Can be differentiated via ekg-gated CT angiocoronaries.