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Blunt Cardiac Injury: March 2019

Volume 21, Number 3
Emergency Department Authors

Eric J. Morley, MD

Diagnosis and Management

Associate Professor, Clinical Director, Department of Emergency
Medicine, Deputy Chief Medical Informatics Officer, Stony Brook
Medicine, Stony Brook, NY
Bryan English, MD
Abstract Assistant Professor, Department of Emergency Medicine, Stony Brook
Medicine, Stony Brook, NY
David B. Cohen, MD, FACEP
Blunt cardiac injury describes a range of cardiac injury patterns Associate Professor, Department of Emergency Medicine, Stony Brook
resulting from blunt force trauma to the chest. Due to the mul- Medicine, Stony Brook, NY

titude of potential anatomical injuries blunt force trauma can William F. Paolo, MD
Associate Professor, Residency Program Director, SUNY Upstate
cause, the clinical manifestations may range from simple ectopic Medical University, Syracuse, NY
beats to fulminant cardiac failure and death. Because there is no
Peer Reviewers
definitive, gold-standard diagnostic test for cardiac injury, the
emergency clinician must utilize an enhanced index of suspicion Jennifer Maccagnano, DO, FACOEP
Assistant Professor, New York Institute of Technology College of
in the clinical setting combined with an evidence-based diag- Osteopathic Medicine, Old Westbury, NY; Emergency Medicine
nostic testing approach in order to arrive at the diagnosis. This Attending Physician, Brookdale Hospital Medical Center and
Maimonides Medical Center, Brooklyn, NY
review focuses on the clinical cues, diagnostic testing, and clini-
Ashley Norse, MD, FACEP
cal manifestations of blunt cardiac injury as well as best-practice Associate Chair of Operations, Department of Emergency Medicine,
management strategies. University of Florida Health Jacksonville, Jacksonville, FL

Prior to beginning this activity, see “CME Information”

on the back page.

Editor-In-Chief
Andy Jagoda, MD, FACEP
Professor and Interim Chair,
Department of Emergency Medicine;
Director, Center for Emergency
Medicine Education and Research,
Icahn School of Medicine at Mount
Sinai, New York, NY
Associate Editor-In-Chief
Kaushal Shah, MD, FACEP
Associate Professor, Department of
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY
Editorial Board
Saadia Akhtar, MD, FACEP
Associate Professor, Department of
Emergency Medicine, Associate Dean
for Graduate Medical Education,
Program Director, Emergency
Medicine Residency, Mount Sinai
Beth Israel, New York, NY
William J. Brady, MD
Professor of Emergency Medicine
and Medicine; Medical Director,
Emergency Management, UVA
Medical Center; Operational Medical
Director, Albemarle County Fire
Rescue, Charlottesville, VA
Calvin A. Brown III, MD
Director of Physician Compliance,
Credentialing and Urgent Care
Services, Department of Emergency
Medicine, Brigham and Women's
Hospital, Boston, MA
Peter DeBlieux, MD FAAEM, FACP
Professor of Clinical Medicine,
Louisiana State University School of
Medicine; Chief Experience Officer,
University Medical Center, New
Orleans, LA
Daniel J. Egan, MD
Associate Professor, Vice Chair of
Education, Department of Emergency Memorial Hospital, Miami, FL
Medicine, Columbia University
Vagelos College of Physicians and
Surgeons, New York, NY
Nicholas Genes, MD, PhD
Associate Professor, Department of
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY
Michael A. Gibbs, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Carolinas
Medical Center, University of North
Carolina School of Medicine, Chapel Charles V. Pollack Jr., MA, MD,
Hill, NC
Steven A. Godwin, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Assistant
Dean, Simulation Education,
University of Florida COM-
Jacksonville, Jacksonville, FL
Joseph Habboushe, MD MBA
Assistant Professor of Emergency
Medicine, NYU/Langone and
Bellevue Medical Centers, New York,
NY; CEO, MD Aware LLC
Gregory L. Henry, MD, FACEP
Clinical Professor, Department of
Emergency Medicine, University
of Michigan Medical School; CEO,
Medical Practice Risk Assessment,
Inc., Ann Arbor, MI
John M. Howell, MD, FACEP
Clinical Professor of Emergency
Medicine, George Washington
University, Washington, DC; Director
of Academic Affairs, Best Practices,
Inc, Inova Fairfax Hospital, Falls
Church, VA
Shkelzen Hoxhaj, MD, MPH, MBA
Chief Medical Officer, Jackson
Eric Legome, MD
Chair, Emergency Medicine, Mount
Sinai West & Mount Sinai St. Luke's;
Vice Chair, Academic Affairs for
Emergency Medicine, Mount Sinai
Health System, Icahn School of
Medicine at Mount Sinai, New York, NY
Keith A. Marill, MD, MS
Associate Professor, Department
of Emergency Medicine, Harvard
Medical School, Massachusetts
General Hospital, Boston, MA
FACEP, FAAEM, FAHA, FESC
Professor & Senior Advisor for
Interdisciplinary Research and
Clinical Trials, Department of
Emergency Medicine, Sidney Kimmel Ron M. Walls, MD
Medical College of Thomas Jefferson
University, Philadelphia, PA
Michael S. Radeos, MD, MPH
Associate Professor of Emergency
Medicine, Weill Medical College
of Cornell University, New York;
Research Director, Department of
Emergency Medicine, New York
Hospital Queens, Flushing, NY
Ali S. Raja, MD, MBA, MPH
Executive Vice Chair, Emergency
Medicine, Massachusetts General
Hospital; Associate Professor of
Emergency Medicine and Radiology,
Harvard Medical School, Boston, MA Scott D. Weingart, MD, FCCM
Robert L. Rogers, MD, FACEP,
Assistant Professor of Emergency
Medicine, The University of
Maryland School of Medicine,
Baltimore, MD
Alfred Sacchetti, MD, FACEP
Assistant Clinical Professor,
Department of Emergency Medicine,
Thomas Jefferson University,
Philadelphia, PA
Robert Schiller, MD
Chair, Department of Family Medicine,
Beth Israel Medical Center; Senior
Faculty, Family Medicine and
Community Health, Icahn School of
Medicine at Mount Sinai, New York, NY
Scott Silvers, MD, FACEP
Associate Professor of Emergency
Medicine, Chair of Facilities and
Planning, Mayo Clinic, Jacksonville, FL
Corey M. Slovis, MD, FACP, FACEP
Professor and Chair, Department
of Emergency Medicine, Vanderbilt
University Medical Center, Nashville, TN
Professor and Chair, Department of
Emergency Medicine, Brigham and
Women's Hospital, Harvard Medical
School, Boston, MA
Critical Care Editors
William A. Knight IV, MD, FACEP,
FNCS
Associate Professor of Emergency
Medicine and Neurosurgery, Medical
Director, EM Advanced Practice
Provider Program; Associate Medical
Director, Neuroscience ICU, University
of Cincinnati, Cincinnati, OH
Professor of Emergency Medicine;
Chief, EM Critical Care, Stony Brook
Medicine, Stony Brook, NY
Research Editors
Aimee Mishler, PharmD, BCPS
Emergency Medicine Pharmacist,
Program Director, PGY2 EM
Pharmacy Residency, Maricopa
Medical Center, Phoenix, AZ
Joseph D. Toscano, MD
Chief, Department of Emergency
Medicine, San Ramon Regional
Medical Center, San Ramon, CA
International Editors
Peter Cameron, MD
Academic Director, The Alfred
Emergency and Trauma Centre,
Monash University, Melbourne,
Australia
Andrea Duca, MD
Attending Emergency Physician,
Ospedale Papa Giovanni XXIII,
Bergamo, Italy
Suzanne Y.G. Peeters, MD
Attending Emergency Physician,
Flevo Teaching Hospital, Almere,
The Netherlands
Edgardo Menendez, MD, FIFEM
Professor in Medicine and Emergency
Medicine; Director of EM, Churruca
Hospital of Buenos Aires University,
Buenos Aires, Argentina
Dhanadol Rojanasarntikul, MD
Attending Physician, Emergency
Medicine, King Chulalongkorn
Memorial Hospital; Faculty of
Medicine, Chulalongkorn University,
Thailand
Stephen H. Thomas, MD, MPH
Professor & Chair, Emergency
Medicine, Hamad Medical Corp.,
Weill Cornell Medical College, Qatar;
Emergency Physician-in-Chief,
Hamad General Hospital,
Doha, Qatar
Edin Zelihic, MD
Head, Department of Emergency
Medicine, Leopoldina Hospital,
Schweinfurt, Germany
Case Presentation
You are working a quiet morning shift when 2 patients are
brought in after a motor vehicle crash. The first patient
is hypotensive, and the FAST exam reveals a pericardial
effusion. You know that time is of the essence, so you
rapidly assess the options and wonder whether a needle
pericardiocentesis is the best option…
The second patient from the MVC has an ecchy-
mosis across his chest. He has normal vital signs and
a normal ECG, so you decide to send him for a CT to
assess for thoracic and abdominal injuries. Upon return-
ing from CT, he is tachycardic at 115 beats/min, the CT
is negative, and he has a troponin of 0.0. Given that he
has a seat belt sign and tachycardia, you are still con-
cerned there may be a cardiac injury, and you wonder
whether the ECG without ischemic changes and negative
troponin are sufficient to exclude blunt cardiac injury.
You question whether the patient needs to be admitted or
observed . . . and if so, for how long?
Introduction
Blunt cardiac injury (BCI) encompasses a spectrum
of cardiac conditions resulting from blunt force
trauma to the anterior chest wall. In 1992, Mat-
tox used the term blunt cardiac injury to describe
the spectrum of disease from a minor “bruise” to
the heart to specific postcontusion cardiac con-
ditions such as free wall rupture or myocardial
hemorrhage.1 Depending upon the extent and the
anatomical location of injury, the manifestations
of these injury patterns range from benign ectopic
beats to cardiac wall rupture resulting in sudden
death. Because there are no universally accepted
diagnostic criteria for the diagnosis of BCI, the true
incidence is undetermined. the emergency department (ED) alive. Ninety-nine
Motor vehicle crashes (MVCs) are the cause of
most reported cases of BCI,2,3 accounting for many
of the deaths related to these accidents.4-6 Failure to
identify and understand the extent of blunt cardiac
injuries can result in significant morbidity to the
trauma patient. A high index of suspicion, applica-
tion of current diagnostic protocols, and prompt
and appropriate management are fundamental to
maximizing good outcomes. This issue of Emergency
Medicine Practice describes the most common car-
diac injuries resulting from blunt trauma, the most
effective diagnostic studies, and the most effective
treatments for these life-threatening injuries.
Critical Appraisal of the Literature
PubMed was queried using the search term blunt
cardiac injury. The search produced 1209 articles;
however, most were case reports and reviews; large
prospective trials on this topic are lacking. Ad-
ditionally, this review was informed by guidelines
Copyright © 2019 EB Medicine. All rights reserved. 2
from the Eastern Association for Surgery in Trauma
(EAST), at: www.east.org. (See Table 1.)
Etiology and Epidemiology
Trauma is the leading cause of death in persons
aged < 40 years who sustain blunt trauma to the
thorax, and thoracic trauma accounts for approxi-
mately 25% of all trauma deaths.8,9 Each year in
the United States, approximately 900,000 cases of
cardiac injuries result from trauma.10 Some 70% to
80% of patients with a BCI sustained other injuries
as well, including brain (42%-54%), thoracic aorta
(47%-49%), lung (44%-46%), hemothorax (37%-
89%), rib or sternal fracture (26%-97%), and spinal
injuries (37%).2,3,11-14
A 1989 study of patients with rapid decelera-
tion injuries or direct precordial trauma found a
60% incidence of cardiac concussion (35/58) and
40% incidence of cardiac contusion (23/58).10 In
this study, cardiac concussion was defined as an el-
evated serum creatinine kinase isoenzyme (CK-MB)
level and a normal 2-dimensional echocardiogram,
whereas a cardiac contusion was defined as an
elevated CK-MB and an abnormal 2-dimensional
echocardiogram. Nonetheless, elevated CK-MB
levels and positive echocardiograms have not been
shown to be predictive of adverse outcomes.15
Alternatively, conduction abnormalities seen on
electrocardiogram (ECG) can predict the develop-
ment of serious dysrhythmias.15
An autopsy study looking at 1597 fatalities
from blunt trauma reported cardiac injuries in
11.9% of cases.3 It was determined that cardiac
injuries were the cause of or contributed to death
in 45.2% of these patients, and only 13% made it to
percent of the patients had extracardiac injuries,
including pulmonary contusions, sternal fractures,
head injuries, fractures of long bones, and soft-
tissue injuries.
BCI is often noted in the polytrauma patient
and it is associated with a high mortality rate. BCI
may carry a mortality of up to 44%, as seen in a
2016 retrospective review of 117 patients diagnosed
with BCI.16 Patients in this case series who died
Table 1. Eastern Association for the Surgery
of Trauma – Levels of Recommendation7
Level Criteria for Recommendation
1 The recommendation is convincingly justifiable based on
the available scientific information alone.
2 The recommendation is reasonably justifiable by available
scientific evidence and strongly supported by expert
opinion.
3 The recommendation is supported by available data, but
adequate scientific evidence is lacking.
Reprints: www.ebmedicine.net/empissues
were more likely to have a serum lactate level Cardiac Wall Rupture
> 2.5 mmol/L, an elevated cardiac troponin I (cTnI) Cardiac wall rupture is the most devastating type
level, and hypotension.16 of BCI, and mortality rates for these injuries are
The spectrum of potential cardiac injuries extremely high.20,21 Approximately 70% of patients
depends on the mechanism and degree of force.4,17 with cardiac wall rupture will develop a pericar-
The forces that cause a BCI may be direct or indi- dial effusion and tamponade.2 The incidence of the
rect, involve rapid deceleration, be bidirectional, rupture site varied across different autopsy series
compressive (between spine and sternum), con- (right ventricle 19%-32%, right atrium 10%-15%,
cussive, or involve a combination thereof.4 Most left ventricle 5%-44%, left atrium 1%-7%).20,22 Atrial
patients who die from BCI likely experienced high- ruptures are less common than ventricular ruptures,
force mechanisms. The right ventricle is the most and patients with isolated atrial ruptures are more
frequently injured area, likely due to the proximity likely to survive.5 Complete free wall rupture is rare
to the chest wall, but all chambers can be injured and usually fatal.23 The sealing of a ruptured free
in blunt trauma and many patients have injuries to wall may result in the formation of a pseudoaneu-
multiple chambers.4,18,19 rysm, which carries with it the possibility of delayed
rupture and tamponade.24,25
Differential Diagnosis
Septal Injuries
The differential diagnosis in patients presenting with The literature on septal injuries is comprised al-
chest pain following blunt chest trauma is primar- most entirely of case reports. The best summary of
ily focused on the cardiovascular, pulmonary, and the reports is found in a 2012 case report with an
musculoskeletal organ systems. (See Table 2.) While accompanying literature-based review26 that found
this review focuses primarily on cardiovascular inju- the following: (1) septal injuries occur immedi-
ries, consideration of noncardiac injuries should be ately either from direct impact or when the heart is
included, as part of a comprehensive evaluation. compressed between the sternum and spine, and (2)
delayed rupture may occur secondary to an inflam-
matory reaction, which may be more likely to occur
in patients with a history of healed or repaired septal
Table 2. Differential Diagnosis of Chest Pain defects. Of the 68 cases reviewed, 35 were diagnosed
Following Blunt Chest Trauma immediately, 17 were diagnosed within 48 hours,
and 16 were diagnosed > 48 hours after injury.26
Cardiovascular Injuries
• Cardiac wall rupture Valvular Injuries
• Myocardial septum injury
• Valvular injury
Similar to septal injuries, isolated valvular injuries
• Coronary artery injury are rare, and the literature base for these injuries is
• Pericardial effusion/tamponade comprised of case reports. In our opinion, it is rea-
• Dysrhythmia sonable to consider the diagnosis of valvular injury
• Conduction blocks
in any patient who appears to have cardiogenic
• Commotio cordis
• Myocardial contusion
shock, hypotension with no obvious hemorrhage, or
• Aortic rupture pulmonary edema. The left-sided valves are more
• Caval Injury commonly affected due to higher pressures on the
left side,27 and injuries to the left-sided structures
Pulmonary Injuries carry a higher mortality compared with those on the
• Pulmonary contusion
right.4 The aortic valve is most commonly injured;
• Pneumothorax/hemothorax
• Tension pneumothorax
the mitral valve is the second most commonly
• Tracheobronchial injury injured, followed by the tricuspid valve. Valvular
• Diaphragm injury injury may be due to papillary muscle rupture or
damage to the chordae tendineae.28,29
Musculoskeletal Injuries
• Rib fracture
Coronary Artery Injury
• Flail chest
• Sternoclavicular fracture/dislocation Traumatic injury to the coronary arteries may take
• Scapular fracture the form of lacerations, dissections, or aneurysms.27
• Vertebral injury The left anterior descending artery is the most com-
monly involved. Thrombosis in a coronary artery
Other may also occur, leading to myocardial infarction.23
• Pneumomediastinum
• Esophageal injury
The myocardial infarction may be secondary to in-
• Nerve injury creased sympathetic activity, with increased platelet
www.ebmedicine.net activity after trauma.23 Injuries to the coronary arter-

