II. Causes

  1. Chest Traumatic Injury
  2. High speed injury (e.g. MVA)
  3. Sternal Fracture

III. History

  1. Bent stearing wheel in a Motor Vehicle Accident

IV. Symptoms

V. Signs

  1. Hypotension
  2. Anterior chest wall injury
  3. Sternal Fracture signs
    1. Sternal tenderness
    2. Sternal deformity

VI. Labs

  1. Serial Troponin levels
    1. Standard Troponin at 4-6 hours or High Sensitivity Troponin at 3 hours after injury

VII. Diagnostics

  1. Telemetry monitoring
  2. Electrocardiogram (EKG) - obtain serial EKGs
    1. See EKG monitoring in Trauma
    2. Changes occur typically in first 8-24 hours of injury and typically resolve spontaneously
    3. Premature Ventricular Contractions (PVC)
    4. Unexplained Sinus Tachycardia
    5. Atrial Fibrillation (most common Arrhythmia)
    6. Right Bundle Branch Block
    7. ST Segment changes
      1. Myocardial Infarction may occur in blunt cardiac Trauma
  3. Advanced hemodynamic monitoring (if central access)
    1. Central Venous Pressure increased

VIII. Imaging

  1. FAST Exam
    1. Pericardial Effusion may be present
  2. Echocardiogram
    1. Wall motion abnormality
    2. Right Ventricle is most commonly injured chamber in Sternal Fracture
    3. Evaluate for valvular injury

IX. Evaluation

  1. Normal Troponin, EKG, hemodynamic and cardiac monitoring without significant other Chest Injury
    1. Unlikely to have significant cardiac injury
    2. May be discharged home after 6 hour observation
  2. Abnormal Troponin, EKG hemodynamic or cardiac monitoring (esp. in displaced Sternal Fracture, other Chest Trauma)
    1. Complete full evaluation with Echocardiogram, telemetry, trauma Consultation

X. Differential Diagnosis

  1. See Blunt Chest Trauma
  2. See associated conditions below
  3. Rib Fracture

XII. Management

  1. ABC Management
  2. Manage Hypoxia, Hypotension and identified complications
  3. Indications for observation (24-48 hour)
    1. See Evaluation above
    2. Complications (see below) are most likely to present in the first 24-48 hours

XIII. Complications

  1. Cardiogenic failure
  2. Arrhythmia (including lethal, ventricular Arrhythmia)

XIV. References

  1. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
  2. (2012) ATLS, ACOS, p. 105
  3. Killu and Sarani (2016) FCCS, p. 160-1

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