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Image challenge
A shocking bike accident
  1. Jerrold Spapen1,
  2. Stijn Lochy1,2,
  3. Vincent Michiels1
  1. 1 Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
  2. 2 Department of Intensive Care Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
  1. Correspondence to Dr Jerrold Spapen, Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Jette 1090, Belgium; jerrold.spapen{at}


Clinical introduction A man in his late 40s presented with severe chest pain and progressive dyspnoea after hitting a tree at high speed during a bike ride in the woods. On admission, the patient appeared agitated, pale and sweaty. Core temperature was 35.5°C, respiratory rate 35/min and blood pressure 90/50 mm Hg with a regular pulse at 110 beats/min. Physical examination revealed multiple sternal bruises, distended jugular veins and muffled heart sounds (figure 1A). Lactate level was 4.4 mmol/L (normal <2.0 mmol/L) and high-sensitivity cardiac troponin T 0.142 mcg/L (normal <0.005 mcg/L). An ECG and a total body CT scan were performed (figure 1B,C).

Figure 1

(A) Multiple sternal bruises. (B) ECG on admission. (C) Thoracic CT.

Question:  What is the most likely diagnosis?

  1. Inferior myocardial infarction with right ventricular involvement.

  2. Cardiac contusion with tamponade.

  3. Commotio cordis.

  4. Aortic laceration.

  • pericardial tamponade
  • cardiac computer tomographic (CT) imaging
  • echocardiography

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  • Contributors JS wrote the paper. SL and VM supervised it.

  • Funding The authors declare have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.