March 2019 • www.ebmedicine.net 3 Copyright © 2019 EB Medicine. All rights reserved.

ies can lead to all the downstream complications of
an atraumatic myocardial infarction. For example,
in a case report,30 a 30-year-old patient developed
cardiogenic shock as a result of posteromedial papil-
lary muscle rupture, 14 days after his initial injury.
This was the result of occlusion of the right coronary
artery. In a literature review that included 179 pa-
tients with traumatic myocardial infarction, 58% of
the cases had an injury to the left anterior descend-
ing artery and 14% had injuries to the right coronary
artery.31 The most common mechanism was dissec-
tion with or without thrombosis (71%) followed by
thrombosis/subtotal occlusion (7%).
Pericardial Injury
Traumatic injury to the pericardium may result in
pericarditis, effusion, and tamponade. The pericar-
dium rarely ruptures; however, cases of pericardial
lacerations causing myocardial herniation have been
reported.23
Dysrhythmias
Sinus tachycardia is the most common dysrhythmia
associated with BCI.27 Rhythms other than sinus
tachycardia are rare after chest trauma and are
found in only 1% to 6% of patients.32,33 Ventricular
premature contractions, atrial premature contrac-
tions, and atrial fibrillation have all been reported in
association with BCI.5 One study that evaluated 240
patients following BCI found 4% of patients to have
atrial fibrillation.34
Conduction Blocks
Following BCI, atrioventricular and intraventricu-
lar conduction blocks are rare, but have been re-
ported.35-37 Right bundle branch block is the most
commonly associated conduction block, followed
by first-degree atrioventricular block.2,38 Conduction
blocks and other traumatic cardiac dysrhythmias may
be delayed for up to 48 hours after an incident.39
Commotio Cordis
Commotio cordis is a rare type of BCI resulting in
sudden cardiac death in patients without pre-exist-
ing disease or morphologic injury.40 It is the second
most common cause of death in athletes aged < 18
years41 and is caused by blunt trauma to the precor-
dium that induces ventricular fibrillation, but it may
also present with ventricular tachycardia.42 In a case
series of 25 patients who experienced cardiac arrest
immediately following an unexpected blow to the
chest, 16 cases were related to competitive sports
and 9 cases were related to recreational activities at
home, school, or on the playground.43 Experimental
swine models have demonstrated that a precisely
timed impact to the chest wall during the T-wave
upstroke can reliably precipitate ventricular fibril-
lation.44 Increased awareness of this condition and
Copyright © 2019 EB Medicine. All rights reserved. 4
early recognition, resulting in bystander cardiopul-
monary resuscitation and early defibrillation, may
lead to better outcomes.
Myocardial Contusion
Myocardial contusion, a subset of BCI, refers to a
bruise of the cardiac muscle. It is one of the most
common forms of cardiac pathology following blunt
trauma to the heart.27 There is no standard definition
or gold-standard test to make the diagnosis.45 Some
studies make the diagnosis of myocardial contusion
in any patient with chest pain and an increase in
cardiac enzymes following trauma.27 Other stud-
ies reserve the diagnosis for more seriously injured
patients who present with cardiac dysfunction,
ECG abnormalities, wall motion abnormalities, and
enzyme elevations.27
Aortic Root Injuries
The majority of aortic injuries occur in the distal arch
at the insertion of the ligamentum arteriosum and
isthmus.46,47 The literature base for aortic root inju-
ries is sparse. These injuries should be considered in
any patient with evidence of aortic insufficiency or
cardiogenic shock following blunt trauma.
Prehospital Care
Hospital Destination
Prehospital management of the trauma patient
involves the rapid identification and stabilization of
life-threatening injuries and expeditious transport
to definitive care. In many studies, longer prehos-
pital times have been associated with an increased
mortality for trauma patients.48-50 In a review of a
trauma registry data set of 164,471 patients, it was
noted that the odds of mortality increased by 20%
in those with prolonged on-scene time.51 Immediate
transport to a Level I trauma center should be the
highest priority for a patient with suspected BCI.
Level of Care
Based on available data, prehospital providers must
focus on transporting patients rapidly to trauma
centers instead of calling more-advanced emergency
medical services (EMS) providers to the scene. A
Cochrane review evaluating the utility of advanced
life support (ALS) versus basic life support (BLS)
in trauma concluded, “The evidence indicates that
there is no benefit of advanced life support training
for ambulance crews on patient outcomes.”52 In fact,
mortality increased in the ALS-trained group when
logistic regression analysis accounted for trauma
severity. Similarly, a 2016 retrospective study of
2300 patients and a 2017 systematic review of 35,838
trauma patients demonstrated advanced airway
management techniques performed by ALS-trained
paramedics in the field were also associated with
Reprints: www.ebmedicine.net/empissues
decreased odds of survival.53,54 Since the data seem
counterintuitive, further investigation is needed to
determine how the level of training of EMS provid-
ers affects mortality. In the meantime, we recom-
mend placing priority on rapid transport and avoid-
ing any delay that would be sustained by waiting on
scene for advanced-care providers.
Providing Comfort and Alleviating Pain During
Transport to the Emergency Department
Prehospital management should include the early
evaluation and treatment of pain, if feasible, in order
to aid the longitudinal care of the patient. Antiplate-
let agents (eg, aspirin) should be avoided in the
management of chest pain resulting from trauma in
order to avoid potentiation of bleeding. Singh et al
looked at the incidence of postmedication hypoten-
sion after administration of sedatives and opioids
during the transportation of critically ill trauma
patients and noted a rare incidence (0.6%) of hypo-
tension.55 Fentanyl was marginally safer than mor-
phine, and titration of analgesics was recommended,
as needed. Pain management should not delay rapid
transport to definitive care.
Rapid Identification of Blunt Cardiac Injury
With Ultrasound
In select cases, the deployment of emergency physi-
cians in the field has been noted to provide blunt
trauma patients early access to advanced diagnostics
and lifesaving procedures, such as point-of-care
ultrasound and pericardiocentesis, without signifi-
cantly extending on-scene time.56-60 Breitkreutz et
al implemented a prehospital echocardiographic
resuscitation algorithm that was able to identify
pseudo-pulseless electrical activity and other revers-
ible causes of shock and cardiac arrest, altering the
management of critically ill patients in up to 78% of
cases and subsequently increasing survival to hos-
pital admission.61 However, in a systematic review
including 14 studies and 885 patients, it was deter-
mined that the data regarding use of point-of-care
ultrasound in the prehospital setting are sparse and
lack quality, making it difficult to conclude that pre-
hospital ultrasound definitively improves the care of
trauma patients.62
Emergency Department Evaluation
History
The available history in the evaluation of BCI may
be limited, and a high index of suspicion is always
needed. The most common chief complaint is chest
pain, which will typically prompt the emergency
clinician to consider a BCI evaluation pathway. It is
important to discern whether the chest pain began
before or after the traumatic event. In some cases,
chest pain may be absent, complicated by a distract-
March 2019 • www.ebmedicine.net
ing injury, or may be unable to be elicited secondary
to altered mentation. Other common symptoms may
include dyspnea, fatigue, palpitations, and light-
headedness. Prehospital providers are often helpful
in providing insight into understanding the mecha-
nism of injury. Ask about the condition of the patient
and a description of the scene where they were
found. In cases of motor vehicle incidents, elicit ap-
proximate speed of travel, airbag deployment, need
for extrication, and extent of vehicle damage.
Elements of the past medical history, including
ischemic cardiac disease, dysrhythmias, cardio-
myopathy, and thoracic surgeries are high-yield
and should be explored and sought from collateral
sources, if necessary. A review of medications may
reveal therapies that potentiate bleeding and/or
mask shock, such as antiplatelets, anticoagulants,
beta blockers, and other antiarrhythmics. Ask about
allergies to medications. If available, review the
electronic medical record for previous treatments
and diagnostic studies, including the appearance of
a baseline ECG and prior echocardiogram results.
Physical Examination
In patients with suspected BCI, the physical exami-
nation focuses primarily on the cardiovascular and
respiratory systems. (See Table 3.) However, a thor-
ough primary and secondary survey should be per-
formed. Vital signs in patients with BCI may provide
indicators of impaired conduction or contraction;
however, young patients may have excellent reserve
and be able to compensate for impaired function, so
normal vital signs do not exclude injury. Tachycardia
is the most common abnormality in BCI. The blood
pressure may be within normal limits in less severe
cases of BCI, and alternatively demonstrate signifi-
cant hypotension refractory to treatment in cases
of cardiogenic shock. Hypotension in the trauma
Table 3. Physical Examination Findings in
Blunt Cardiac Injury
Cardiovascular
• Delayed capillary refill
• Peripheral cyanosis
• Elevated jugular venous pressure
• Muffled heart sounds
• Friction rub
• Tachycardia
• Hypotension
• Pulsus paradoxus
• Electrical alternans
• Diminished heart sounds
Respiratory/Chest
• Sternal/chest wall tenderness
• Flail chest
• Crepitus
• Tracheal deviation
• Tachypnea
www.ebmedicine.net
5 Copyright © 2019 EB Medicine. All rights reserved.
patient should be presumed to be hypovolemia sec-
ondary to blood loss until proven otherwise.
Exposure, inspection, and palpation of the chest
wall should be performed, looking for bruising, ten-
derness, flail segments, and presence of a pacemaker
or internal cardiac defibrillator. Auscultate for abnor-
mal lung sounds, new murmurs, and a friction rub,
which may be clues to valvular injury. Pericardial
injury complicated by tamponade physiology may
present with one or more of the Beck triad (hypoten-
sion, jugular venous distention, and muffled heart
sounds), although they rarely present all together.63
Assess the abdomen for ecchymosis, pain, ten-
derness, and rigidity, as compressive forces to the
abdomen can also transmit to mediastinal struc-
tures. Unequal pulses in the extremities may signal
injury to the abdominal or thoracic aorta. Associated
injuries such as rib fractures, sternal fracture, lung
contusion, scapular fracture, hemopneumothorax,
flail chest, and a seat belt sign have all been noted to
increase the risk of having a coexisting BCI.64
Diagnostic Studies
Laboratory Testing
The following laboratory tests should be consid-
ered when evaluating patients with suspected BCI:
complete blood cell count, chemistry, coagulation
studies, troponin, lactate, and type and screen. In a
retrospective analysis, a lactate level > 2.5 mmol/L
(68% vs 31%) and an elevated cTnI (86% vs 11%)
were significant predictors of mortality in patients
with suspected BCI.16 The structure of the cTnI is
exclusive to the myocardium and is therefore the
preferred diagnostic enzyme when compared to
other markers, including the cardiac troponin T
(cTnT) and CK-MB.65 In patients with blunt chest
trauma, cTnI levels > 1.05 g/L are associated with
a greater risk for dysrhythmias and left ventricular
dysfunction.66 Isolated elevations of troponins are
poor diagnostic indicators, with a cTnT and cTnI
carrying a 12% and 23% sensitivity for the diagnosis
of BCI, respectively.65
Electrocardiogram
According to the 2012 EAST guidelines, an ECG
should be performed on all patients in whom BCI is
suspected (EAST 2012 Level 1 recommendation; see
Table 1, page 2.).7 Clinically significant abnormali-
ties requiring intervention are rare and are often best
detected on the initial ECG.6 If the ECG abnormality
is new, the patient should be admitted for continu-
ous cardiac monitoring (EAST 2012, Level 2 recom-
mendation).7 Examples of abnormalities include:
supraventricular tachycardia, junctional tachycardia,
atrial flutter or fibrillation, sinus arrest, ventricular
tachycardia/fibrillation, bundle branch blocks, and
acute ischemic changes. Management is per usual
Copyright © 2019 EB Medicine. All rights reserved. 6
advanced cardiovascular life support (ACLS) treat-
ment algorithms; however, multiple studies indi-
cate that an isolated ECG does not have sufficient
diagnostic characteristics to be utilized as a solo test
to diagnose or rule out BCI. Therefore, though the
ECG is low in cost, it does not perform well alone as
a screening tool to rule out BCI.6,64,67,68
Electrocardiogram and Troponin Testing
In a prospective study of 333 patients who sustained
blunt thoracic trauma, serial ECG and troponin
testing at hours 0, 4, and 8 were shown to have a
specificity of 71% and a sensitivity of 100% for de-
tecting significant BCI.64 Additionally, the timing of
troponin and ECG testing may not be critical; of the
44 positive patients, 43 had an abnormal ECG or tro-
ponin at admission, and therefore the combination
of initial ECG and troponin had a negative predic-
tive value of 98% for significant BCI. Based on this
literature and modern troponin testing, serial tropo-
nin and serial ECG testing may not be necessary in
patients with no other injuries. Further conclusions
on serial troponins and serial ECGs are not available
at this time.
Chest X-Ray
The chest x-ray is generally the first radiograph
obtained in the workup for BCI, and it should be
supplemented by more advanced cross-sectional im-
aging. Obtain anterior-posterior and lateral views, if
possible. Findings such as rib fractures, hemopneu-
mothorax, and mediastinal free air increase the risk
for an associated BCI.64,69 There may be enlargement
of the cardiac silhouette. (See Figure 1.) However,
the pericardium is poorly compliant and may not
Figure 1. Pericardial Effusion on Chest X-Ray
Chest radiograph shows cardiomegaly suggestive of pericardial
effusion.
Image reprinted courtesy of Stony Brook Medicine, Stony Brook, NY.
Reprints: www.ebmedicine.net/empissues
stretch acutely even in the presence of significant
intrapericardial fluid.69 Up to 200 mL of fluid can be
contained in the pericardial space and remain unde-
tectable by chest x-ray.70 Despite advances in bed-
side ultrasound, the chest x-ray can add significant
information to the resuscitation when the patient is
unstable for chest CT.71
Focused Assessment With Sonography in
Trauma (FAST) Examination
The focused assessment with sonography in trauma
(FAST) examination is a core emergency medicine
application. It allows for a rapid bedside assess-
ment and has a high sensitivity for noninvasively
detecting pericardial fluid.72 (See Figure 2.) When
performed by trained emergency clinicians using a
combination of the parasternal, apical, and subcos-
tal views, an overall accuracy of 97.5% in diagnos-
ing a pericardial effusion has been reported.72 The
FAST examination should be performed early in the
evaluation of the unstable blunt trauma patient as
an adjunct to the primary survey. In a randomized
controlled trial, the FAST examination reduced the
time from arrival in the ED to operative care by 64%
in trauma patients.73
The overall prevalence of hemopericardium in
blunt trauma is low, and therefore the greatest util-
ity of FAST is in the management of patients with
high-acuity injuries. Examples include patients who
sustained a high-force mechanism of injury, those
with hypotension, or those requiring emergent in-
tubation.74 In these patients, we suggest performing
an extended FAST examination (eFAST) by adding
a lung examination to the FAST examination. This
is quick and has moderate sensitivity for detecting
Figure 2. Pericardial Effusion on Ultrasound and Noncontrast Chest Computed Tomography
A
In View A, the arrow points to pericardial effusion with mild right ventricular collapse on ultrasound, indicating early pericardial tamponade. In the same
patient, the arrow in View B points to pericardial thickening on noncontrast CT.
Images reprinted courtesy of Stony Brook Medicine, Stony Brook, NY.
March 2019 • www.ebmedicine.net
pneumothoraces that require intervention.75 eFAST
has the potential to help refine the differential diag-
noses while at the bedside, especially in the hypo-
tensive patient.
Computed Tomography
CT is used routinely in the evaluation of patients
who have sustained blunt trauma. The identification
of associated skeletal, solid organ, and vascular in-
juries should increase the index of suspicion for BCI.
With the increased availability of contrast-enhanced
ECG-gated multidetector computed tomography,
specific cardiac pathologies capable of causing
hemodynamic instability can be rapidly diagnosed
early in the workup.76-78 Examples include myo-
cardial rupture, pneumopericardium, pericardial
rupture, hemopericardium, coronary artery insult,
ventricular septal defect, and valvular dysfunction.79
(See Figure 2.) CT does not perform well in evaluat-
ing for myocardial contusions, especially of the right
ventricle, which is at the greatest risk for injury.80
Echocardiogram
The echocardiogram performs well at detecting focal
cardiac dysfunction consistent with injuries to the
heart, such as cardiac contusion, wall motion defects,
hemopericardium, and valve disruption. Trans-
esophageal echocardiography (TEE) is more sensitive
than transthoracic echocardiography (TTE) for subtle
findings; however, it has not been shown to alter
management in hemodynamically stable patients.81
In a multicenter prospective study including patients
with significant blunt chest trauma, 66 of 117 patients
exhibited pathologic findings on TEE. The most com-
mon was right ventricular wall hypokinesis, found in
B
7 Copyright © 2019 EB Medicine. All rights reserved.
 Clinical Pathway for Management of Emergency Department
Patients With Suspected Blunt Cardiac Injury

