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EVALUATION OF THE PATIENT

WITH BLUNT CHEST TRAUMA:
AN EVIDENCE BASED APPROACH
Myles D. Greenberg, MD, and Carlo L. Rosen, MD

Chest trauma is the second commonest cause of traumatic death in

the United States after head trauma, accounting for approximately 20%
of deaths.49Many of these deaths are due to serious chest injuries that
are reversible if discovered and treated in a timely fashion. Rapid detec-
tion and treatment of blunt chest injuries are essential to the resuscitation
of the multiple trauma patient. For example, of those patients who
sustain traumatic aortic disruption that is not immediately fatal, 71% to
84% will survive with prompt diagnosis and su~gery,7~, 82 whereas 90%
will die without intervention.”
Major injuries to the chest caused by blunt mechanism can be
classified into chest wall injuries (e.g., rib fractures, flail chest, sternal
fractures), pulmonary injuries (e.g., pulmonary contusion, hemothorax,
pneumothorax, tracheobronchial disruption), cardiovascular injuries
(e.g., myocardial contusion, aortic disruption, cardiac rupture/tampon-
ade), and esophageal injuries. The diagnosis of these injuries depends
on multiple modalities and has changed dramatically in recent years
with the advent of newer imaging technology.
We will examine the use of plain chest radiography and computed
tomography (CT) to diagnose selected pulmonary and chest wall injur-
ies. Because this has been an area of minimal controversy, however,
there are few published data. Much of our current practice in diagnosing
these injuries is not evidence based; presumably expert opinion or local

From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center,
Harvard Medical School (MDG); and the Harvard Affiliated Emergency Medicine
Residency Program and Department of Emergency Medicine, Massachusetts General
Hospital (CLR), Boston, Massachusetts

EMERGENCY MEDICINE CLINICS OF NORTH AMERICA

- -
VOLUME 17 NUMBER 1 FEBRUARY 1999 41
42 GREENBERG & ROSEN

practice drives these practices patterns. These injuries are very common,
nevertheless. Pulmonary contusion is reported in 30% to 75% of patients
with significant blunt chest trauma, and pneumothorax is present in
15% to 50% of these patients.18
Because most of the recent literature on blunt chest trauma focuses
on the controversy regarding the diagnosis of blunt aortic and myocar-
dial injuries, much of this article is devoted to the use of CT, transesopha-
geal echocardiography (TEE), aortography, electrocardiography (ECG),
transthoracic echocardiography (TTE), and biochemical markers to iden-
tify these injuries. The true incidence of these two entities is not entirely
clear. The incidence of blunt myocardial injury is difficult to ascertain
because of the lack of agreement on the criteria for diagnosis. Reported
incidences vary from 3% to 75% in series of chest trauma ~atients.3~. 46

Thoracic great vessel injury accounts for approximately 8% to 9% of

vascular injuries; however, most of these are caused by penetrating
rne~hanisms.~~ Blunt disruption of the thoracic aorta usually is rapidly
fatal prior to hospital arrival; it is estimated that only approximately
10% to 20% of patients with these injuries survive to reach the emergency
department (ED).44, 86

METHODS

MEDLINE was searched using the terms blunt chest trauma, aortic
injury, and myocardial contusion for the years 1973 to 1998. All prospective
and retrospective studies on the use of chest x-ray (CXR), chest com-
puted tomography (chest CT), TEE, TTE, aortography, ECG, creatine
kinase (CK) determination, and troponin determination were identified.
In addition, reference lists in commonly available emergency medicine
and trauma textbooks were examined for appropriate studies.
All studies using CXR or chest CT for diagnosing chest wall and
pulmonary injury, studies using CXR, TEE, or aortography for blunt
aortic injury, and studies using ECG, TTE, TEE, CK, or troponin for
blunt myocardial injury were included. Review articles, case reports,
expert opinions, and letters to the editor (which were not actual studies)
were excluded from consideration. One hundred twenty-seven articles
were initially identified; of these, eighty met the criteria and were in-
cluded in this analysis.

CHEST WALL AND PULMONARY INJURY

Chest Radiography

The primary use of CXR is in the initial resuscitation of blunt

trauma patients for detection of rib fractures, flail chest, pneumothorax,
hemothorax, tracheobronchial injuries, pneumomediastinum, mediasti-
nal hematoma, and pulmonary contusion. The CXR is used both to
 EVALUATION OF THE PATIENT WITH BLUNT CHEST TRAUMA 43

diagnose these clinical entities and to direct the need for further diagnos-
tic intervention. This latter use is more fully addressed in the discussion
of aortic injury.
The use of the CXR as the primary imaging modality for detection
of these injuries is widespread; its use can be attributed to low cost and
easy availability. There is little evidence on the sensitivity or specificity
of plain CXR in the detection of pulmonary or thoracic injuries, however.
Although the anteroposterior (AP) CXR has been used as the initial
imaging modality of the blunt trauma patient, along with pelvis and
cervical spine radiographs, there are several studies suggesting that
there is a significant rate of missed serious chest injuries on the initial
CXR. In one level I1 study, 11 of 37 patients (30%) had chest injuries
missed on the initial trauma room CXR that were detected at autopsy.
These included two diaphragmatic tears and an aortic injury.59In another
level I1 study, 27 of 94 patients had serious injuries missed on the initial
CXR. These included pneumothoraces, hemothoraces, injuries to the
great vessels, and sternal or thoracic vertebral fractures. The erect AP
CXR had a sensitivity of 79% for detecting serious injuries, whereas the
supine CXR had a sensitivity of 58Y0.~~

