Diagnostic approach for myocardial contusion: a retrospective evaluation of patient data and review of the literature

Molecular biomarkers of blunt cardiac injury: recent advances and future perspectives

INTRODUCTION

Blunt cardiac injury (BCI), associated with high morbidity and mortality, involves multiple injuries. With no widely accepted gold standard diagnostic test and molecular biomarkers still in debate and far from application in clinical practice, exploring specific molecular biomarkers of BCI is of great significance. The clarification of molecular biomarkers can improve the diagnosis of BCI, leading to more precise care for victims in various situations.

AREAS COVERED

Using the search term 'Biomarker AND Blunt cardiac injury,' we carefully reviewed related papers from June 2004 to June 2024 in PubMed and CNKI. After reviewing, we included 20 papers, summarizing the biomarkers reported in previous studies, and then reviewed molecular biomarkers such as troponins, Nterminal proBtype natriuretic peptide (NT proBNP), hearttype fatty acid binding protein (hFABP), and lactate for BCI diagnosis. Finally, valuable views on future research directions for diagnostic biomarkers of BCI were presented.

EXPERT OPINION

Several advanced technologies have been introduced into clinical medicine, which have ultimately changed the research on cardiac diseases in recent years. Some biomarkers have been identified and utilized for BCI diagnosis. Herein, we summarize the latest relevant information as a reference for clinical practice and future studies.

Estimation of time since death using cardiac troponin I in case of death due to asphyxia and cardiotoxicity of acebutolol

The objective of this study was to investigate the degradation pattern of cardiac troponin I in rats in vivo, and to determine whether the pattern was dependent on the cause of death, for the purpose of estimating the postmortem interval. The rats were categorized into three distinct groups depending on the factors leading to their demise: the control group, the group experiencing acebutolol-induced cardiotoxicity, and the group affected by asphyxia. The analysis encompassed the isolation and segregation of the protein, subsequently employing Western blotting as a means of visualizing the results. The results revealed a distinct degradation pattern of cTnI into smaller fragments over time, indicating that cardiac troponin I can serve as a reliable marker for estimating the postmortem interval. Furthermore, noteworthy variations were noted in the degradation pattern of cardiac troponin I among the different causes of death, which suggests that this method can also be used to determine whether cardiac failure was the cause of death or not.

Karate kick-induced myocardial contusion

Myocardial contusion should be suspected in a selected patient group with blunt thoracic trauma, who have elevated troponin, ECG changes and/or haemodynamical instability. Echocardiography is useful for direct visualisation of possible complications. In stable conditions, MRI allows for good visualisation of the heart and can confirm a suspected myocardial contusion as well as demonstrate the extent of myocardial damage. Based on the present literature, the authors developed a diagram for the diagnostic approach of a patient with suspected myocardial contusion.

Serum pro-B-type natriuretic peptide levels and cardiac index as adjunctive tools of blunt cardiac injury

BACKGROUND

Blunt cardiac injury (BCI) has a variety of symptoms that may be a potentially life-threatening injury that can lead to death. Depending on the diagnosis of BCI, treatment direction and length of stay may vary. In addition, the utility of other diagnostic tests for cardiac disease as diagnostic tools for BCI remain unclear. The purpose of this study was to investigate the competence of N-terminal pro-B-type natriuretic peptide (NT pro-BNP) and cardiac index (C.I) as adjunctive diagnostic tools for BCI.

METHODS

From January 2018 to March 2020, severe trauma patients with sternum fracture who were admitted to the traumatic intensive care unit (TICU) were included this study. Patients with sternum fracture, 18 years of age or older, and with an injury severity score > 16 who required intensive care were included. Invasive measurement for the analysis of the pulse contour for C.I monitoring and intravenous blood sampling for NT pro-BNP measurement were performed. Sampling and 12-lead electrocardiogram were performed at different time points as follows: immediately after TICU admission and at 24 h and 48 h after trauma.