Elevated suspicion for blunt cardiac injury

(significant mechanism + precordial pain / tenderness / ecchymosis)

Evaluate blood pressure

STABLE UNSTABLE

Perform initial ECG and cTnI testing Perform initial ECG and FAST examination
(Class I) (Class I)

NEGATIVE POSITIVE NEGATIVE POSITIVE

• Blunt cardiac injury ruled out • Admit to ICU (Class II)

• Tele-observation (Class II) Obtain emergent
(Class I) • Perform serial cTnI testing
• Perform serial cTnI testing surgical evaluation
• Consider discharge • Perform echocardiogram
• Initiate ACLS
• +/- echocardiogram

Abbreviations: ACLS, advanced cardiovascular life support; cardiac troponin I, cTnI; ECG, electrocardiogram; FAST, focused assessment with
sonography in trauma; ICU, intensive care unit.

Class of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I Class II Class III Indeterminate
• Always acceptable, safe • Safe, acceptable • May be acceptable • Continuing area of research
• Definitely useful • Probably useful • Possibly useful • No recommendations until further
• Proven in both efficacy and effectiveness • Considered optional or alternative treat- research
Level of Evidence: ments
Level of Evidence: • Generally higher levels of evidence Level of Evidence:
• One or more large prospective studies • Nonrandomized or retrospective studies: Level of Evidence: • Evidence not available
are present (with rare exceptions) historic, cohort, or case control studies • Generally lower or intermediate levels of • Higher studies in progress
• High-quality meta-analyses • Less robust randomized controlled trials evidence • Results inconsistent, contradictory
• Study results consistently positive and • Results consistently positive • Case series, animal studies, • Results not compelling
compelling consensus panels
• Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2019 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Copyright © 2019 EB Medicine. All rights reserved. 8 Reprints: www.ebmedicine.net/empissues

24% of patients.67 There are several limiting factors to
the utility of echocardiography, including high cost,
operator expertise, and patient characteristics that
may limit optimal views. The 2012 EAST guidelines
recommend an echocardiogram in hemodynami-
cally unstable patients or those with a persistent new
dysrhythmia. TEE should be considered in patients
in whom an optimal transthoracic study cannot be
performed (Level 2 recommendation).7
Treatment
Transfusion and Fluids
The role of blood transfusion in patients with blunt
cardiac trauma is limited mainly to treatment of con-
comitant injuries associated with the multitrauma
patient and follows similar indications. Increased
severity of cardiac injury is directly associated with
increased rates of massive transfusion, whereas
minor injuries are associated with a decreased need
for transfusion.82
Blunt cardiac trauma may predispose a patient
to the development of pericardial effusion and
degeneration to pericardial tamponade and cardio-
vascular collapse.83 There is evidence that volume
expansion in patients with pericardial tamponade
improves cardiac output while preparing for defini-
tive management.84 In a case series, 49 patients with
atraumatic tamponade who were referred to the
cardiac catheterization laboratory for drainage were
given a volume challenge to determine the effect on
hemodynamics. Cardiac output was measured us-
ing the thermodilution technique, after preinfusion
and postinfusion of a 500 mL bolus over 10 minutes.
Patients with an initial systolic blood pressure (SBP)
of < 100 mm Hg showed a significant increase in
cardiac output after the fluid bolus. This was not
seen in patients with an initial SBP > 100 mm Hg.
However, an increase in left ventricular end-diastolic
pressure was seen regardless of the initial blood
pressure.84 As an increasing amount of evidence
demonstrates the benefit of blood transfusion over
the administration of crystalloids in patients re-
quiring volume expansion after trauma, it may be
reasonable to follow similar recommendations when
providing hemodynamic resuscitation in individuals
with blunt cardiac injuries.
Operative Management
Patients with suspected or confirmed BCIs may be
candidates for ED thoracotomy. An EAST guideline
from 2015 conditionally recommends ED thoracot-
omy for patients who appear moribund but have a
pupillary response, spontaneous ventilation, pres-
ence of carotid pulse, measurable or palpable blood
pressure, extremity movement, or cardiac electrical
activity. In this same guideline, there is a conditional
recommendation against ED thoracotomy in patients
March 2019 • www.ebmedicine.net
who present after blunt trauma pulseless and with
no signs of life.85 A 2016 systematic review per-
formed in Europe showed a 12.9% (18/139 patients)
survival rate after ED resuscitative thoracotomy
following blunt trauma.86 The authors were unable
to draw a firm conclusion on clear indications for
this procedure. A study of 187 patients found initial
ultrasound was 100% sensitive for predicting survi-
vors; of the 9 patients who survived, all had cardiac
motion on their initial ultrasound. However, as in
other studies, this prospective evaluation portrays
no clear, single independent preoperative factor that
could uniformly predict death.87
The Western Trauma Association recommends
ED thoracotomy in blunt trauma patients if there
are any signs of life, including electrical activity, or
if there are no signs of life but less than 10 minutes
of CPR has been performed.88 They also recommend
resuscitative thoracotomy for refractory shock (de-
fined as SBP < 60 mm Hg). Emergent thoracotomy
can be life-saving when patients present with cardiac
tamponade or ventricular injury.
Emergent pericardiocentesis may be another
option in the unstable patient if definitive opera-
tive management is not possible. Pericardiocentesis
can be diagnostic as well as therapeutic, but it is not
definitive treatment for cardiac tamponade.89
Dysrhythmia
Again, randomized trials are lacking for the prophy-
laxis and treatment of dysrhythmia in BCI. Any dys-
rhythmia that develops should be treated according
to ACLS protocols.
Myocardial Infarction
Myocardial infarction from blunt trauma is rare, and
large trials to guide therapy are lacking. At the cur-
rent time, available literature suggests percutaneous
transluminal coronary angiography is the best first
option for these patients.31 We recommend involving
cardiology and cardiothoracic surgery, in addition
to trauma surgery, for any blunt trauma patient with
an ST-elevation myocardial infarction. This may
require transfer, depending on the setting in which
the patient is being seen. Additionally, we recom-
mend extreme caution with aspirin until significant
bleeding at other sites is ruled out. Decisions to give
aspirin should be made with input from trauma and
cardiology. There is no clear role for nitroglycerin in
this setting, and it is our opinion that this medication
should be avoided, given the potential for hypoten-
sion in the setting of trauma.
Pain Management Strategies
Inpatient management of pain associated with chest
injuries has been shown to reduce mortality in pul-
monary-related complications such as pneumonia.90
The EAST guidelines for pain management in blunt
9 Copyright © 2019 EB Medicine. All rights reserved.
thoracic trauma recommend a multimodal approach or advanced imaging should prompt an immediate
of opioid and nonopioid medications.91 surgical evaluation and preparation for the operat-
ing room.
Special Circumstances
Admission for Observation
Sternal Fractures In the event a patient has either a positive ECG find-
Liberal use of CT has led to an increase in the ing or positive cTnI, the next consideration should
diagnosis of sternal fractures that are traditionally be given to the patient’s hemodynamic stability. He-
not seen on x-ray. The rate of cardiac contusion in modynamically stable patients should be observed
patients with sternal fractures is 1.8% to 2.4%.92 In on telemetry. While there are no clear recommen-
secondary analyses of the NEXUS chest CT study, dations for duration, most studies have noted that
292/14,553 patients were found to have sternal clinically significant events will tend to occur early
fractures.92-94 Of these, 94% were seen only on CT within the first 24-hour period of observation.1,64,68,99
and not on x-ray. Of the 292 patients with sternal Patients with persistent ECG abnormalities or rising
fractures, cardiac contusion was diagnosed in 7 pa- troponins warrant an echocardiogram to further
tients (2.4%), and 2 patient deaths in this group were evaluate the cardiac valves, systolic/diastolic func-
attributed to a cardiac cause. Extensive workups and tion, septum, and pericardium.100 In the event of
admissions for all patients with sternal fractures are both a positive ECG finding and cTnI, closer obser-
likely unnecessary.92 There have been studies that vation in a step-down unit or intensive care unit
suggest that patients with isolated sternal fractures should be considered, as nearly two-thirds of these
with negative biomarkers, ECG, and chest x-rays patients have been observed to develop subsequent
may safely be discharged from the ED, if the pa- myocardial dysfunction.68 Hemodynamically unsta-
tient’s pain is controlled, in order to avoid atelectasis ble patients should prompt an echocardiogram, se-
and respiratory compromise.95,96 rial cardiac enzymes, and admission to an intensive
care unit. Those with significant associated injuries
may also require intensive care unit admission.
Controversies/ Cutting Edge
Advanced Cardiac Imaging
Magnetic resonance imaging (MRI) can be help-
ful to further evaluate myocardial contusions and
areas of subendocardial ischemia that are difficult to Figure 3. Sternal Fracture and Myocardial
detect with other imaging modalities. (See Figure Contusion on Magnetic Resonance Imaging
3.) However, in the acute evaluation of an undiffer-
entiated trauma patient, MRI is not useful in many
situations because of the long imaging times, patient
compatibility issues, and interobserver variability
that severely limit its practical use.97
The 2012 EAST guidelines offer the option of CT
or MRI in differentiating acute myocardial ischemia
from BCI in patients with abnormal ECG results, el-
evated cardiac enzymes, and/or abnormal echocar-
diograms (Level 3 recommendation).7 These modali-
ties may be useful in cases when there is suspicion
that an ischemic cardiac event may have preceded
the traumatic injury, therefore helping to further
guide medical management and determine the need
for cardiac catheterization.