CXR and Pneumothorax

Up to 57% of patients with blunt chest trauma will have ”occult”
pneumothorax diagnosed by abdominal or chest CT, and not by the
initial CXR.”,93 In one recent study, 43% of patients who had an occult
pneumothorax detected by CT required changes in their initial therapeu-
tic management.l’

CXR and Pulmonary Contusion

There are minimal human data on the use of CXR to detect pulmo-
nary contusion; however, an animal study (using a canine model) found
that immediately after experimentally induced pulmonary injury, CT
detected the pulmonary contusion in 100% of patients, whereas CXR
only detected 38% of these contusions. After 30 minutes, 75% were
visible by plain radiograph. In 58% however, CXR underestimated the
size of the contusion.” One human study showed a much lower rate of
pulmonary contusion detection on CXR versus chest CT (23% vs. 40%
incidence of contusion in study subjects, re~pectively).~~

Chest CT Scan

Chest CT is commonly considered to be the gold standard for the

detection of other serious chest injuries, such as pulmonary contusion,
pneumothorax, hemothorax, flail chest, and rib fractures. This belief has
not been studied by a large randomized controlled trial, however. There
are some data to suggest that the use of CT over CXR alone may result
44 GREENBERG & ROSEN

in changes in patient management. For example, 41% of patients in a

recent prospective study (level 11) of 103 patients had findings on tho-
racic CT that resulted in a change in management when compared with
plain radiograph findings. These injuries included diaphragmatic injury,
aortic rupture, and hemopericardium. Thoracic CT was found to be
more sensitive than CXR for the detection of pulmonary contusion,
pneumothorax, and h e m o t h ~ r a x In
. ~ ~another prospective study (level
11) of 73 patients with blunt torso trauma who underwent upright CXR
and chest CT, CT was more sensitive for the detection of pleural effusion
and pulmonary contusion than CXR. Of the 15 patients with pleural
effusion by CT, only three had effusion detected by CXR. Of the 27
patients with pulmonary contusion by CT, 6 had contusion seen on
upright CXR. Rib fractures, however, were detected more frequently by
CXR than CT. Of six patients with rib fractures by CXR, only one had
rib fractures detected by CT.80

Recommendations
Plain CXR should be used as the first imaging modality when one
suspects chest wall or pulmonary injuries. This test is inexpensive,
readily available, and has no morbidity associated with it. It appears
that there is a significant missed injury rate to CXR, however. If suspicion
is high for undetected injury, CXR should be followed by chest CT
scanning. Because chest CT is more expensive and exposes the patient
to the risk of IV contrast dye, however, it should be performed only if
the results are expected to alter patient management.

BLUNT AORTIC INJURY

CXR and Aortic Injury

Plain CXR is the least costly and invasive modality for imaging
patients with suspected aortic injury; however, its utility as the sole
diagnostic study for TAI is very limited. The recent literature has focused
on the use of chest radiography as an indicator of traumatic aortic injury
(TAI), and many standard textbooks of emergency medicine and trauma
recommend further diagnostic testing on the basis of an abnormal chest
radi~graph.~ ~ ,The
69,91 ~ ~ ,most sensitive sign of aortic injury and the focus
of most of the literature is the finding of a widened mediastinurn, which
has a sensitivity of 50% to 92%, specificity of 10%. Given the low
prevalence of this injury and the large number of CXRs performed on
trauma patients, however, the positive predictive value of widened
mediastinum in most studies is only 10% to 20%. Moreover, the mediasti-
num will be normal in 5% to 7.3% of those patients with documented
aortic injury.5,3", 31, 33, 45*63* 67* 76, 78, 85, 86 The CXR will be entirely normal in
up to 15% to 28% of patients with aortic injury4,6o Mediastinal width
 EVALUATION OF THE PATIENT WITH BLUNT CHEST TRAUMA 45

depends on both patient position and on whether the film is taken

during inspiration or e ~ p i r a t i o n . ~ ~
In the only large-scale, multicenter, prospective trial of CXR in blunt
chest trauma, 93% of patients with TAI had abnormal initial films,
with the commonest abnormalities being widened mediastinum (85%),
indistinct aortic knob (24%),left pleural effusion (19”/.),apical cap (19”/.),
first or second rib fracture (13%), tracheal deviation (12%), nasogastric
tube deviation ( l l y ~ ) and , depressed left bronchus (59’0).~OA smaller
prospective trial of 55 patients showed that 38% of patients with a
widened mediastinum on supine CXR had a normal mediastinum on
upright CXR; however, not all patients in this study underwent an
aortogram. The authors of this study conclude that if the supine CXR is
abnormal, an upright film should be performed if clinically feasible to
avoid unnecessary further studies.76In the largest retrospective study
prior to 1990, which included 173 patients, 43% of patients with a
widened mediastinum had a traumatic aortic injury confirmed by aor-
tography. Seventeen patients had an apical cap, and none had TAI. In
this study, the sensitivity of widened mediastinum was 95% in patients
under the age of 65 years; however, two thirds of patients over the age
of 65 years with TAI did not have a widened mediastinum on CXR.30 In
another retrospective study, 408 patients with widened mediastinum on
CXR underwent aortography; 13% had injury to the aorta or one of its
major branch vessels.67Other retrospective studies show that a widened
mediastinum on CXR has a sensitivity of 82% to 100% and a specificity
of 34% to 60% for predicting TAI. This includes studies that looked at
either subjective impression of width or objective measurement of width
> 8.0 cm. In this same group of studies, the test characteristics of other
CXR findings for the presence of TAI were assessed. The included
findings were abnormal aortic contour (sensitivity 53%-100%, specificity
21%-55%), tracheal deviation (sensitivity 12%-1007’0, specificity 80%-
%%), nasogastric tube deviation (sensitivity 23%-71%, specificity 90%-
%YO), left apical cap (sensitivity 20%-63%, specificity 75%-76%), and
depressed left mainstem bronchus (sensitivity 7%-809’0, specificity 80%-
100~0).3, 6, 31, 44, 53, 54, 77,85, 95

