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Abstract
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).
(A) Multiple sternal bruises. (B) ECG on admission. (C) Thoracic CT.
Question: What is the most likely diagnosis?
Inferior myocardial infarction with right ventricular involvement.
Cardiac contusion with tamponade.
Commotio cordis.
Aortic laceration.
- pericardial tamponade
- cardiac computer tomographic (CT) imaging
- echocardiography
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Answer B: Diagnosis: cardiac contusion with tamponade
Clinical examination revealed sternal ecchymosis suggesting high-impact blunt chest trauma. Arterial hypotension, sinus tachycardia, turgescent jugular veins and elevated lactate indicated obstructive shock. Thoracic CT ruled out myocardial rupture and large vessel laceration, but highlighted a pericardial effusion. Transthoracic echocardiogram (TTE) confirmed the diagnosis of cardiac tamponade (figure 2 and supplementary movie 1). Left ventricular function was preserved and no valvular impairment was noticed. Pericardiocentesis evacuated 650 mL sanguineous fluid resulting in prompt haemodynamic recovery.
Supplementary file 1
Apical four-chamber transthoracic echocardiogram (TTE) revealing a large pericardial effusion (asterisk) causing cardiac tamponade. LV, left ventricle; RV, right ventricle.
Traumatic pericardial effusion with tamponade must always be considered in high-impact blunt chest trauma. It is described as a severe manifestation of ‘cardiac contusion’. The latter term, however, is confusing as it refers to structural cardiac damage due to non-penetrating thoracic injury without documenting the exact nature of the cardiac lesion(s). Diagnosis is challenging because symptoms are non-specific and sternal lesions are easily overlooked in patients with polytrauma. Serial ECGs and troponin measurements are mandatory. TTE is required to assess ventricular function and to rapidly exclude valvular impairment, myocardial rupture and/or pericardial effusion.1 2
Commotio cordis is an often fatal event that occurs when a blow to the precordium alters electric stability of the myocardium resulting in ventricular fibrillation.3
Trauma-induced myocardial infarction due to coronary artery thrombosis, rupture or spasm has occasionally been reported. Right ventricular myocardial infarction should be ruled out in case of obstructive shock. Although potentially mistaken for inferior myocardial infarction, concave ST-segment elevations in leads II, III and aVF without reciprocal ST depressions are suggestive for acute pericardial injury. Moreover, profound PR-segment depression is almost pathognomonic for pericardial inflammation.4
High central venous pressure argues against vascular rupture and hypovolaemic shock.5 Nevertheless, laceration or dissection of great vessels are dreaded complications after high-impact thoracic injury which must rapidly be excluded.
Footnotes
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.