Disposition
Emergent Transfer to the Operating Room
Traumatic injuries to the aorta, pericardium, and
myocardium are associated with severe hemody-
namic instability and drastically impaired survival.98 Patient with blunt chest trauma noted to have sternal fracture (left
These unstable patients need surgical evaluation by arrow) and myocardial edema and early enhancement suggestive of
the trauma and cardiothoracic service in a time- myocardial contusion (right arrow) on MRI.
sensitive manner. Such injuries noted on initial FAST Copyright 2017 by Dr Gregor Savli. Image courtesy of Dr Gregor Savli
and Radiopaedia.org. Used under license.

Copyright © 2019 EB Medicine. All rights reserved. 10 Reprints: www.ebmedicine.net/empissues

Discharge
There is good evidence that hemodynamically stable
patients with a negative workup, including ECG and
cTnI, can be effectively ruled out for clinically signif-
icant BCI and considered for discharge home from
the ED or after an 8-hour observation period.7,64,68
The emergency clinician should keep in mind all
other injuries and comorbidities when evaluating
for discharge. Special precautions in the elderly
and those with low physiologic reserve should be
considered, including the assessment of mobility,
functional status, and support systems, during dis-
position planning. The adoption of evidence-based
protocols has been shown to improve early identifi-
cation and reduce unnecessary diagnostics, resource
utilization, and costs associated with the evaluation
of BCI.101
Summary
BCI resulting from blunt force trauma encompasses
a spectrum of conditions that can be challenging to
diagnose. Many of the life-threatening variants may
be fatal in the field; however, the emergency clini-
cian must maintain a high index of suspicion for
occult injuries that have the potential for deteriora-
tion, as the history and physical examination is often
nonspecific. The initial diagnostic approach should
include an ECG and troponin testing; advanced
imaging may be required based on the patient’s
history and physical examination. Unstable patients
should have a FAST examination in addition to a
formal echocardiogram, surgical consultation, and
admission to an intensive care unit for continuous
assessment and diagnostic studies. While the exact
duration of observation required is unclear, evidence
supports that, in patients with a negative ECG and
troponin, a clinically significant BCI can be effec-
tively ruled out.
Case Conclusions
The first patient was triaged directly to the resuscitation
unit and the trauma surgery service was immediately
available at bedside. Further review of the FAST exam
revealed right ventricular collapse, and the initial blood
pressure of 80/40 mm Hg was consistent with pericardial
tamponade. Two large-bore peripheral IVs were placed,
and an ECG revealed sinus tachycardia. A bedside peri-
cardiocentesis was performed under ultrasound guidance
and 25 mL of blood was aspirated. Repeat blood pressure
was 100/60 mm Hg. Chest and pelvic x-rays were within
normal limits. The patient was then emergently trans-
ported to the operating room for further management. A
thoracotomy was performed and noted a 2.5-mm rupture
of the right anterior ventricular wall. The defect was
repaired, and the patient had an uneventful recovery.
March 2019 • www.ebmedicine.net
The second patient was triaged to the acute care unit.
The initial management included IV access, labs, 1 liter
lactated Ringer’s IV bolus, and morphine 4 mg IV for
pain. Repeat vital signs were within normal limits after
these interventions. Advanced CT imaging was nega-
tive for traumatic injury. The initial ECG showed sinus
tachycardia, and all repeats as well as telemetry monitor-
ing for the remainder of the patient’s stay demonstrated
normal sinus rhythm. Labs were within normal limits,
and the troponin was negative. BCI was ruled out and the
patient was observed in the ED for a total of 4 hours prior
to being discharged home with close outpatient follow-up.
Time- and Cost-Effective Strategies
• An ECG is a low-cost bedside test that should be
performed on all patients with suspected BCI.
Any abnormality discovered on the ECG should
prompt further investigation for potential BCI.
• In patients with suspected BCI, the combination
of a negative troponin and ECG has an excellent
negative predictive value, precluding the need
for further advanced diagnostic testing.
• In hemodynamically unstable patients with a
clinical suspicion for BCI, a bedside FAST exami-
nation is an excellent low-cost test to confirm the
presence or absence of pericardial effusion
and/or tamponade physiology.
• Consideration for discharge home can reason-
ably be given in patients with both a negative
ECG and troponin.
References
Evidence-based medicine requires a critical ap-
praisal of the literature based upon study methodol-
ogy and number of subjects. Not all references are
equally robust. The findings of a large, prospective,
randomized, and blinded trial should carry more
weight than a case report.
To help the reader judge the strength of each
reference, pertinent information about the study, such
as the type of study and the number of patients in the
study is included in bold type following the references,
where available. The most informative references cited
in this paper, as determined by the authors, are noted
by an asterisk (*) next to the number of the reference.
1. Mattox KL, Flint LM, Carrico CJ, et al. Blunt cardiac injury. J
Trauma. 1992;33(5):649-650. (Editorial)
2. Teixeira PG, Georgiou C, Inaba K, et al. Blunt cardiac
trauma: lessons learned from the medical examiner. J Trauma.
2009;67(6):1259-1264. (Retrospective; 881 patients)
3. Turan AA, Karayel FA, Akyildiz E, et al. Cardiac injuries
caused by blunt trauma: an autopsy based assessment of the
injury pattern. J Forensic Sci. 2010;55(1):82-84. (Retrospective;
1597 patients)
4. Parmley LF, Manion WC, Mattingly TW. Nonpenetrating
traumatic injury of the heart. Circulation. 1958;18(3):371-396.
(Retrospective; 546 patients)
11 Copyright © 2019 EB Medicine. All rights reserved.
5. Marcolini EG, Keegan J. Blunt cardiac injury. Emerg Med Clin
North Am. 2015;33(3):519-527. (Review article)
6. Fulda GJ, Giberson F, Hailstone D, et al. An evaluation of
serum troponin T and signal-averaged electrocardiography
in predicting electrocardiographic abnormalities after blunt
chest trauma. J Trauma. 1997;43(2):304-310. (Prospective; 71
patients)
7.* Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt
cardiac injury: an Eastern Association for the Surgery of
Trauma practice management guideline. J Trauma Acute Care
Surg. 2012;73(5 Suppl 4):S301-S306. (Guideline)
8. Feghali NT, Prisant LM. Blunt myocardial injury. Chest.
1995;108(6):1673-1677. (Review article)
9. Allen GS, Coates NE. Pulmonary contusion: a collective
review. Am Surg. 1996;62(11):895-900. (Review article)
10. Frazee RC, Mucha P Jr, Farnell MB, et al. Objective evalua-
tion of blunt cardiac trauma. J Trauma. 1986;26(6):510-520.
(Retrospective; 291 patients)
11. Teixeira PG, Inaba K, Barmparas G, et al. Blunt thoracic
aortic injuries: an autopsy study. J Trauma. 2011;70(1):197-202.
(Retrospective; 304 patients)
12. Kaptein YE, Talving P, Konstantinidis A, et al. Epidemiology
of pediatric cardiac injuries: a National Trauma Data Bank
analysis. J Pediatr Surg. 2011;46(8):1564-1571. (Retrospective;
626 patients)
13. Shackelford S, Nguyen L, Noguchi T, et al. Fatalities of the
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Risk Management Pitfalls in Blunt Chest Trauma (Continued on page 13)
1. “I always wait 3 hours before obtaining a tro-
ponin as part of my BCI workup.”
It would be appropriate to send troponin
as part of the initial blood draw, therefore
decreasing the duration of workup in the ED.
Very few patients with significant BCI will
have both a negative initial ECG and troponin.
The important concept is to perform both tests
initially, and if both are negative, then there is
very little value to serial testing.
2. “The chest x-ray was normal, so I felt comfort-
able ruling out a pericardial effusion.”
A significant amount of fluid may be present in
the pericardium despite a normal chest x-ray.
If suspicion for a BCI or pericardial effusion
remains, both point-of-care ultrasound and CT
have high sensitivity and should be considered.
3. “I avoid opioids in patients with major chest
trauma, to avoid hypotension.”
Effective pain management is important and
has been shown to improve outcomes in
patients with chest injuries. While the chance of
opioid-related hypotension is low and opioids
are probably safe to administer, a multimodal
approach with opioid and nonopioid analgesics
(acetaminophen, nerve blocks, ketamine, etc)
working in a synergistic fashion may be optimal.
Consider using fentanyl or hydromorphone
instead of morphine, due to its mechanism.
Copyright © 2019 EB Medicine. All rights reserved. 12
Med. 2011;6(2):127-131. (Retrospective review; 25 patients)
14. Turk EE, Tsang YW, Champaneri A, et al. Cardiac injuries in
car occupants in fatal motor vehicle collisions--an autopsy-
based study. J Forensic Leg Med. 2010;17(6):339-343. (Retro-
spective review; 380 patients)
15. Wisner DH, Reed WH, Riddick RS. Suspected myocardial
contusion. Triage and indications for monitoring. Ann Surg.
1990;212(1):82-86. (Retrospective; 3010 patients)
16. Joseph B, Jokar TO, Khalil M, et al. Identifying the broken
heart: predictors of mortality and morbidity in suspected
blunt cardiac injury. Am J Surg. 2016;211(6):982-988. (Retro-
spective; 117 patients)
17. Tenzer ML. The spectrum of myocardial contusion: a review.
J Trauma. 1985;25(7):620-627. (Review article)
18. Sutherland GR, Driedger AA, Holliday RL, et al. Frequency
of myocardial injury after blunt chest trauma as evaluated
by radionuclide angiography. Am J Cardiol. 1983;52(8):1099-
1103. (Prospective; 77 patients)
19. Mishra B, Gupta A, Sagar S, et al. Traumatic cardiac injury:
experience from a level-1 trauma centre. Chin J Traumatol.
2016;19(6):333-336. (Prospective; 21 patients)
20. Brathwaite CE, Rodriguez A, Turney SZ, et al. Blunt
traumatic cardiac rupture. A 5-year experience. Ann Surg.
1990;212(6):701-704. (Retrospective review; 32 patients)
21. Pinni S, Kumar V, Dharap SB. Blunt cardiac rupture: a diag-
nostic challenge. J Clin Diagn Res. 2016;10(11):PD27-PD28.
(Case report)
4. “I always avoid intubation in patients with
blunt chest trauma in order to prevent cardio-
vascular collapse.”
Management of blunt chest trauma should
not preclude emergent airway management.
Consideration of the patient’s ability to protect
his airway, severe head injury with GCS score
< 8, severe chest injury, insufficient ventilation,
low physiologic reserve, and anticipated
clinical course should all be taken into account.
Assure adequate volume resuscitation and
preoxygenation, as needed, prior to intubation,
to avoid cardiovascular collapse.
5. “My patient with significant blunt chest
trauma had no evidence of bleeding, yet he
remained hypotensive.”
Hemorrhagic shock should always be suspected
and immediately addressed in patients with
major trauma and hypotension. Failure to
identify nonhemorrhagic causes (such as
tension pneumothorax) can result in futile
resuscitation efforts. Consider bedside eFAST,
chest x-ray, and pelvic x-ray for alternate causes
of shock. In suspected myocardial injury and
persistent hypotension despite adequate volume
resuscitation, patients may require inotropic
vasopressor support.
Reprints: www.ebmedicine.net/empissues
22.* Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin.
2004;20(1):57-70. (Review article)
23.* El-Chami MF, Nicholson W, Helmy T. Blunt cardiac trauma. J
Emerg Med. 2008;35(2):127-133. (Review article)
24. Helmy TA, Nicholson WJ, Lick S, et al. Contained myocar-
dial rupture: a variant linking complete and incomplete
rupture. Heart. 2005;91(2):e13. (Case report)
25. Rodriguez A, Ong A. Delayed rupture of a left ventricular
aneurysm after blunt trauma. Am Surg. 2005;71(3):250-251.
(Case report)
26. Ryan L, Skinner DL, Rodseth RN. Ventricular septal de-
fect following blunt chest trauma. J Emerg Trauma Shock.
2012;5(2):184-187. (Case report)
27.* Bock JS, Benitez RM. Blunt cardiac injury. Cardiol Clin.
2012;30(4):545-555. (Review article)
28. Bruschi G, Agati S, Iorio F, et al. Papillary muscle rupture
and pericardial injuries after blunt chest trauma. Eur J Car-
diothorac Surg. 2001;20(1):200-202. (Case report)
29. Cordovil A, Fischer CH, Rodrigues AC, et al. Papillary
muscle rupture after blunt chest trauma. J Am Soc Echocar-
diogr. 2006;19(4):469.e1-3. (Case report)
30. Neiman J, Hui WK. Posteromedial papillary muscle rupture
as a result of right coronary artery occlusion after blunt chest
injury. Am Heart J. 1992;123(6):1694-1699. (Case report)
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infarction secondary to blunt chest trauma. Am J Med Sci.
2018;355(1):88-93. (Case report and literature review; 179
Risk Management Pitfalls in Blunt Chest Trauma (Continued from page 12)
6. “For all patients with BCI, I order a formal
echocardiogram and admit them to inpatient
telemetry.”
Patients with suspected BCI can be effectively
ruled out while in the ED or observation unit.
Formal echocardiograms are reserved for
patients with hemodynamic instability,
persistent new dysrhythmias, and increasing
troponin levels, and in symptomatic patients
with significant mechanisms of injury. In
otherwise stable patients, consideration of
discharge home versus observation can avoid an
inpatient admission.
7. “I administer magnesium sulfate to avoid dys-
rhythmias in patients with suspected BCI.”
There are no data to support prophylactic
medication administration for traumatic cardiac
injury-related dysrhythmias. Follow usual ACLS
management guidelines.
8. “I’m not sure whether the elevated troponin
is a result of myocardial ischemia or traumatic
myocardial injury.”
In addition to a full cardiac workup, an
advanced cardiac CT or MRI may be considered
in these cases, and it is often deferred to
inpatient management. Be careful to assure