Previous trauma care doctrine held that there was an association

between high rib and sternal fractures and aortic injuryz4;however, more
recent data suggest that thoracic rib fractures detected by CXR do not
have a clinically relevant predictive value for aortic 48*94 There-
fore, the work-up should be based on other clinical or radiographic
criteria. In addition, the presence of sternal fractures on CXR has been
shown to have no predictive value for myocardial contusion.37

Recommendations
CXR is a useful initial screening tool for chest injury but cannot be
used as the sole test for diagnosing or excluding aortic injury. High
clinical suspicion in the setting of a normal CXR should prompt further
testing. In addition, mediastinal abnormalities on the CXR should
46 GREENBERG & ROSKN

prompt further testing, although skeletal injuries on the CXR should not
be used as a marker for aortic injury.

Chest CT Scan

CT is a widely available and relatively rapid imaging modality. It is

more expensive than CXR and requires IV contrast dye, yet is not an
invasive procedure like aortography. Because of these beneficial quali-
ties, chest CT has been extensively studied recently as a screening tool
for the detection of traumatic aortic injury after blunt chest trauma.
Table 1 summarizes the recent literature on the use of CT for detecting
aortic injury.
In a recent large multicenter trial (level 11) of TAI, CT was diagnostic
of aortic injury in 74% of patients. An additional 23% had findings of
mediastinal hematoma. Thus, only 3% of patients with a confirmed
injury had a negative CT. The limitations of this study are that it was
neither randomized nor controlled, and only 40% (88 of 220 patients)
underwent both aortogram and CT.20Another recent prospective nonran-
domized study reported that helical CT was actually more sensitive
(100% vs. 94%), although less specific (82% vs. 96%), than aortography
for the detection of aortic injury2*The limitations of these studies are
that not all patients underwent aortography or surgery.
In another smaller study of 28 patients, 12 of whom had aortic
injury, there was only one false-negative CT, yielding a sensitivity of
92% and a specificity of 100%. This level I1 study documented a 67%
decrease in the use of aortography when CT was used as the initial
screening test. This study also demonstrated that chest CT may be
limited in its ability to detect great vessel injury, which can occur in

Table 1. STUDIES ON THE USE OF CT FOR DETECTING AORTIC INJURY

~ ~ ~

Reference Type of No. of

No. Study Patients Accuracy “Gold Standard”
20 Prospective 220 Sensitivity: 74% for actual Aortography, surgery
level I1 injury, 97% for signs of
* j y
10 Level I1 28 Sensitivity: 92% Aortography, surgery
Specificity: 100%
(1 false negative: left
subclavian injury)
28 Prospective 127 Sensitivity: 100% Surgery, clinical outcome,
level 11 Specificity: 82% or aortography
23 Prospective 88 No false negatives Aortography or clinical
level I1 follow-up
58 Retrospective 17 Sensitivity: 83% All had aortography
level 111 Specificity: 23%
68 Prospective 90 No false negatives Aortography or clinical
level I1 follow-up
 EVALUATION OF THE PATIENT WITH BLUNT CHEST TRAUMA 47

association with TAI. Of the 28, 1 patient had a left subclavian injury
that was missed.1° Other level I1 studies have confirmed that CT is
helpful in determining the need for aortography but should not be used
as the sole diagnostic modality in patients with high clinical suspicion
for TAI.5s,68
Another use of helical CT in patients with suspected TAI is CT
angiography. In this technique, multiple thin cuts are taken through
the aorta during the injection of iodinated contrast. Three-dimensional
reconstructions are used to demonstrate the injury. In a recent level I11
study of only five cases of surgically proven thoracic aortic ruptures,
there was one case that was a false positive by both CT angiography
and conventional angiography. The authors concluded that this tech-
nique had good correlation with conventional angi~graphy.~~ In another
larger study, however, helical CT was found to be as accurate as CT
angiography for the detection and definition of aortic Thus, CT
angiography may be able to further define an aortic injury but does not
appear to have a higher sensitivity than helical CT for the detection
of TAI.

Recommendations
The data presented support the use of CT as a screening test to
diagnose TAI or to show mediastinal abnormalities, which should lead
to further testing (i.e., angiography). The major advantages of CT are
noninvasiveness and speed. In patients with a low clinical suspicion of
aortic injury, a negative CT can be used to exclude the diagnosis and
significantly decrease the number of aortograms necessary. It is not clear
whether CT is adequate for detecting great vessel injuries or clearly
defining the extent of an aortic injury. CT may demonstrate only the
presence of a mediastinal hematoma or nonspecific aortic abnormality.
Therefore, if the clinical suspicion is high or the CT demonstrates the
nonspecific finding of mediastinal hematoma, aortography is required
to confirm the presence of an aortic tear or to further define the injury
prior to surgery. As the technology of CT and CT angiography improves,
however, these modalities may eventually become the sole diagnostic
procedures of choice for detecting TAI.