RESULTS

Among 103; 33 patients with factors that could affect NT pro-BNP were excluded; therefore, 63 patients were included in this study. According to the American Association for the Surgery of Trauma Cardiac Injury Scale, 33 patients were diagnosed with non-BCI, and 30 patients constituted with BCI. The median ages of the patients were 58 (52-69), and 60 (45-69) years in the non-BCI and BCI groups, respectively (p = 0.77). The median NT pro-BNP values were higher in the BCI group on admission, hospital day (HD) 2, and HD 3, however, no statistical difference was observed (125 (49-245) vs. 130 (47-428) pg/mL, p = 0.08, 124 (68-224) vs. 187 (55-519) pg/mL, p = 0.09, and 121(59-225) vs. 133 (56-600) pg/mL, p = 0.17, respectively). On the contrary, significantly lower values were observed in the median C.I measurement on admission and HD 3 in the BCI group (3.2 (2.8-3.5) vs. 2.6 (2.3-3.5) L/min/m², p < 0.01 and 3.2 (3.1-3.9) vs. 2.9 (2.4-3.2) L/min/m², p < 0.01, respectively); however, no significant difference was observed on HD 2 (3.4 (3.0-3.7) vs. 2.6 (2.4-3.4) L/min/m², p = 0.17), Furthermore, The median lactate levels in the BCI group upon admission, HD 2, and HD 3 were significantly higher than those in the non-BCI group (1.8 (1.1-2.6) vs. 3.1 (2.1-4.4) mmol/L, p < 0.01; 1.3 (0.8-2.3) vs. 3.0 (2.2-4.7) mmol/L, p < 0.01; and 1.5 (0.9-1.5) vs. 2.2 (1.3-3.7) mmol/L, p < 0.01, respectively).

CONCLUSION

Consecutive values of NT pro-BNP and C.I show no correlation with ECG-based BCI diagnosis. However, lactate level measurement may help in the early recognition of BCI as an adjunctive tool. It should be noted that this is a hypothesis-generating study for BCI diagnosis. Further studies should be conducted in larger populations with a prospective approach.

Cardiac Contusion Complicated by Heart Failure in a Young Athlete

Chest trauma is a relatively common injury in athletes. Here, we report a case of a cardiac contusion in a football player that led to hemodynamically significant low-output state. Early invasive management was critical in treatment with imaging playing an important role in diagnosis. (Level of Difficulty: Advanced.)

Blunt Cardiac Injury in Patients With Sternal Fractures

Background

Blunt cardiac injury (BCI) is a possible consequence of sternal fractures (SF). There is a scarcity of studies addressing BCI in patients with different types of SF and with pre-existing cardiac conditions. The goal of this study was to delineate diagnostic patterns of BCI in different cohorts of SF patients.

Methods

This retrospective cohort study included 380 blunt trauma patients admitted to two level 1 trauma centers between January 2015 and March 2020 with radiologically confirmed SF. Electrocardiography, cardiac enzymes and echocardiography were evaluated for BCI diagnosis. Analyzed variables included: age, comorbidities, injury severity score, Glasgow coma score, type of SF (isolated, combined, displaced), incidence of traumatic brain injury, co-injuries, retrosternal hematoma, intensive care unit admissions, hospital lengths of stay, and mortality.

Results

In 380 SF patients there were 250 (66%) females and 130 (34%) males and the mean age was 63 years old. Electrocardiography was done in all patients, cardiac enzymes in 234 (62%) and echocardiography in 181 (48%). BCI was diagnosed in 19 (5%) of patients, all having combined SF. BCI patients had higher injury severity score (mean 18.4) and 14 (74%) had pulmonary co-injuries. Multivariable analysis confirmed pulmonary co-injuries as a statistically significant predictor of BCI (p<0.001). BCI patients compared to no BCI patients had all three tests (electrocardiography, cardiac enzymes and echocardiography) performed statistically more often (90% vs 36%, p<0.001). SF patients with pre-injury cardiac comorbidities had similar incidence of BCI as without cardiac comorbidities (5% vs 6%, p=0.6). In SF patients with traumatic brain injury, cardiac enzymes (troponin, creatine kinase) were elevated significantly more often compared to patients without traumatic brain injury (58% vs 38%, p=0.02). SF displacement or retrosternal hematoma presence were not associated with BCI. Mortality in SF patients with BCI versus without was not statistically different (16 vs 9%, p=0.4).