hemodynamic stability prior to ordering
prolonged diagnostic testing.
March 2019 • www.ebmedicine.net
cases)
32. Ismailov RM, Ness RB, Redmond CK, et al. Trauma as-
sociated with cardiac dysrhythmias: results from a large
matched case-control study. J Trauma. 2007;62(5):1186-1191.
(Retrospective case-control study; 672,042 cases)
33. Hadjizacharia P, O’Keeffe T, Brown CV, et al. Incidence,
risk factors, and outcomes for atrial arrhythmias in trauma
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patients)
34.* Berk WA. ECG findings in nonpenetrating chest trauma: a
review. J Emerg Med. 1987;5(3):209-215. (Review article)
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heart block following a horse kick. Pacing Clin Electrophysiol.
1999;22(5):816-818. (Case report)
36. Pontillo D, Capezzuto A, Achilli A, et al. Bifascicular block
complicating blunt cardiac injury. A case report and review
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review)
37. Lazaros GA, Ralli DG, Moundaki VS, et al. Delayed develop-
ment of complete heart block after a blunt chest trauma.
Injury. 2004;35(12):1300-1302. (Case report)
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39. van Wijngaarden MH, Karmy-Jones R, Talwar MK, et al.
Blunt cardiac injury: a 10 year institutional review. Injury.
9. “I identified a pericardial tamponade, but I was
unable to aspirate blood during the pericardio-
centesis.”
It can be difficult to use traditional landmarks
to assure proper special localization, and
patients with large-volume hemopericardium
may have coagulated blood that is difficult to
aspirate. Ultrasound-guided pericardiocentesis
may assure proper localization of the needle tip
in the pericardial space. In these challenging
circumstances, it is reasonable to consider
volume expansion to improve cardiac output
as a resuscitative bridge to definitive surgical
management. For a description of ultrasound-
guided pericardiocentesis go to:
https://www.aliem.com/2013/08/ultrasound-
guided-pericardiocentesis/
10. “I avoided getting the CT scan to minimize
ionizing radiation exposure.”
CT of the chest is not always required as a
screening tool for suspected BCI, and should
not preclude a good history and physical
examination. In patients for whom there
is a high suspicion for chest/mediastinal
injuries, the CT scan will likely be beneficial in
evaluating for culprit pathologies and associated
injuries.
13 Copyright © 2019 EB Medicine. All rights reserved.
 1997;28(1):51-55. (Review article)
40. Pasquale M, Fabian TC. Practice management guidelines
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42. Jones LA, Sullivan RW. Ventricular tachycardia: a rare com-
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43. Maron BJ, Poliac LC, Kaplan JA, et al. Blunt impact to the
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44. Link MS, Wang PJ, Pandian NG, et al. An experimental
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(Animal model)
45. Fildes JJ, Betlej TM, Manglano R, et al. Limiting cardiac
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48. Feero S, Hedges JR, Simmons E, et al. Does out-of-hos-
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261. (Prospective; 360 patients)
50. Gonzalez RP, Cummings GR, Phelan HA, et al. Does in-
creased emergency medical services prehospital time affect
patient mortality in rural motor vehicle crashes? A statewide
analysis. Am J Surg. 2009;197(1):30-34. (Retrospective; 45,763
patients)
51. Brown JB, Rosengart MR, Forsythe RM, et al. Not all pre-
hospital time is equal: influence of scene time on mortality.
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52. Jayaraman S, Sethi D, Wong R. Advanced training in trauma
life support for ambulance crews. Cochrane Database Syst Rev.
2014(8):CD003109. (Cochrane review)
53. Evans CC, Petersen A, Meier EN, et al. Prehospital traumatic
cardiac arrest: management and outcomes from the resusci-
tation outcomes consortium epistry-trauma and PROPHET
registries. J Trauma Acute Care Surg. 2016;81(2):285-293.
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54. Fevang E, Perkins Z, Lockey D, et al. A systematic review
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in trauma patients. Crit Care. 2017;21(1):192. (Systematic
review/meta-analysis; 21 studies, 34,838 patients)
55. Singh JM, MacDonald RD, Ahghari M. Post-medication hy-
potension after administration of sedatives and opioids dur-
ing critical care transport. Prehosp Emerg Care. 2015;19(4):464-
474. (Retrospective; 8328 patients)
56. Osterwalder JJ. Mortality of blunt polytrauma: a compari-
son between emergency physicians and emergency medical
technicians--prospective cohort study at a level I hospital in
eastern Switzerland. J Trauma. 2003;55(2):355-361. (Prospec-
tive; 267 patients)
57. Otsuka H, Sato T, Morita S, et al. A case of blunt traumatic
cardiac tamponade successfully treated by out-of-hospital
pericardial drainage in a “doctor-helicopter” ambulance
Copyright © 2019 EB Medicine. All rights reserved. 14
staffed by skilled emergency physicians. Tokai J Exp Clin Med.
2016;41(1):1-3. (Case report)
58. Garner A, Rashford S, Lee A, et al. Addition of physicians to
paramedic helicopter services decreases blunt trauma mor-
tality. Aust N Z J Surg. 1999;69(10):697-701. (Retrospective;
207 patients)
59. Iirola TT, Laaksonen MI, Vahlberg TJ, et al. Effect of physi-
cian-staffed helicopter emergency medical service on blunt
trauma patient survival and prehospital care. Eur J Emerg
Med. 2006;13(6):335-339. (Retrospective; 81 patients)
60. Campo dell’ Orto M, Kratz T, Wild C, et al. Pre-hospital
ultrasound detects pericardial tamponade in young patients
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and review of literature. Clin Res Cardiol. 2014;103(5):409-411.
(Case report)
61. Breitkreutz R, Price S, Steiger HV, et al. Focused echocar-
diographic evaluation in life support and peri-resuscitation
of emergency patients: a prospective trial. Resuscitation.
2010;81(11):1527-1533. (Prospective; 230 patients)
62. Jorgensen H, Jensen CH, Dirks J. Does prehospital ultra-
sound improve treatment of the trauma patient? A system-
atic review. Eur J Emerg Med. 2010;17(5):249-253. (Systematic
review)
63. Stolz L, Valenzuela J, Situ-LaCasse E, et al. Clinical and
historical features of emergency department patients with
pericardial effusions. World J Emerg Med. 2017;8(1):29-33.
(Retrospective; 153 patients)
64.* Velmahos GC, Karaiskakis M, Salim A, et al. Normal electro-
cardiography and serum troponin I levels preclude the pres-
ence of clinically significant blunt cardiac injury. J Trauma.
2003;54(1):45-50. (Prospective; 333 patients)
65. Bertinchant JP, Polge A, Mohty D, et al. Evaluation of inci-
dence, clinical significance, and prognostic value of circulat-
ing cardiac troponin I and T elevation in hemodynamically
stable patients with suspected myocardial contusion after
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tive; 94 patients)
66. Rajan GP, Zellweger R. Cardiac troponin I as a predictor of
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67. Garcia-Fernandez MA, Lopez-Perez JM, Perez-Castellano
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of echocardiographic findings with the electrocardiogram
and creatine kinase monoclonal antibody measurements. Am
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69. Baum VC. The patient with cardiac trauma. J Cardiothorac
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73.* Melniker LA, Leibner E, McKenney MG, et al. Randomized
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75. Sauter TC, Hoess S, Lehmann B, et al. Detection of pneu-
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CME Questions
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receive your free CME credits for this issue, scan
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1. What is the most common dysrhythmia associ-
ated with a blunt cardiac injury (BCI)?
a. Atrial fibrillation
b. Atrial flutter
c. Sinus tachycardia
d. Ventricular tachycardia
15 Copyright © 2019 EB Medicine. All rights reserved.
2.
CME What intervention has been shown to reduce
Questions 9.
5. A 26-year-old
Which woman was
of the following a restrained
tests should not driver
be
mortality in patients with major trauma and involved
used to assessin a moderate-speed motor
for popliteal artery vehicle
injury?
should be the highest priority for prehospital crash.
a. X-ray Herseries
examination
of the kneewas concerning for a
providers? Take This Test Online! seat belt sign
b. Duplex across her chest, prompting a
ultrasound
a. Early access to advanced life support pan-trauma
c. CT angiogram CT scan. Imaging revealed a trans-
Current subscribers
b. Rapid receive CME credit absolutely
transport verse sternal fracture. Vital signs and labora-
d. Arteriogram
free c.
by completing
Pain control following test.TMEach issue in-
the tory results are within normal limits. What is
cludes 4 AMA PRA Category
d. Point-of-care 1 Credits , 4 ACEP Cat-
ultrasound 6. the
Thenext
common best step
forceinthat
management?
is applied in the reduc-
egory I credits, 4 AAFP Prescribed credits, or 4 AOA a.
tionConsider
of all types discharge
of kneehomedislocation is:
Take This Test Online!
Category
3. 2A or
Describe 2Bstatistical
the credits. Online testing is
performance ofavailable
the b.
a. Perform MRI to assess for myocardial injury
Axial loading
for current
ECG combined with cardiac troponin your
and archived issues. To receive I. free c.
b. Admit
Anterior to force
telemetry
on theobservation with serial
proximal tibia
CME a. credits
Highfor this issue, scan the QR code below
specificity c. troponins
Posterior force on the proximal tibia
withb.
yourLow sensitivityor visit
smartphone d.
d. Perform echocardiogram to asses for
Traction/counter-traction
www.ebmedicine.net/E1217.
c. High positive predictive value myocardial injury
d. High negative predictive value 7. When should a knee or ankle joint be reduced
10. A
in46-year-old
the field byman EMSwith no transport?
before significant past
4. What is the approximate amount of fluid medical historydeformity
a. Significant presents to the ED after a high-
volume that can accumulate in the pericardial speed
b. Severemotorcycle accident. Prehospital
and unremitting pain vital
space and remain undetectable on chest x-ray? signs
c. Open include blood pressure, 110/70 mm Hg;
dislocation
a. 20 mL b. 50 mL heart rate, 115for
d. Concern beats/min; respiratory
ischemia distal to the rate, 20
injury
c. 100 mL d. 200 mL breaths/min; and O2 saturation, 96%. His physi-
8. cal
What examination
type of knee was concerning
dislocation is for
themultiple
most com-
1. In
5. What is the most controlled
a randomized common type
trialof hip disloca-
performed by abrasions
mon? to the upper and lower extremities
tion?
Melniker et al, the FAST examination reduced and anterior chest wall tenderness. Imaging
a. Medial
a. Lateral
time of arrival to the ED to operative care in revealed
b. Anterior a nondisplaced left anterior fourth rib
b. Medial
trauma patients by what percentage? fracture.
c. Posterior ECG showed normal sinus rhythm,
c. 9%
a. Anterior b. 21% and a full set of labs, including troponin, was
d. Lateral
d. 64%
c. Posterior d. 95% unremarkable.
e. Rotational Repeat vital signs were within
normal limits. What is the most appropriate
2. ECG-gated
6. Delaying a multidetector
native hip reduction can result
CT performs wellinin 9. disposition
What other injuryfor thisshould
patient?be excluded before
which of the following complications?
the early identification of all of the following a. Admit to
attempting intensiveof
reduction care
an unit
ankle with formal
dislocation?
a. Compartment
cardiac pathologiessyndrome
resulting in hemodynamic a. echocardiogram
Hip fracture and serial cardiac enzymes.
b. Further blood loss
instability, EXCEPT: b.
b. Perform
CalcanealFAST exam; if negative, admit to
fracture
c. Myocardial
a. Avascular necrosis
contusion c. telemetry unit and obtain serial cardiac
Subtalar dislocation
d. Infection rupture
b. Myocardial d. enzymes.
Tibial shaft fracture
c. Pneumopericardium c. Obtain formal echocardiogram and consider
3. d.
Which of the following
Coronary hip dislocations should
artery insults 10. What discharge
potential home if normal.from a dislocated
complication
not be reduced by an emergency clinician d.
ankle BCIis is ruled
the out; consider
primary discharge
reason for home.
timely reduc-
without
7. A an orthopedic
68-year-old man withsurgeon present?
past medical history of tion of the talus?
a. Dislocation with associated fracture
atrial fibrillation on warfarin presents to the ED a. Postoperative infection
b. Dislocation
after motor vehiclewithcrash.
a prosthetic hip
He complains of chest b. Avascular necrosis of the talus
c. Dislocation without fracture
pain, with an obvious seat belt sign and chest c. Long-term osteoarthritis
d. No
wall dislocation
tenderness. should be
According toreduced
the 2012without
EAST d. Compartment syndrome
orthopedic consultation
guidelines, which of the following is an indica-
tion for obtaining a formal echocardiogram?
4. To avoid
a. complications,
International whatratio
normalized should
> 2 be the
goal time-to-reduction of a native hip disloca- Don't forget...
b. Atrial fibrillation
tion?
c. Hemodynamic instability
You can LISTEN to highlights and CME
a. Age
d. Less >than 1 hour
65 years hints for this issue on
b. Less than 6 hours
c. Less
8. Which ofthan 24 hours medications is consid-
the following
d. Less than 72 hours
ered as appropriate dysrhythmia prophylaxis
for patients with high suspicion for a BCI?
a. Amiodarone
b. Lidocaine
c. Magnesium sulfate
d. All of the above
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artery dis hyperte exclude CV
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Severity
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uld be reserv
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he onset is
mass
with IV hep Treat intracranial dis LP
rs of headac of this time window,
Clinical Pathway