Transesophageal Echocardiography

For the detection of thoracic aortic injury, TEE has the advantage of
being less invasive and more rapid than aortography. In addition, it can
be performed at the bedside and does not require contrast administra-
tion; however, it is limited by the need for an experienced operator and
is contraindicated in patients who have esophageal or cervical spine
injuries. Table 2 shows a summary of the recent literature on the use of
TEE for aortic injury.
In an early prospective study (level 11) of 69 patients by Kearney, all
48 GREENBERG & ROSEN

Table 2. STUDIES ON THE USE OF TEE FOR DETECTING AORTIC INJURY

Reference Type of No. of Sensitivity Specificity
No. Study Patients % % “Gold Standard”
16 Prospective 134 93 98 Aortography in 25
level I1 patients
89 Prospective 40 I00 88 Aortography, follow-
level I1 UP
88 Prospective 32 91 100 Aortography,
level I1 autopsy, surgery
71 Retrospective 114 63 84 Aortography or
level I11 surgery
81 Prospective 93 100 98 Aortography, surgery,
level 11 autopsy
13 Prospective 126 100 100 Aortography, surgery
level I1
42 Prospective 69 100 100 Aortography, surgery
level I1

of whom underwent both TEE and aortography, TEE had a diagnostic

sensitivity and specificity of 100% when compared with thoracotomy or
autopsy findings. In this study, aortography had a sensitivity of only
67% and specificity of 989’0.~~ In another prospective, nonrandomized
study of 160 consecutive patients suspected of having traumatic aortic
injury, 108 patients underwent TEE and aortography, 39 underwent
aortography only, and 18 underwent TEE only. The sensitivity and
specificity of TEE were 100%; however, 3 of the 121 studies (2.5%) were
equivocal. Aortography had a sensitivity and specificity of 73% and
99%, re~pectively.’~
Using aortography, surgery, or autopsy results as the gold standard,
Smith performed a prospective (level 11) study of 93 patients who under-
went TEE followed by aortography. The mean study time to perform
TEE was 29 k 12 minutes. The reported sensitivity and specificity were
100% and 98%, respectivelyFl In a prospective study (level 11) of 32
consecutive patients with suspected traumatic aortic injury based on
mechanism plus widened mediastinum on CXR, overall sensitivity and
specificity for detection of subadventitial tears were 91% and 100%
respectively. One 2-mm medial tear was missed by TEE. The gold stan-
dards were aortography, surgery, or autopsy.88 Another prospective
study (level 11) by the same author looked at patients with a normal
mediastinum on CXR. In 40 consecutive patients with significant mecha-
nism for TAI, all of whom underwent TEE, 6 patients (15%) had medias-
tinal hematoma and 2 patients (5%) had an aortic injury. Although both
injuries were confirmed by aortography, only these six patients actually
underwent a o r t ~ g r a p h y . ~ ~
Chirillo et a1 performed a prospective study (level 11) of 134 consecu-
tive patients with clinical evidence of significant chest trauma or history
of significant mechanism for aortic injury. Almost all patients (131 of
134) in this study underwent TEE. This study demonstrated a sensitivity
 EVALUATION OF THE PATIENT WITH BLUNT CHEST TRAUMA 49

of 93% and specificity of 98% for the detection of TAI. Furthermore, the
time to surgery in those patients undergoing procedures solely on the
basis of TEE was significantly shorter (30 min vs. 71 min). TEE also
detected pleural effusion, pericardial effusion, valvular disruption, and
blunt myocardial injury. Based on these findings, the authors conclude
that TEE may complement but is not an alternative to aortography. The
authors concluded that TEE can be used to select patients who can
proceed directly to surgery (when the study demonstrates unequivocal
evidence of aortic disruption). Furthermore, they concluded that patients
with negative TEE and high clinical suspicion, evidence of periaortic
hematoma, or indeterminate findings should undergo aortography.16
In a retrospective review (level 111), Saletta reported on 114 patients
who underwent TEE as the initial diagnostic study for radiographic or
clinical suspicion of traumatic aortic injury. In this study, 17 patients had
indeterminant results. Definitive diagnosis of an aortic tear was made in
only eight patients (7%),and only five patients were diagnosed correctly
using surgery or aortography as the gold standard. The resulting test
characteristics of TEE for detecting aortic injury were sensitivity 63%,
specificity 84%, positive predictive value 23%, and negative predictive
value 97%. This study tested TEE as the initial, sole diagnostic test
for TAI.71

Recommendations
The data from the prospective studies suggest that TEE is a valuable
tool for the diagnosis of TAI in experienced hands and may have a
higher sensitivity than aortography for the diagnosis. Because operative
repair can be performed without additional studies, TEE can signifi-
cantly reduce the time to surgery. TEE also can detect other cardiac
injuries such as pericardial effusions, valvular disruptions, and blunt
myocardial injury. One retrospective study, however, suggests that TEE
may not be appropriate as the initial screening study in blunt chest
trauma, especially when chest CT is readily available.49Finally, the utility
of this test is limited by the need to have an experienced operator
immediately available to perform the study.

