Cardiac contusions in the acute care setting: Historical background, evaluation and management

INTRODUCTION

Albeit described since 1763, cardiac contusions is still an under-recognised clinical condition in the acute care setting. This evidence-based review aims to provide an overview of the topic by focusing on etiopathogenesis, classification and clinical presentation of patients with cardiac contusions, as well as on the diagnostic work-up and therapy options available for this subset population in the acute care setting.

METHODS

A targeted research strategy was performed using PubMed, MEDLINE, Embase and Cochrane Central databases up to June 2022. The literature search was conducted using the following keywords (in Title and/or Abstract): ("cardiac" OR "heart" OR "myocardial") AND ("contusion"). All available high-quality resources written in English and containing information on epidemiology, etiopathogenesis, clinical findings, diagnosis and management of cardiac contusions were included in our research.

RESULTS

Biochemical samples of cardiac troponins together with a 12‑lead ECG appear to be sufficient screening tools in hemodynamically stable subjects, while cardiac ultrasound provides a further diagnostic clue for patients with hemodynamic instability or those more likely to have a significant cardiac contusion.

CONCLUSIONS

The management of patients with suspected cardiac contusion remains a challenge in clinical practice. For this kind of patients a comprehensive diagnostic approach and a prompt emergency response are required, taking into consideration the degree of severity and clinical impairment of associated traumatic injuries.

Cardiac changes after simulated behind armor blunt trauma or impact of nonlethal kinetic projectile ammunition

BACKGROUND

Cardiac-related injuries caused by blunt chest trauma remain a severe problem. The aim of this study was to investigate pathophysiological changes in the heart that might arise after behind armor blunt trauma or impacts of nonlethal projectiles.

METHODS

Sixteen pigs were shot directly at the sternum with "Sponge Round eXact I Mpact" (nonlethal ammunition; diameter 40 mm and weight 28 g) or hard-plastic ammunition (diameter 65 mm and weight 58 g) to simulate behind armor blunt trauma. To evaluate the influence of the shot location, seven additional pigs where exposed to an oblique heart shot. Physiologic parameters, electrocardiography, echocardiogram, the biochemical marker troponin I (TnI), and myocardial injuries were analyzed.

RESULTS

Nonlethal kinetic projectiles (101-108 m/s; 143-163 J) did not cause significant pathophysiological changes. Five of 18 pigs shot with 65-mm plastic projectiles (99-133 m/s; 284-513 J) to the front or side of the thorax died directly after the shot. No major physiologic changes could be observed in surviving animals. Animals shot with an oblique heart shot (99-106 m/s; 284-326 J) demonstrated a small, but significant decrease in saturation. Energy levels over 300 J caused increased TnI and myocardial damages in most of the pigs.

CONCLUSION

This study indicates that nonlethal kinetic projectiles "eXact iMpact" does not cause heart-related damage under the examined conditions. On impact, sudden heart arrest may occur independently from the cardiac's electrical cycle. The cardiac enzyme, TnI, can be used as a reliable diagnostic marker to detect heart tissue damages after blunt chest trauma.

Cardiogenic shock following blunt chest trauma

Cardiac contusion, usually caused by blunt chest trauma, has been recognized with increased frequency over the past decades. Traffic accidents are the most frequent cause of cardiac contusions resulting from a direct blow to the chest. Other causes of blunt cardiac injury are numerous and include violent fall impacts, interpersonal aggression, explosions, and various types of high-risk sports. Myocardial contusion is difficult to diagnose; clinical presentation varies greatly, ranging from lack of symptoms to cardiogenic shock and arrhythmia. Although death is rare, cardiac contusion can be fatal. We present a case of cardiac contusion due to blunt chest trauma secondary to a fall impact, which manifested as cardiogenic shock.