Conclusions

Blunt cardiac injury is rare in patients with SF. Higher degree of BCI suspicion must be applied in combined SF patients, especially those with pulmonary co-injuries. Cardiac comorbidities did not affect the rate of BCI. Echocardiography for BCI diagnosis is essential in SF patients with traumatic brain injury, as cardiac enzymes may be less informative, however is less important in isolated SF patients. Performing all three diagnostic tests in combined SF patients improves the accuracy of BCI diagnosis.

Myocardial Contusion: A Case of Fatal Cardiac Dysrhythmias During Air Medical Transportation

A 34-year-old male worker suffered from blunt chest trauma after falling from a height of about 10 m. The initial assessment of the emergency physician (EP) indicated that he was confused but recalled the event and had a midthoracic superficial laceration, ecchymosis, tenderness, and severe substernal pain. Because of the urgent need for advanced medical management in a trauma center, the EP coordinated with the nearest trauma center and the air medical crew (AMC) for his evacuation. Blood pressure of 100/55 mm Hg, heart rate of 128 beats/min, respiratory rate of 24 breaths/min, pulse oximetry of 91%, and a capillary refill time of about 2 seconds were the bedside AMC findings. Despite the adverse weather conditions and darkness, the AMC performed the following preflight assessments and preparations for the patient: neck and body fixation, 2 saline locks, intravenous hydration, ketorolac 30 mg intravenously, oxygen mask, a 12-lead electrocardiogram with cardiac monitoring, and echocardiography. During the evacuation, the patient decompensated further from sudden cardiac dysrhythmias, hypotension, loss of consciousness, and apnea. However, despite the difficult and unusual in-flight conditions, the EP performed 30 minutes of cardiopulmonary resuscitation, which was unsuccessful. The forensic report indicated that the fatal cardiac dysrhythmias due to myocardial contusion were a possible cause of death.

Traumatic tricuspid regurgitation following equine related blunt chest trauma and review of the literature

Myocardial injury following blunt chest trauma may be difficult to detect. We advocate for cardiac screening in such scenarios. Observation versus intervention should be based on symptoms and the degree of intracardiac disease.

Traumatic Sternal Fractures can be Safely Treated Conservatively - A 13-Year Retrospective Cohort Study

Background

Traumatic sternal fractures are rare injuries with little evidence supporting the best treatment strategy. This study assessed treatment outcomes from our level-I trauma centre.

Methods

A retrospective cohort study was conducted, including all sternal fracture patients admitted to our level-I trauma centre between 2007 and 2019. Patients with sternal fractures due to cardiopulmonary resuscitation, patients <16 years, patients who died during initial hospital stay, and patients lost to follow-up were excluded from analysis.

Results

In 13 years, 355 patients with traumatic sternal fractures were admitted, corresponding to 2% of all trauma patients. 262 patients were included in analysis. Mean age was 52 years and 71% of patients were male. Mean ISS was 19 (range 4-66). The majority of sternal fractures was located in the sternal body. Six patients (2%) underwent primary sternal fixation. Treatment failure occurred in three patients (1%) and was significantly higher in the surgical treatment group (p=0.001). There was no difference in treatment failure between patients with and without concomitant spinal fractures.

Conclusions

Conservative treatment is safe and effective for traumatic sternal fractures. Surgical treatment should be reserved for rare cases, such as imminent respiratory failure or debilitating symptomatic non-union.