Aortography

Aortography has long been considered the gold standard for trau-
matic aortic injury, although its invasiveness, risk, and expense have
prompted many to search for an alternative screening tool. The advan-
tage of aortography over TEE and chest CT is that it localizes the injury
precisely, especially in the case of multiple aortic tears. It also is more
accurate for the detection of great vessel injuries. The literature on the
use of aortography for the detection of aortic injury is limited in that
there is no true gold standard for the diagnosis aside from operative
thoracotomy and autopsy. The more recent literature, therefore, focuses
50 GREENBERG & ROSEN

on comparing CT or TEE with aortography. In a level I1 study by

Buckmaster et a1 and a level I11 study by Sturm et al, the sensitivity and
specificity of aortography for traumatic aortic injury were 73% to loo%,
and 99%, re~pectively.'~, In a recent level I1 study of 72 patients with
aortic rupture, 1% had an injury to the distal ascending aorta, and 19%
(17 patients) had aortic arch branch injuries. The authors of this study
conclude that these types of injuries may be missed if TEE is used as
the sole diagnostic test for aortic injury.4O Because aortography is more
accurate than CT and TEE for detecting ascending aortic injuries, it is
better able to determine the need for cardiopulmonary bypass for the
operative management of these patients. In contrast to other studies, a
recent prospective study (level 11) of TEE by Keamey for the detection
of aortic injury found that aortography actually had a lower sensitivity
than TEE (sensitivity of 67% and specificity of 98% versus an accuracy
of 100%for TEE). Sixty-nine patients with suspected aortic injury under-
went both TEE and aortography. There were two false-negative aorto-
grams and one false-positive aortogram in this

Recommendations
Aortography is still considered the gold standard for diagnosing
TAI; however, it appears that TEE and CT have greatly reduced the need
for this invasive test. Aortography still should be used to diagnose
nonaortic great vessel injury and also is frequently necessary to define
the extent of an injury once it has been discovered by other modalities.
Its invasiveness, cost, and iodinated-dye exposure risk probably will
limit its future use to these indications. Patients with a suggestive
mechanism and worrisome clinical or radiographic findings should un-
dergo aortography because it provides anatomic detail that enables the
cardiovascular surgeon to proceed to surgery. Additionally, in patients
at very high risk for TAI by clinical suspicion, aortography should be
ordered even if other studies are negative. This algorithm is summarized
in Figure 1.

Low/Equivocal
7 1 Clinical Suspicion
I High

+
ChestX-Ray
I 1 I I
Mediastinal .)
Hematoma Aortography

Negative

I
Figure 1. Diagnosis of thoracic aortic injuty.
 EVALUATION OF THE PATIENT WITH BLUNT CHEST TRAUMA 51

BLUNT MYOCARDIAL INJURY

There is no gold standard for the diagnosis of blunt myocardial

injury, short of autopsy. Thus, it is difficult to interpret studies that report
the test characteristics of any currently available diagnostic modality.
Fortunately, the incidence of clinically significant complications that
actually require treatment is negligible; therefore, even the necessity of
making this diagnosis is in question. The goal is to differentiate low-risk
patients who can be discharged safely from the ED from the small
number of patients who may develop complications requiring treatment.
Although there are several other tests that are currently used to diagnose
and risk-stratify blunt myocardial injury, this article focuses on electro-
cardiography, biochemical marker determination, and echocardiography.

Electrocardiography

ECG is a quick, inexpensive, and noninvasive test that is readily

available in any ED. Although ECG is neither specific nor sensitive for
blunt myocardial injury, it is the best screening test available in the ED.
Table 3 summarizes the studies on the use of ECG to diagnose blunt
myocardial injury.
One recent study (prospective, level 11) demonstrated an incidence
of 54% of abnormal ECG findings in patients with echocardiographic
abnormalities after blunt myocardial injury. Forty-nine percent of the
abnormalities were nonspecific ST-segment depression and T-wave
changes and the rest constituted conduction abnormalities, axis devia-
tion, and dy~rhythmias.~~ In a meta-analysis of 41 studies of blunt
myocardial injury, an abnormal ED ECG correlated with complications
requiring treatment (lethal dy~rhythmia).~~ Fildes et a1 prospectively
reported on 74 hemodynamically stable patients less than 55 years of
age with a normal initial ECG and no history of cardiac disease, who
did not have associated injuries requiring surgery. None of these patients
had a cardiac complication.22A level I1 retrospective study of 184 patients
with blunt myocardial injury demonstrated that patients with a normal
ED ECG did not develop complications requiring treatment.I7In contrast
to this, in a prospective study (level 11) by Biffl and coworkers, 17 of 107
patients with contusion developed complications requiring treatment.
Only 2 of 17 patients had an initial ECG that was abnormal; 3 had
sinus tachycardiaP Another retrospective study looked at 133 patients
admitted to two institutions with clinical suspicion for myocardial contu-
sion. In this study, there were 13 patients (9.7%)who developed cardiac
problems; no patient with a normal ED ECG developed a cardiac compli-
cation?* In a study by Miller et a1 only 4 of 172 patients had dysrhyth-
mias requiring treatment. All four patients had abnormal initial ED
ECGS.~~ Baxter et a1 also noted that nearly all cardiac complications in
patients without preexisting cardiac disease sustaining blunt chest
trauma were manifest on initial e~aluation.~ Wisner and coworkers stud-
52 GREENBERG & ROSEN