t.
Management for Emergency
of Subarachnoid Department

lan hou
Hemorrhage

agu Abbreviations
antico tside
Patient presents
with concern
for SAH

pidogrel. t is : CAD, cerv

headache tha ing out SAH. Ou d.
Obtain head
CT without
contrast

ical artery
aspirin or clo
thrombosis;
Onset ≤ 6
hours prior

dissection;
dual-onset
Onset > 6
hours prior

ead uire ICH, intracran CVT, cerebral

CT negative
for SAH

sents as a gra botic disease and spr will be req

CT positive
for SAH

CT negative

ial hemorrh
for SAH

venous
SAH ruled

ed SAH, suba
out (Class
I)
• Obtain neurosurgery

diagnose rais
• Obtain CT consultation

• CVT pre
angiogram
of the head

age; ICP, intra

• Elevate Obtain lumbar
head of
• For aneurysmal bed 30° puncture
(Class I)

rachnoid hem
SAH, maintain
systolic blood goal
pressure <

t
using titratable 160 mm Hg
• Administer agent (Class
nimodipine II)

ult of throm lecular weigh

(Class I)

cranial pres
can rapidly
orrhage.
Lumbar
puncture Lumbar
positive for puncture

m-
negative for

sure;
often the res
SAH
SAH

with low-mo ultrasound ve sheath dia

Abbreviations:
CT, computed
tomography;
SAH, subarachnoid
hemorrhage. SAH ruled
out (Class
I)
Class of Evidence
Definitions

er
Each action

at lar
in the clinical
pathways

sid ner
Class I section of Emergency

Tre
• Always acceptable, Medicine Practice

Ocu tic
• Definitely safe Class II receives a
useful • Safe, acceptable
score based
on the following

Con
• Proven in

ns.
both efficacy Class III definitions.
and effectiveness • Probably useful

Op
Level of Evidence: • May be acceptable

in.
Level of Evidence: Indeterminate

.
• One or more • Possibly useful

facial infectio arin bridge to warfar re.

large prospective • Generally • Considered • Continuing
are present studies higher optional or area of research
• High-quality
(with rare exceptions) • Nonrandomized levels of evidence ments alternative • No recommendations

> 20 mm Hg
treat-
meta-analyses historic, cohort, or retrospective studies: until further

anial pressu
• Study results research
consistently • Less robust or case control Level of Evidence:
compelling positive and randomized studies Level of Evidence:
• Results consistently controlled • Generally
trials lower or intermediate • Evidence
positive evidence not

y is
levels of
• Case series, • Higher studiesavailable
animal studies, in progress
• Results inconsistent,
This clinical consensus

www.ebmedic
pathway is panels • Results not contradictory
needs. Failure intended • Occasionally
to comply with to supplement, rather positive results compelling

log
Copyright © this
pathway does than
substitute for,
2019 EB Medicine. not represent professional

acr
www.ebmedicine.net. a breach of judgment and
the standard

ICP
may be changed

etio
No part of of care. depending
this publication upon a patient’s
Copyright © may be reproduced

intr of
individual
2019 EB

us
in any format
Medicine. All without written
rights reserved.

ine.net
consent of

Clinical Path
EB Medicine.

if an infectio is predictive
8

hep
Reprints: www.ebmedicine.net/empissues

heparin or ant ibio tics eter > 5 mm Department

way for Eme
rgency Access the
m
broad-spectru Looking for Management issue
the QR code by scanning
childbearing mo Subarachnoi of
suspected. se women of re about cervica re info d Hemorrh
age with a
phone or table smart-
h obe pun ctu l arte
ociated wit A. Lumbar ry
July 2016
Cervical Artery Dissection:
dissection? t.
• IIH is ass as hypervitaminosis
Questions,
Volume 18, Number 7

en- e Authors
Author

Early Recognition
. Op com
Rhonda Cadena, MD

Issu ck
IIH men
Assistant Professor, Departments of Neurology, Neurosurgery, and

ensa
rapeutic for
And Stroke Prevention
ts, sugges
Emergency Medicine, University of North Carolina, Chapel Hill, NC

dency, Hack
age as well MD, FACEP rgency Medicine Resi
Peer Reviewers

the ent of Check the to the edit

Christopher Lewandowski, MD

tions? To
e is
Abstract

and da, writ

Vice Chair, Department of Emergency Medicine, Henry Ford Health

artm or,
Acetazolamid
Zod ema e a letter
System, Clinical Professor of Emergency Medicine, Wayne State

July
diagnostic David , Dep 2016 issue
University, Detroit, MI

il: Jagoda
tor, Eme t Professor
Cervical artery dissections involve the carotid or vertebral Stephan A. Mayer, MD, FCCM

n Hall
(LP) is both
arteries. Although the overall incidence is low, they remain a

O. t Program Direc of Emergen MD@ebm

Director, Neurocritical Care, Mount Sinai Health System, Professor of

H er; Assistan icine at Seto

common cause of stroke in children, young adults, and trauma Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai,

mm
New York, NY

cy edic
patients. Symptoms such as headache, neck pain, and dizziness

Cent
will be ≥ 25
stan ma of Med Med ine.
CME Objectives

2 Assi
are commonly seen in the emergency department, but may not

Trau dian Scho ol icine net

Medical and
Upon completion of this article, you should be able to:
be apparent in the obtunded trauma patient. A missed diagnosis

Practice: CAD 1. List the risk factors for carotid and vertebral artery dissections.

ing pressures rmacotherapy.

of cervical artery dissection can result in devastating neurological

University ensack Meri

2. Describe clues in the history and physical examination that can be
sequelae, so emergency clinicians must act quickly to recognize

: Early
indicative of a dissection.

ly Hack
this event and begin treatment as soon as possible while neuro-

,
3. Perform appropriate emergency department workup for carotid

lusive icine Rec

logical consultation is obtained. This issue reviews the evidence and vertebral artery dissections.

Med ognition and

n, almost exc in-
4. Initiate the appropriate interventions to prevent stroke and for the

Emergency
in applying advanced screening criteria and choosing imaging treatment of acute ischemic strokes due to dissections.

pha
and antithrombotic treatment strategies for patients with cervical

a first-line
NJ Stroke
Prior to beginning this activity, see “Physician CME Information”

Hackensack,
artery dissections to reduce the occurrence of ischemic stroke. on the back page.

n in wome Prevention MDCalc Sco

This issue is eligible for 4 Trauma CME credits

University, rmD, BCPSDepartment of Pharmac

and 4 Stroke CME credits.

y,
n features
at
more commo re Calculato
Editor-In-Chief Daniel J. Egan, MD Eric Legome, MD Robert Schiller, MD International Editors

copio, Pha
Associate Professor, Department Chief of Emergency Medicine, Chair, Department of Family Medicine,

rs. Commo
www.ebmedic
Andy Jagoda, MD, FACEP Peter Cameron, MD

ssor,
Beth Israel Medical Center; Senior

• GCA is
of Emergency Medicine, Program King’s County Hospital; Professor of Academic Director, The Alfred

r
Professor and Chair, Department of
Director, Emergency Medicine Clinical Emergency Medicine, SUNY Faculty, Family Medicine and

Gabrielle Pro icine Clinical Pharmac ma Center; Assistant Profe

Ottawa Sub
Emergency Medicine, Icahn School Emergency and Trauma Centre,

ist,
Residency, Mount Sinai St. Luke's Downstate College of Medicine, Community Health, Icahn School of
of Medicine at Mount Sinai, Medical Monash University, Melbourne,

and
Brooklyn, NY Medicine at Mount Sinai, New York, NY

ine.net/CAD
Roosevelt, New York, NY

aged > 50 yea ias, jaw claudication,

Director, Mount Sinai Hospital, New Australia
York, NY Keith A. Marill, MD Scott Silvers, MD, FACEP

arachnoid
Nicholas Genes, MD, PhD Giorgio Carbone, MD
Research Faculty, Department of Chair, Department of Emergency
Assistant Professor, Department of Chief, Department of Emergency

(Stroke and
Associate Editor-In-Chief Emergency Medicine, Icahn School Emergency Medicine, University Medicine, Mayo Clinic, Jacksonville, FL
Medicine Ospedale Gradenigo,

School of
of Pittsburgh Medical Center,

in patients
Kaushal Shah, MD, FACEP

Hemorrhage
of Medicine at Mount Sinai, New Corey M. Slovis, MD, FACP, FACEP Torino, Italy

t Emergency Med
Pittsburgh, PA

Trau
Associate Professor, Department of York, NY Professor and Chair, Department

Trauma CME
Emergency Medicine, Icahn School Suzanne Y.G. Peeters, MD

y Medical and Hackensack Meridian https://www.m

Charles V. Pollack Jr., MA, MD, of Emergency Medicine, Vanderbilt
of Medicine at Mount Sinai, New Michael A. Gibbs, MD, FACEP Emergency Medicine Residency

a is presen Hackensack Universitrgen

FACEP University Medical Center, Nashville, TN

, myalg
Professor and Chair, Department Director, Haga Teaching Hospital,

Rule:
York, NY Professor and Chair, Department of
of Emergency Medicine, Carolinas Ron M. Walls, MD The Hague, The Netherlands

)
Medical Center, University of North Emergency Medicine, Pennsylvania
Editorial Board Professor and Chair, Department of

dcalc.com/ot
Hospital, Perelman School of Hugo Peralta, MD

gue
Carolina School of Medicine, Chapel Emergency Medicine, Brigham and

atic
Saadia Akhtar, MD

icine,
Medicine, University of Pennsylvania, Chair of Emergency Services, Hospital

fati
Hill, NC Women's Hospital, Harvard Medical
Associate Professor, Department of

um
Philadelphia, PA Italiano, Buenos Aires, Argentina

er,
Emergency Medicine, Associate Dean Steven A. Godwin, MD, FACEP School, Boston, MA

rhe Med tawa-subarac

Michael S. Radeos, MD, MPH Dhanadol Rojanasarntikul, MD

clude fev
cy
for Graduate Medical Education, Professor and Chair, Department

NJ
Critical Care Editors

gia hemorrhage-
Program Director, Emergency of Emergency Medicine, Assistant Assistant Professor of Emergency Attending Physician, Emergency

ck,
. Polymyal
Medicine Residency, Mount Sinai Dean, Simulation Education, Medicine, Weill Medical College Medicine, King Chulalongkorn

of Eme
William A. Knight IV, MD, FACEP

Hackensa
of Cornell University, New York; Memorial Hospital, Thai Red Cross,

oids. hnoid-
Beth Israel, New York, NY University of Florida COM- Associate Professor of Emergency
Research Director, Department of Thailand; Faculty of Medicine,

Department sah-rule-hea
Jacksonville, Jacksonville, FL Medicine and Neurosurgery, Medical

