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).

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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.