Table 3. STUDIES OF ECG USE FOR BLUNT MYOCARDIAL INJURY

Reference Type of No. of
No. Study Patients Results
17 Retrospective 184 No complications for patients with
level I1 normal ECG in ED; all with
complications had arrhythmia or
shock in ED
51 Meta-analysis 2,210 Abnormal ECG correlated with
level I (prospective) complications: Odds ratios = 3.2 and
2,471 26.0 (prospective and retrospective
(retrospective) data); normal ECG correlated with
the lack of complications
22 Prospective 93 No complications
level I1
9 Retrospective 359 17 (5%) had complications; 2 of 17 had
level 111 a normal ECG; 3 of 17 had sinus
tachycardia (occurred at 6-22 hr)
14 Prospective 336 No cardiac complications in those
level I1 admitted for abnormal initial ECG or
mechanism; all 19 complications
occurred in patients >60 yr old or
with otherwise significant chest
injury (i.e., 2 four rib fractures,
pulmonary contusions, flail chest,
major vascular injury, or severe
associated injuries)
32 Prospective 123 ECG does not correlate well with
level I1 cardiac complications or abnormal
nuclear medicine study
38 Retrospective 123 No complications in patients with
level I1 normal ECGs
92 Retrospective 95 Conduction abnormalities on initial
level I1 ECG predicted serious arrhythmias
35 Prospective 68 54% of patients had abnormal ECGs,
level 111 no correlation with echo findings;
authors did not report predictive
factors for complications
83 Retrospective 104 ECG did not predict complications that
level I1 occurred in 23% of patients

ied 95 patients with suspected contusions and found that only four
patients developed clinically significant dysrhythmias; only one of these
patients had a normal initial ECG.92
In contrast, two other studies, one prospective and one retrospective,
found no correlation between ECG findings and cardiac complica-
t i o n ~ .83~ Furthermore,
~, Cachecho and coworkers prospectively studied
336 patients with suspected myocardial contusion. In this study, none of
the 198 patients admitted solely for mechanism of injury or abnormal
initial ECG developed cardiac complications. The 19 patients who devel-
oped complications had four or more rib fractures, pulmonary contusion,
flail chest, or extrathoracic injuries, or were over 60 years of age.I4
Nevertheless, most authors recommend that stable patients with normal
 EVALUATION OF THE PATIENT WITH BLUNT CHEST TRAUMA 53

ECGs who are asymptomatic without other significant injuries can be

safely discharged from the ED.

Biochemical Markers

Creatine Kinase (CK)

Creatine kinase MB (CK-MB) is a relatively inexpensive, noninva-
sive test that is readily available and widely used for diagnosing non-
traumatic cardiac injury. CK-MB fractions are frequently ordered as part
of the work-up of patients to rule out blunt myocardial injury. The
evidence in support of this practice is not substantial, however. All of
the studies on the use of CK-MB for detecting myocardial injury suffer
from the same major limitation: there is no clear definition of myocardial
contusion, nor is there an established gold standard. Table 4 summarizes
the studies on the use of CK-MB determination in blunt myocardial in-
jury.
In a retrospective study (level 11) of 182 patients with significant
blunt chest trauma who underwent serial CK-MB fraction analysis, there

Table 4. STUDIES OF CK-MB DETERMINATION IN BLUNT MYOCARDIAL INJURY

Reference Type of No. of
No. Study Patients Results
41 Meta-analysis 4,681 Abnormal CK-MB level correlated with
level I1 increased complications (odds ratios
3.7 and 7.7 for prospective and
retrospective data).
9 Retrospective 359 41% of patients with complications had
level I1 elevated CK-MB level; 59% had
normal CK-MB level.
19 Prospective 92 52% patients with echo-demonstrated
level I1 contusion had elevated CK-MB vs.
19% with elevations who had no
echo findings
32 Prospective 123 Elevated CK-MB level not predictive of
level I1 cardiac complications
35 Prospective 68 Elevated CK-MB level 17% sensitive for
level I1 echo-demonstrated contusion
62 Prospective 172 No patients with elevated CK-MB level
level I1 as sole diagnostic criterion for
contusion developed complications.
92 Retrospective 95 No correlation of elevated CK-MB level
level I1 with complications
43 Retrospective 182 No correlation of elevated CK-MB level
level I1 with complications or echo/MUGA
findings
83 Retrospective 104 23% developed complications but CK-
level I1 MB not predictive
25 Prospective 58 Elevated CK-MB did not correlate with
level I1 TTE abnormalities.
54 GREENBERG & ROSEN