University,
William J. Brady, MD Emergency Medicine, New York Chulalongkorn University, Thailand

ster
Gregory L. Henry, MD, FACEP Director, EM Midlevel Provider

ms
Professor of Emergency Medicine Hospital Queens, Flushing, NY

h
Clinical Professor, Department of Program, Associate Medical Director, Stephen H. Thomas, MD, MPH
and Medicine, Chair, Medical

pto wit
Ali S. Raja, MD, MBA, MPH Neuroscience ICU, University of Professor & Chair, Emergency

dach
Emergency Medicine, University

Hall
Emergency Response Committee,

cases. Treat
Vice-Chair, Emergency Medicine,

n
Medicine, Hamad Medical Corp.,

visual sym
Medical Director, Emergency of Michigan Medical School; CEO, Cincinnati, Cincinnati, OH

EB MEDICINE
e-ev
Massachusetts General Hospital,

Seto
Medical Practice Risk Assessment, Weill Cornell Medical College, Qatar;
Management, University of Virginia Scott D. Weingart, MD, FCCM

Medicine at Hackensack aluation

Boston, MA Emergency Physician-in-Chief,
Medical Center, Charlottesville, VA Inc., Ann Arbor, MI Associate Professor of Emergency
Robert L. Rogers, MD, FACEP, Hamad General Hospital, Doha, Qatar
John M. Howell, MD, FACEP Medicine, Director, Division of ED

n half of all od
Calvin A. Brown III, MD FAAEM, FACP Critical Care, Icahn School of Medicine

Residency,
Clinical Professor of Emergency Edin Zelihic, MD

on and blo
Director of Physician Compliance, Assistant Professor of Emergency at Mount Sinai, New York, NY
Medicine, George Washington Head, Department of Emergency
Credentialing and Urgent Care Medicine, The University of
University, Washington, DC; Director Medicine, Leopoldina Hospital,
Services, Department of Emergency Maryland School of Medicine, Senior Research Editors

artment of
of Academic Affairs, Best Practices, Schweinfurt, Germany
Medicine, Brigham and Women's

cy Medicine
in more tha
MD
Inc, Inova Fairfax Hospital, Falls Baltimore, MD

ation cessati
Hospital, Boston, MA James Damilini, PharmD, BCPS

Amit Gupta,ram Director, Emergen Assistant Professor, Dep at Seton Hall

Church, VA Alfred Sacchetti, MD, FACEP Clinical Pharmacist, Emergency
Peter DeBlieux, MD Shkelzen Hoxhaj, MD, MPH, MBA Assistant Clinical Professor, Room, St. Joseph’s Hospital and
Professor of Clinical Medicine, Department of Emergency Medicine, Medical Center, Phoenix, AZ

lol.
Chief of Emergency Medicine, Baylor
Interim Public Hospital Director Thomas Jefferson University,

dic eta
College of Medicine, Houston, TX Joseph D. Toscano, MD
of Emergency Medicine Services, Philadelphia, PA

me lab
Louisiana State University Health Chairman, Department of Emergency

h or
Science Center, New Orleans, LA Medicine, San Ramon Regional

S wit e
Medical Center, San Ramon, CA

t Prog er; icine

ipin Cent Emergency
• Treat PRE trol, typically nicard
Assistan ical and Trau
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Termination date: March 1, 2022.
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agnosis ACCME.
Influenza: Di nt in the
Authors
P, FAAEM Icahn School of Medic
ine
MBA, FACE ine,
AL Giwa MD, sor of Emergency Medic

me
and Manage partment
Assistant ProfesNew York, NY

Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA
at Mount Sinai, P
MPH, FACE Hackensack Meridian
egbe, MD, ine,
Chinwe Oged sor of Emergency MedicUniversity, Nutley, NJ;

nc y De Associate
Profes at Seton Hall Jersey

Emerge
l of Medicine Rutgers-New
Medicine,

Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their
Health Schoo of Emergency
Professor
Associate l, Newark,
NJ
Medical Schoo r,
MD Medical Cente
Murphy, Metrowest
Charles G. Emergency Medicine,
Abstract
participation in the activity.
ic
nt diagnost Depar tment
of
of the curre l- MA
t be aware and the avai Framingham,
clinicians mus for influenza ensive
Emergency ic recommendations
ers
Peer Review
This compreh influenza am, MD nd School
of Medicine,
and therapeut to guide management. Maryla

Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits.
Abrah of
enza viruses, Michael K. sor, Univer
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able resou
rces
class ificat ion of influ patie nts, and the Clinical Assist
ant Profes
nes the of high -risk MD
review outli gy, the identification enza are Baltimore, of
tions of influ
tment
, MD tion, Depar
Daniel J. Egansor, Vice Chair of Educa
pe- of
siolo varia ng s College
pathophy on. Seasonal testing duri en- Profes sity Vagelo
e of vaccinati rationale for limiting Associate Univer

ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency
Columbia
Medicine,
importanc ns of influ Emergency ons, New York,
NY
as well as
the between strai al and Surge
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Information”
prevalence. the challenges in achie the currently , see “Physi
ing this activity back page.
riods of high , as well as for use of Prior to beginn

Physicians for 48 hours of ACEP Category I credit per annual subscription.

on the
discu ssed ndat ions treat men ts
za are mme iral
tiveness. Reco venous antiv aking with
vaccine effec intranasal, and intra
ed decision-m
available oral, as well as utilizing shar treatment. Maricopa
of
AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been
, fits
are provided and bene Pharmacy
Residency, AZ
Phoenix,
rding risks tti, MD, FACEP Medical Center,
patients rega MPH, MBA
Alfred Sacche Professor, e, Joseph D.
Toscano,
MD
ncy
Hoxhaj, MD, Jackson Assistant Clinical ncy Medicin ent of Emerge
Shkelzen of Emerge Chief, DepartmRamon Regional
Department

reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of
l Officer, n University, Medicine,
San , CA
MD Chief Medica l, Miami, FL Thomas Jefferso San Ramon
Daniel J. Egan,
of
Vice Chair
ncy Memor
ial Hospita
Philadelphia,
PA Medical Center,
Professor,
Associate
hief
Editor-In-C, MD, FACEP Department
of Emerge
Eric Legom
e, MD e, Mount r, MD e, al Editors
Education,
Columbia
University
Chair, Emerge
ncy Medicin Luke's; Robert Schille ent of Family Medicin Internation
Medicine, and Sinai St. Chair, Departm Senior on, MD

approval begins 07/01/2018. Term of approval is for one year from this date. Physicians should
Andy Jagoda Interim Chair, e; of Physicians West & Mount ic Affairs for Medical Center; Peter Camer Alfred
Professor
and
ncy Medicin Vagelos College Sinai Beth Israel
Medicine and Director, The Centre,
of Emerge New York,
NY
Vice Chair,
Academ
Mount Sinai Faculty, Family of Academic
Department for Emerge
ncy Surgeons, Medicine, Icahn School NY Emergency
and Trauma rne,
Emergency School of nity Health, New York, ity, Melbou
Director, Center ion and Research, Genes, MD, PhD
of , Icahn NY Commu
Mount Sinai, Monash Univers
Nicholas Department Health System New York, Medicine at
Medicine Educat e at Mount Professor, Mount Sinai, Australia
of Medicin Associate Medicine at

claim only the credit commensurate with the extent of their participation in the activity. Approved for
Icahn School FACEP
Icahn School Medicine, MS Scott Silvers, MD, or of Emergency
York, NY Emerge ncy New MD, MD
Sinai, New e at Mount
Sinai, Keith A. Marill, Department Associate
Profess and Andrea Duca, Physician,
hief of Medicin Professor, of Facilities Emergency
Associate Medicine, Chair Clinic, Jacksonville,
FL Attending
ciate Editor-In-C York, NY ncy Medicine,
Harvard
le Papa Giovanni XXIII,
Asso MD, FACEP FACEP of Emerge , Massachusetts Plannin g, Mayo Ospeda
of Gibbs, MD, Medical School l, Boston, MA FACEP Bergamo,
Italy
Kaushal Shah, Department Michael A. Department MD, FACP,

4 AAFP Prescribed credits.

Professor, or and Chair, e, Carolinas l Hospita M. Slovis, ent s, MD
Associate Icahn School Profess Genera Corey Chair, Departm e Y.G. Peeter
Physician,
Medicine, ncy Medicin ity of North Pollack Jr.,
MA, MD, Professor and Medicine, Vanderbilt Suzann
Emergency
Emergency Sinai, New of Emerge Charles V. e, TN Attending Almere,
of Medicin
e at Mount Univers
Medical Center, of Medicine, Chapel , FAHA, FESC of Emergency l Center, Nashvill g Hospital,
FACEP, FAAEM for
University Medica Flevo Teachin
York, NY Carolina School & Senior Advisor ands
Professor y Research
and MD of The Netherl
Hill, NC InterdisciplinarDepartment of Ron M. Walls, Chair, Department Peralta, MD
Editorial Board
FACEP s,
Godwin, MD,

AOA Accreditation: Emergency Medicine Practice is eligible for 4 Category 2-A or 2-B credit hours
l and
Steven A. Department Clinical Trials, Sidney Kimmen Professor Brigham and l Hugo of Emergency Service
, MD, FACEP ent of Medicine, Medicine,
Saadia Akhtar Professor
and Chair, Assistant Emergency Jefferso Emergency Medica Chair , Buenos Aires,
Professor,
Departm
te Dean Medicine, of Thomas 's Hospita
l, Harvard Hospital Italiano
Associate Associa ncy l College PA Women
Medicine, of Emerge ion Educat
ion, Medica
Philadelphia, , MA Argentina
Emergency Education, Dean, SimulatFlorida COM- University, School, Boston ul, MD
te Medical s, MD, MPH ncy rs Rojanasarntik
for Gradua ncy ity of FL Radeo Edito Dhanadol Emergency

per issue by the American Osteopathic Association.

r, Emerge Univers S. an,
Critical Care
nville, l Physici
Program Directo cy, Mount Sinai Jacksonville,
Jackso Michae
Professor
of Emerge , Attending ngkorn
Medicine ResidenYork, NY MD MBA Associate l College IV, MD, FACEP Medicine,
King Chulalo Red Cross,
New Habboushe, of Emergency Medicin e, Weill Medica New York; William A. Knight ial Hospita l, Thai
Beth Israel, Joseph or ity, Memor e,
Univers ent of ncy of Medicin
Assistant Profess ngone and of Cornell
Director, DepartmYork
FNCS
Professor
of Emerge Thailand; Faculty Thailand
Brady, MD e NYU/La Research Associate Medical University,
William J. ncy Medicin Medicine, l Centers,
New York,
Medicine,
New Neurosurgery, Chulalongkorn
of Emerge Director, Emergency Medicine and
Professor Bellevue Medica , Flushing,
NY Practice s, MD, MPH
e; Medical LLC Advanced Medical Stephen H. Thoma

Needs Assessment: The need for this educational activity was determined by a survey of medical
MD Aware Hospital Queens Director, EM
and Medicin
Management,
UVA NY; CEO, ; Associate ncy
& Chair, Emergel Corp.,
Emergency Medical FACEP MD, MBA,
MPH
Provider Program University Professor
Operational Henry, MD, Ali S. Raja, Emergency cience ICU, Hamad Medica
Medical Center; rle County Fire Gregory L. or, Departm ity
ent of
Vice Chair, l Director, Neuros ati, OH Medicine, , Qatar;
Clinical Profess Executive husetts Genera ati, Cincinn Medical College
Director, Albematesville, VA ncy Medicine,
Univers
; CEO, Medicin e, Massac or of of Cincinn FCCM Weill Cornell an-in-C hief,
Emerge te Profess rt, MD, Physici
Rescue, Charlot n Medical
School
Hospital; Associa e and Radiolo
gy,
Scott D. Weinga Medicine; Emergency l Hospital,

staff, including the editorial board of this publication; review of morbidity and mortality data from the
of Michiga ment,
MD e Risk Assess Medicin Emergency Hamad Genera
Calvin A.
Brown III,
Compliance, Medical Practic MI Emergency l School, Boston
, MA Professor of Stony Brook
Physician Critical Care, Doha, Qatar
Director of Care Inc., Ann Arbor, Harvard Medica Chief, EM NY
and Urgent FACEP, Stony Brook,
Credentialing ncy , MD, FACEP Rogers, MD, Medicine, Edin Zelihic,
MD ncy
ent of Emerge John M. Howell or of Emergency Robert L. ent of Emerge l,
Services, Departm and Women's Clinical Profess Washington FAAEM, FACP or of Emergency Editors Head, Departm Hospita

CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Medicine,
Brigham George Director Assistant
Profess Research Medicine,
Leopoldina
, MA Medicine, gton, DC; University
of D, BCPS Germany
Hospital, Boston Washin
University, Affairs, Best Practic
es, Medicin e, The
Medicine,
r, Pharm
Aimee MishleMedicine Pharma cist, Schwei nfurt,
ic School of
ux, MD of Academ l, Falls Maryland Emergency r, PGY2 EM
Peter DeBlie Clinical Medicine, Fairfax Hospita MD
Professor
of ity School
of Inc, Inova Baltimore, Program Directo
State Univers nce Officer, Church, VA
Louisiana
Chief Experie New

Target Audience: This enduring material is designed for emergency medicine physicians, physician
Medicine;
Medical Center,
University
Orleans, LA

First Trimester Pregnancy January 2019 assistants, nurse practitioners, and residents.
Emergencies: Recognition Author
Volume 21, Number 1

and Management Ryan Pedigo, MD

Director of Undergraduate
Medical Education, Harbor-UCLA
Center, Torrance, CA; Assistant Medical
Professor of Emergency Medicine,
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-
making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most
David Geffen School of Medicine,
Los Angeles, CA
Abstract Peer Reviewers

Jennifer Beck-Esmay, MD
Timely management of patients
their first trimester of pregnancy
presenting to the ED while
can
the patient and the fetus. Common improve outcomes for both
in
Assistant Residency Director,
West, New York, NY
Taku Taira, MD, FACEP
Mount Sinai St. Luke’s – Mount
Sinai critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
obstetric problems encoun- Associate Director of Undergraduate
tered include vaginal bleeding
Objectives: Upon completion of this activity, you should be able to: (1) describe the spectrum
Medical Education; Associate
and miscarriage, ectopic preg- Clerkship Director, LAC +
USC Department of Emergency
nancy and pregnancy of undetermin Keck School of Medicine, Los Medicine,
and vomiting of pregnancy, ed location, and nausea Angeles, CA
including hyperemesis gravidarum Prior to beginning this activity,

of conditions caused by blunt cardiac injury; (2) list the indications and limitations of diagnostic
Optimal diagnostic approaches . see “CME Information”
and management strategies on the back page.
covered, including which are
antiemetics are safe to give This issue is eligible for
nancy. Common nonobstetri in preg- 2 Pharmacology CME credits.
c problems include asymptoma
bacteriuria, urinary tract infections
and acute appendicitis. This
aging modalities available
including pyelonephritis,
article also reviews the various
tic

im-
modalities for blunt cardiac injury; (3) describe appropriate management of pericardial effusion and
tamponade; and (4) utilize a clinical pathway for disposition in the patient with suspected blunt
for pregnant patients and
risks of ionizing radiation reviews the
as well as various contrast
media.