was no correlation of CK-MB levels with ECG findings suggestive of

myocardial injury. The major limitation of this study is that myocardial
injury was confirmed in only ten patients who underwent 2-D echocardi-
ography or multiple-gated acquisition (MUGA) ~cintigraphy.~~ Another
investigator prospectively documented the lack of correlation of elevated
CK-MB with abnormal nuclear medicine studies (MUGA) or cardiac
morbidity.32A prospective study (level 11) of 68 patients demonstrated
that 12 patients had elevated CK-MB levels; however, only 3 of these
patients also had abnormal echocardiographic findings (present in 18
patients). These authors conclude that CK-MB may be used in conjunc-
tion with echocardiography and ECG to diagnose myocardial In
a larger prospective study of 92 patients, all of whom underwent serial
ECG, CK-MB analysis, continuous Holter monitoring, and noninvasive
cardiac output measurement, 23 developed dysrhythmias. No patients
required specific therapy, however. This highlights another area of confu-
sion about the diagnosis of myocardial contusion; the incidence of clini-
cally significant dysrhythmias that actually require treatment is negligi-
ble. Fifty-two percent of patients who developed dysrhythmias had an
elevated CK-MB, whereas only nineteen percent of patients without
dysrhythmia had CK-MB elevation. Although this difference was statisti-
cally significant in this study, the low sensitivity and specificity preclude
its use clinically.”
In another retrospective study of 359 patients, 217 of whom were
admitted solely for the purpose of ruling out myocardial contusion, 107
(30%) were diagnosed with this injury based on either abnormal ECG
findings or elevated CK-MB fractions. Sixteen percent of patients devel-
oped complications (dysrhythmias or cardiogenic shock) requiring treat-
ment. Every patient with a complication had an abnormal ECG; how-
ever, only 41% had elevated CK-MB fractions. There were no
complications among those patients with normal ECGs and elevated
CK-MB fractions. Thus, in this study, an elevated CK-MB level was
never the sole predictor of a complication after blunt myocardial i n j ~ r y . ~
An earlier study demonstrated that 58 of 291 patients (20%) who were
assessed for possible cardiac injury had a CK-MB fraction elevation
within 24 hours of the injury. Of these patients, five had dysrhythmias
occurring within 72 hours of injury that were hemodynamically signifi-
cant and required intervention. It is not clear from this study whether
these patients had abnormalities on their initial ECGS.~~ Furthermore, in
the study by Miller, none of the patients with isolated CK-MB elevations
had complications.62Other retrospective studies have also documented
the lack of utility of elevated CK-MB fractions in the prognosis of a
patient with suspected blunt myocardial injurys3,92

Troponin
Troponin is a regulatory protein that is found only in cardiac tissue.
Troponin I and T are sensitive and specific markers for myocardial
infarction and are now being used for the detection of myocardial
 EVALUATION OF THE PATIENT WITH BLUNT CHEST TRAUMA 55

injury.2,30 Troponin is more specific than CK-MB because it is not present

in skeletal muscle. There are several recent studies that have investigated
the use of troponin I for detecting blunt myocardial injury. Table 5
summarizes the studies on the use of troponin determination in the
diagnosis of blunt myocardial injury.
In a study of 44 patients, all 6 patients with cardiac injury diagnosed
by echocardiogram had both elevated CK-MB levels and elevated tropo-
nin I. In the 37 patients without echo-detected cardiac injury, 26 had
elevated CK-MB levels, yet none had elevated troponin I.' The major
limitation of this study is that it used echocardiography as the sole test
for diagnosis of cardiac injury. A more recent, very small (level 11) study
of 28 patients, only 5 of whom had myocardial contusion diagnosed by
TEE, reported 100% sensitivity and specificity of elevated serum tropo-
nin I for myocardial contusion for TEE-documented
Other studies have looked at serum troponin T determination. A
level I1 study of 29 patients with myocardial contusion found that
troponin T was more sensitive (31%)than CK-MB (9%) for the detection
of traumatic cardiac injury. The sensitivities were both far too low for
clinical use of these tests, however. The gold standard in this study was
the presence of rhythm or conduction abnormalities, abnormal echo, or
hemopericardium.21Another study of troponin T in 71 patients found
that the sensitivity and specificity of elevated troponin T for predicting
clinically significant electrocardiographic abnormalities were 27% and
91%, respectively. Only 20 patients in this study had or developed a
clinically significant ECG abnormality.26
Although these preliminary data suggest that troponin determina-
tion is a more specific indicator than CK-MB of myocardial injury after
blunt trauma, troponin levels do not appear to have predictive value for
the development of complications and need for hospital admission.
Troponin I may be helpful in predicting echocardiographic abnormali-
ties; however, troponin T determination appears to have little utility in
the diagnosis of blunt myocardial injury.

Table 5. STUDIES OF THE USE OF TROPONIN DETERMINATION IN BLUNT

MYOCARDIAL INJURY
Reference No. of
No. Type of Study Marker Studied Patients Results
65 Level I1 Troponin I 28 100% sensitivity and specificity
for echo-demonstrated
contusion
21 Level I1 Troponin T 29 Sensitivity of troponin T better
than CK-MB (31% vs 9%)
26 Level I1 Troponin T 71 Sensitivity = 27% and
specificity = 91% for
predicting significant ECG
abnormalities
1 Level I1 Troponin I 44 100% sensitivity and specificity
for echo-demonstrated injury
56 GREENBERG & ROSEN

Transthoracic Echocardiography

TTE is another noninvasive bedside test that is frequently ordered

from the ED for patients with suspected blunt myocardial injury, but its
utility in patients who are hemodynamically stable is not well supported
by the literature. Table 6 lists the studies on the use of TTE in the
diagnosis of blunt myocardial injury.
In a study by Frazee et al, of 58 patients with CK-MB elevations, 35
(60%) had normal 2-D echocardiography; 23 (40%) had abnormal 2-D
echocardiography. The abnormalities were primarily right ventricular
dyskinesias. Cardiac dysrhythmias occurred in only 1 of the 35 patients
(3%) with a normal echocardiogram and 9 of 23 (39%) with an abnormal
echocardiogram. The difference was statistically signifi~ant.~~ In a study
by Beggs et al, TTE was performed on 40 patients with clinical suspicion
of blunt chest trauma. One half of these patients manifested at least one
abnormality on either ECG, cardiac enzyme analysis, or two-dimensional
TTE. Twenty-three percent of these patients had echocardiographic ab-
normalities; however, there was no correlation between the echocardio-
graphic abnormalities and ECG or enzyme abnormalities. Moreover,
echocardiography did not predict complications. The one patient with
pericardial tamponade had the diagnosis made on clinical grounds and
then confirmed by echocardiography.*
In a prospective study of 73 patients presenting with blunt chest
trauma, all of whom underwent TTE, serial CK-MB measurements, and
cardiac monitoring, 14 had echocardiographic abnormalities caused by
chest injury. There was only one complication in the group with echocar-
diographic findings; this complication was a persistent ventricular dys-
rhythmia successfully treated with lidocaine. This patient also had an
initially abnormal ECG, however. In the group without echocardio-
graphic findings, there was one complication (frequent PVCs) also suc-
cessfully treated with l i d ~ c a i n eIn
.~~another prospective study, 172 pa-
tients with myocardial injury suspected on clinical grounds underwent
serial ECGs, serial CK-MB isoenzyme determinations, and 2-D echocar-

Table 6. STUDIES ON USE OF TTE IN BLUNT MYOCARDIAL INJURY

Reference No. of
No. TvDe Of Studv Patients Results
62 Prospective level I1 172 No complications among those
patients with isolated TTE
abnormalities but normal ECGs
36 Prospective level I1 73 Only 1 complication in each group;
sensitivity = 50%, specificity =
82%
8 Prospective level I11 40 Echocardiographic abnormalities
did not predict complications
25 Prospective level I1 58 39% sensitive, 97% specific for
complications
 EVALUATION OF THE PATIENT WITH BLUNT CHEST TRAUMA 57

diography. The authors found that ECG abnormalities or shock were the
only two predictors of the need for monitoring or further treatment.
Furthermore, patients with abnormalities of CK-MB or on echocardiogra-
phy without ECG abnormalities did not develop complications requiring
treatment.62
Although there are several studies that investigate the use of TTE
specifically for detecting pericardial effusion and tamponade after pene-
trating trauma, there are few data on its use for this purpose after blunt
trauma.61,64, 66, 70 After blunt trauma, the incidence of cardiac rupture in
patients presenting to the ED alive is low; probably the only survivable
injury of this type is atrial rupture. Based on the existing literature on
penetrating chest trauma, it appears that TTE is useful in the diagnosis
of pericardial effusion and tamponade. One study by Plummer docu-
mented a sensitivity of 98% and specificity of 100% for this technique in
the hands of emergency physicians.66

Transesophageal Echocardiography
There are data that suggest TEE may be more accurate than TTE in
the detection of blunt myocardial injury. Chirillo et a1 prospectively
studied (level 11) 134 consecutive patients with severe blunt chest trauma.
All patients underwent TTE and TEE within 8 hours of admission. TTE
images were technically suboptimal in 62% of patients and demonstrated
myocardial injury in only 15 patients, whereas TEE demonstrated myo-
cardial injury in 45 of the 131 patients in whom the study was technically
feasible. The study did not report the clinical significance of these find-
ings. Based on these results, the authors conclude that TEE is more
accurate than TTE for detecting myocardial injury and that TTE is not
recommended as a routine study for patients with blunt chest trauma.16
In addition, TEE has the ability to demonstrate other cardiovascular
abnormalities, such as valvular disruption, pericardial effusions, and
TAI. The clinical significance of effusion detected by TEE remains to be
determined, however.16,79 In a study comparing TEE to TTE for the
detection of cardiac contusion and aortic injury, 50 patients with a
suspected diagnosis of cardiac contusion or TAI underwent both studies.
Cardiac contusion, as diagnosed by wall motion abnormalities, was
detected in 26 patients (52%)by TEE, but TTE showed this abnormality
in only 6 patients (12Y0).~~ Two other studies have documented the ability
of TEE to detect segmental wall motion abnormalities in severely injured
patients, some of whom could not undergo TTE because of severe
external chest injuries.15,90 Another use for TEE may be in differentiating
pericardial tamponade from right ventricular myocardial contusion. A
recent article reported two such cases diagnosed by TEE.29

Recommendations
Based on the literature, the initial ED ECG is the best screening test
for potential cardiac complications from blunt myocardial injury. Patients
58 GREENBERG & ROSEN

with a normal ECG, normal hemodynamics, and no other significant

injuries can be safely discharged from the ED. Cardiac enzymes have no
role in the prediction of complications in patients with blunt myocardial
injury, although elevated serum troponin I levels may predict echocardi-
ographic abnormalities. Echocardiography should not be used as a
screening test to rule out myocardial contusion in the ED, however.
Furthermore, echocardiographic abnormalities do not seem to predict
clinical complications. The use of echocardiography should be reserved
for unstable patients to detect pericardial tamponade and cardiac rup-
ture. TTE should be the procedure of choice for this indication because
there is no clear evidence that TEE is superior. There appear to be
little data supporting the extra cost and invasiveness of TEE for the
identification of blunt myocardial injury.

RECOMMENDATIONS FOR FUTURE RESEARCH

The most pressing need for further research is in the search for a
quick, noninvasive method for excluding the diagnosis of traumatic
aortic injury. The current state of CT scan technology does not allow this
modality to be used as the sole method of imaging the aorta in the
patient with a high pretest suspicion for TAI. Early investigation into
the use of CT angiography for this purpose seems promising, however.
In addition, further research should be directed at the elucidation of
blunt myocardial injury. There is no gold standard for the diagnosis;
thus efforts to examine all current modalities are limited. In addition,
there is much controversy about the need to make this diagnosis in the
majority of patients with blunt chest trauma.

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Address reprint requests to

Myles D. Greenberg, MD
Department of Emergency Medicine
Beth Israel Deaconess Medical Center
330 Brookline Avenue
UL 202
Boston, MA 02215