Editor-In-Chi ef
Andy Jagoda, MD, FACEP
Professor and Interim Chair,
Daniel J. Egan, MD
Associate Professor, Vice
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Shkelzen Hoxhaj, MD, MPH,
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cardiac injury.
Education, Department of Pharmacy Residency, Maricopa
Department of Emergency Emergency Memorial Hospital, Jackson Assistant Clinical Professor,

Medicine;
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Medicine Education and Research,
Icahn School of Medicine
at Mount
Sinai, New York, NY
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Discussion of Investigational Information: As part of the journal, faculty may be presenting inves-
Miami, FL Department of Emergency Medical Center, Phoenix, AZ
Medicine,
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Chair, Emergency Medicine, Philadelphia, PA Chief, Department of Emergency
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Luke's; Robert Schiller, MD
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for

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tigational information about pharmaceutical products that is outside Food and Drug Administration
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approved labeling. Information presented as part of this activity is intended solely as continuing
School Associate Professor, Department York, NY
of Medicine at Mount Sinai, Scott Silvers, MD, FACEP Emergency and Trauma Centre,
New Professor and Chair, Department of Emergency Medicine, Harvard
York, NY Associate Professor of Emergency Monash University, Melbourne,
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of North General Hospital, Boston, MA and
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Saadia Akhtar, MD, FACEP
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medical education and is not intended to promote off-label use of any pharmaceutical product.
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 Calculated
Decisions
Clinical Decision Support for Emergency Medicine Practice Subscribers
Focused Assessment With
Sonography for Trauma (FAST)
Introduction: The FAST examination predicts the presence of
pericardial or intra-abdominal injury after penetrating or blunt
Click the thumbnail above
to access the calculator. trauma.
Points & Pearls
• The focused assessment with sonography for
trauma (FAST) examination assesses for fluid in
the pericardium (hemopericardium) or abdomen
(hemoperitoneum).
• The 4 traditional FAST views are a subxiphoid
view of the heart and pericardium, right and left
upper quadrant windows, and the pelvis.
• More recently, the extended FAST (eFAST)
examination has entered into clinical practice
with the addition of bilateral thoracic views to
assess for pneumothoraces and hemothoraces.
• A negative FAST result does not exclude
injury. Ultrasound is user dependent; therefore,
clinicians should be cautious in the interpreta-
tion of a negative FAST result. Sensitivities of
the abdominal and suprapubic views in FAST
vary widely, with ranges of 22% to 98% reported
in recent literature (Richards 2017, Carter 2015).
• Pericardial view sensitivity approaches 100% in
penetrating thoracic trauma (Matsushima 2017,
Ball 2009, Rozycki 1999), but cardiac injury can
CALCULATOR REVIEW AUTHORS
Jennie Kim, MD
Department of Surgery
Maimonides Medical Center, Brooklyn, NY
Morgan Schellenberg, MD, MPH
Department of Surgery
Keck School of Medicine of USC, Los Angeles, CA
Kenji Inaba, MD, FRCSC, FACS
Department of Surgery
Keck School of Medicine of USC, Los Angeles, CA
CD1 www.ebmedicine.net
POWERED BY
be missed if there is a concomitant pericardial
laceration allowing decompression into the left
chest (Ball 2009).
• If clinical suspicion for injury persists despite
a negative FAST result, the FAST examination
should be repeated, additional investigations
should be performed, or intervention should
be pursued, depending on the patient’s clinical
condition.
Advice
• Most clinicians use the low-frequency phased
array ultrasonic probe (cardiac probe) to obtain
all windows in the FAST examination.
• Pericardial: Place the probe in the subxiphoid
area and orient it toward the patient's left shoul-
der. Apply downward pressure to look under the
costal margin and toward the heart. The heart
and pericardium will come into view, allowing
inspection for hemopericardium and ultrasound
findings of cardiac tamponade.
• Right upper quadrant: Place the probe in the
right anterior to midaxillary line (between the
eleventh and twelfth ribs). Visualization of the
hepatorenal recess (Morison pouch) allows
assessment for hemoperitoneum in the right up-
per quadrant. Blood is most likely to accumulate
here if hemoperitoneum is present.
• Left upper quadrant: Apply the transducer
firmly onto the skin in the left posterior axillary
line (between the ninth and tenth ribs) to visual-
ize the splenorenal and subphrenic spaces.
• In practice, it is important to remember that
the right and left upper quadrant views are
often more posterior than anticipated. It can
 be helpful to bring the probe all the way down
to the stretcher in order to best visualize these
windows.
• Suprapubic: Place the transducer superior to
the pubic symphysis and fan the probe inferiorly
to visualize the bladder.
Critical Actions
It can be useful to repeat the FAST examination
while preparing to perform diagnostic peritoneal
aspiration, in order to quickly reassess unstable
patients with blunt abdominal trauma who have
an initial negative FAST result. Intra-abdominal
hemorrhage may not be significant enough on initial
presentation to give a positive FAST result.
Clinicians should be cautious if the pericardial
FAST examination is negative in a patient with
penetrating thoracic trauma, especially if the
patient is unstable. Cardiac injuries can decompress
through the injured pericardium, most commonly
into the left hemithorax, resulting in a negative
pericardial FAST result (Ball 2009). Unstable patients
with this mechanism of injury and a negative FAST
finding should undergo a chest x-ray. If the x-ray
reveals a hemothorax, a chest tube must be placed.
Ongoing or high-volume chest tube output in this
clinical context may be from cardiac injury.
Evidence Appraisal
The original study conducted by Rozycki et al in
1993 utilized the FAST examination in patients aged
≥ 16 years who had blunt or penetrating trauma
(n = 476). When compared to the gold standards of
computed tomography scan, diagnostic peritoneal
lavage, and/or operative findings, FAST had a
sensitivity of 79% and a specificity of 96%. FAST

Why to Use
The FAST examination is a rapid, noninvasive, and repeatable imaging modality that can guide a surgeon in
the decision to operate. It is performed in the trauma bay and does not require patient transport out of the
emergency department, which would be risky for an unstable patient.

When to Use
• The FAST examination should be used liberally in the evaluation of trauma patients.
• It is especially useful in patients with penetrating thoracic trauma and in unstable patients after blunt
abdominal trauma.

Next Steps
FAST examination results alone should not determine the decision to operate. However, a FAST
examination can be a helpful adjunct for clinical decision-making, particularly in an unstable blunt trauma
patient, in order to rapidly assess the chest and abdomen for potential causes of hypotension.

Suggested Management
The clinician must consider additional clinical information, including hemodynamic stability and clinical
suspicion for injury.
Pericardial FAST (penetrating thoracic trauma)
• Positive: Emergent surgical intervention is recommended. A median sternotomy is preferred if the pa-
tient is stable; otherwise, use a left anterolateral thoracotomy.
• Equivocal: Pericardial window or formal TTE is recommended.
• Negative: Close clinical monitoring or discharge are recommended, according to the clinical suspicion
for injury.
Abdominal FAST (blunt abdominal trauma)
• Positive: In the unstable patient, emergent exploratory laparotomy is recommended. In the stable pa-
tient, cross-sectional imaging (CT scan) is recommended.
• Equivocal: In the unstable patient, DPA is recommended. In the stable patient, cross-sectional imaging
(CT scan) is recommended.
• Negative: In the unstable patient, DPA is recommended if there is clinical suspicion for intra-abdominal
bleeding. In the stable patient, CT scan, close clinical monitoring, or discharge are recommended, ac-
cording to the clinical suspicion for injury.

Abbreviations: CT, computed tomography; DPA, diagnostic peritoneal aspiration; TTE, transthoracic echocardiography.

Emergency Medicine Practice • March 2019 CD2 Copyright © 2019 EB Medicine. All rights reserved.
was further validated in a much larger study • Rozycki GS, Ochsner MG, Schmidt JA, et al. A prospective
(n = 1540) by the same group in 1998. The study of surgeon-performed ultrasound as the primary
validation study showed that FAST is most sensitive adjuvant modality for injured patient assessment. J Trauma.
and specific in patients with penetrating precordial 1995;39(3):492-498.
wounds (100% sensitivity, 99% specificity) and in https://www.ncbi.nlm.nih.gov/pubmed/7473914
hypotensive patients with blunt abdominal trauma • Rozycki GS, Feliciano DV, Ochsner MG, et al. The role of
(100% sensitivity, 100% specificity). Rozycki et al ultrasound in patients with possible penetrating cardiac
(1998) concluded that the accuracy of FAST in these wounds: a prospective multicenter study. J Trauma.
clinical scenarios justified surgical intervention 1999;46(4):543-551.
on the basis of the FAST examination findings in https://www.ncbi.nlm.nih.gov/pubmed/10217216
these trauma patients. With the application of Other References
FAST outside of study protocols by nonexperts • Richards JR, McGahan JP. Focused Assessment with
and nonradiologists, the contemporary diagnostic Sonography in Trauma (FAST) in 2017: what radiologists can
yield of FAST ranges more broadly. Recent studies learn. Radiology. 2017;283(1):30-48.
indicate a sensitivity of 22% to 98% for FAST in DOI: https://doi.org/10.1148/radiol.2017160107
• Ball CG, Williams BH, Wyrzykowski AD, et al. A caveat to
the detection of hemoperitoneum (Richards 2017,
the performance of pericardial ultrasound in patients with
Carter 2015).
penetrating cardiac wounds. J Trauma. 2009;67(5):1123-1124.
More recently, thoracic views have been added
DOI: https://doi.org/10.1097/TA.0b013e3181b16f30
to the FAST examination, which is then termed • Nandipati KC, Allamaneni S, Kakarla R, et al. Extended
eFAST. These windows assess the chest bilaterally Focused Assessment with Sonography for Trauma (EFAST) in
for pneumothoraces and hemothoraces. In some the diagnosis of pneumothorax: experience at a community
series, the reported sensitivities of eFAST (86%- based level I trauma center. Injury. 2011;42(5):511-514.
100%) are superior to the sensitivities of chest x-ray DOI: https://doi.org/10.1016/j.injury.2010.01.105
(27%-83%) in the detection of pneumothoraces • Governatori NJ, Saul T, Siadecki SD, et al. Ultrasound in the
(Governatori 2015, Nandipati 2011, Wilkerson 2010). evaluation of penetrating thoraco-abdominal trauma: a review
of the literature. Med Ultrason. 2015;17(4):528-534.
Use the Calculator Now DOI: https://doi.org/10.11152/mu.2013.2066.174.evp
Click here to access the calculator. • Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound
and supine anteroposterior chest radiographs for the
Calculator Creator identification of pneumothorax after blunt trauma. Acad
Emerg Med. 2010;17(1):11-17.
Grace Rozycki, MD, MBA
DOI: https://doi.org/10.1111/j.1553-2712.2009.00628.x
Click here to read more about Dr. Rozycki.
• Matsushima K, Khor D, Berona K, et al. Double jeopardy
in penetrating trauma: get FAST, get it right. World J Surg.
References 2018;42(2):99-106.
Original/Primary Reference DOI: https://doi.org/10.1007/s00268-017-4162-9
• Rozycki GS, Ochsner MG, Jaffin JH, et al. Prospective • Carter JW, Falco MH, Chopko MS, et al. Do we really rely
evaluation of surgeons' use of ultrasound in the evaluation of on FAST for decision-making in the management of blunt
trauma patients. J Trauma. 1993;34(4):516-526. abdominal trauma? Injury. 2015;26(5):817-821.
https://www.ncbi.nlm.nih.gov/pubmed/8487337 DOI: https://doi.org/10.1016/j.injury.2014.11.023
Validation References
• Rozycki GS, Ballard RB, Feliciano DV, et al. Surgeon-performed Copyright © MDCalc • Reprinted with permission.
ultrasound for the assessment of truncal injuries: lessons
learned from 1540 patients. Ann Surg. 1998;228(4):557-567.
https://www.ncbi.nlm.nih.gov/pubmed/9790345

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Emergency Medicine Practice (ISSN Print: 1524-1971, ISSN Online: 1559-3908, ACID-FREE) is published monthly (12 times per year) by EB Medicine (5550 Triangle Parkway, Suite
150, Norcross, GA 30092). Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is
intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used
for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Copyright © 2019 EB Medicine. All rights
reserved. No part of this publication may be reproduced in any format without written consent of EB Medicine. This publication is intended for the use of the individual subscriber only
and may not be copied in whole or part or redistributed in any way without the publisher’s prior written permission.

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