Quick Algorithms

All suspected BCI → ECG

Normal ECG → check troponin at ~8 h.
- Both normal → discharge if otherwise safe.
- Troponin ↑ → 24 h telemetry.
Abnormal ECG → 24 h telemetry ± echo if unstable/new persistent arrhythmia.
Shock/arrhythmia/tamponade at any time → echo/TEE + definitive intervention.

Definition: Myocardial/pericardial/valvular injury from blunt thoracic trauma ranging from silent contusion to tamponade, valvular/septal rupture, coronary injury, and cardiac rupture. High index of suspicion in any significant anterior chest trauma (RTC, pedestrian struck, fall, crush).

Who to screen:
Any patient with significant blunt trauma to the anterior chest. Sternal fracture alone is not a predictor.

Screening tests:

12-lead ECG for all suspected BCI on arrival.
Troponin (cTnI or cTnT) supports rule-out when combined with ECG. Normal ECG + normal troponin effectively rules out clinically significant BCI in stable patients. CK/CK-MB adds no value.

Who needs imaging?:

Echo (TTE → TEE if suboptimal) for hemodynamic instability, persistent/new arrhythmia, or unexplained hypotension. Not a routine screen in well patients.
CT/MRI: May help distinguish ACS from BCI when ECG/troponin/echo are equivocal; use selectively with cardiology input.

Timing nuance: Some clinically significant BCIs declare late; a subset manifest after 6–22 h—hence observation pathways below.

Remember:

Sternal fracture ≠ BCI. Manage by ECG/troponin, not fracture alone.
Normal ECG alone is not enough; pair it with troponin to safely rule out.

1. Rapid Clinical Assessment & Stabilization
ABCDE approach

Focus: tamponade, cardiogenic shock, malignant dysrhythmias. Use eFAST early.
If tamponade with shock/near-arrest: Resuscitative thoracotomy for decompression and hemorrhage control; pericardiocentesis is a bridging maneuver only when surgery is delayed.
Airway/ventilation: Avoid hyper/hypoxia; correct acidosis and electrolytes (K⁺/Mg²⁺). Sinus tachycardia is often physiologic, treat the cause.
Analgesia and gentle fluids; vasopressors/inotropes only for cardiogenic physiology after volume optimization. Consider invasive monitoring in shock.
ALS-consistent arrest care and treat reversible causes; defibrillate VT/VF promptly.

2. Admitted Patient Monitoring (who, where, how long)

Admit to monitored/telemetry bed (typically 24 h) if ANY:

Abnormal ECG (new ST/T changes, blocks, ectopy) or elevated troponin, even if stable.
Persistent sinus tachycardia unexplained by pain/hypovolemia, or if admitted for other injuries.
Hemodynamic instability or arrhythmia → echo and higher-acuity monitoring.

3. Condition-Directed Management

Dysrhythmias

Treat per ACLS: vagal maneuvers/AV-nodal agents for SVT; rate/rhythm control for AF; immediate defib for unstable VT/VF. Beta-blockade can be effective in selected cases; correct hypoxia, acidosis, K⁺/Mg²⁺ first. Consider pacing only when clinically indicated.

Pericardial effusion/tamponade

Effusion alone ≠ thoracotomy, but tamponade physiology demands timely drainage (surgical preferred; pericardiocentesis as bridge with US guidance).

Cardiogenic shock

Volume optimization, vasopressors/inotropes as indicated; consider mechanical support (IABP/Impella/ECMO) in select cases with specialist input.

Valve/Septal/Coronary injury

New murmur, acute heart failure, or ischemic ECG → urgent echo and cardiac surgery/interventional cardiology consult; coronary dissection/occlusion requires revascularization.

Antithrombotics

If true ACS/coronary injury is suspected, involve cardiology; anticoagulation/antiplatelets must balance bleeding from concomitant trauma. (Use CT-coronary/echo + specialist review to adjudicate.)

4. Disposition & Observation Pathway

Eligible for ED discharge (no other admission needs):

ECG normal and troponin normal at ~8 h post-injury, vitals stable, pain controlled, reliable follow-up.

Minimum 24 h telemetry (ward/HDU/ICU per physiology):

Abnormal ECG or elevated troponin, persistent tachyarrhythmia, syncope, hemodynamic lability, or echo abnormalities.

Sternal fracture (isolated) with normal ECG & troponin:

No telemetry needed solely for the fracture. Discharge/observe based on pain/respiratory status and other injuries.

Follow-up:

Outpatient review if ECG/troponin ever abnormal or if symptoms (palpitations, syncope, chest pain) recur. Most wall-motion changes normalize by 6 months; long-term adverse remodeling is uncommon but documented—arrange echo follow-up when indicated.

References:

Biffl, W. L., Fawley, J. A., & Mohan, R. C. (2024). Diagnosis and management of blunt cardiac injury: What you need to know. Journal of Trauma and Acute Care Surgery, 96(5), 685–693. https://doi.org/10.1097/TA.0000000000004216 PubMed
Clancy, K., Velopulos, C., Bilaniuk, J. W., Collier, B., Crowley, W., Kurek, S., Lui, F., Nayduch, D., Sangosanya, A., Tucker, B., & Haut, E. R. (2012). Screening for blunt cardiac injury: An Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery, 73(5 Suppl 4), S301–S306. https://doi.org/10.1097/TA.0b013e318270193a PubMed
Kyriazidis, I. P., Jakob, D. A., Hernández Vargas, J. A., Franco, O. H., Degiannis, E., Dorn, P., Pouwels, S., Patel, B., Johnson, I., Houdlen, C. J., Whiteley, G. S., Head, M., Lala, A., Mumtaz, H., Soler, J. A., Mellor, K., Rawaf, D., Ahmed, A. R., Ahmad, S. J. S., & Exadaktylos, A. (2023). Accuracy of diagnostic tests in cardiac injury after blunt chest trauma: A systematic review and meta-analysis. World Journal of Emergency Surgery, 18, 36. https://doi.org/10.1186/s13017-023-00504-9 BioMed Central
Resuscitation Council UK. (2021). Adult advanced life support guidelines. https://www.resus.org.uk/library/2021-resuscitation-guidelines/adult-advanced-life-support-guidelines resus.org.uk
Salim, A., Velmahos, G. C., Jindal, A., Chan, L., Vassiliu, P., Belzberg, H., Asensio, J., & Demetriades, D. (2001). Clinically significant blunt cardiac trauma: Role of serum troponin levels combined with electrocardiographic findings. Journal of Trauma, 50(2), 237–243. https://doi.org/10.1097/00005373-200102000-00008 PubMed
Singh, S., Heard, M., Pester, J. M., & Angus, L. D. (2024, July 17). Blunt cardiac injury. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532267/ NCBI
Velmahos, G. C., Karaiskakis, M., Salim, A., Toutouzas, K. G., Murray, J., Asensio, J., & Demetriades, D. (2003). Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. Journal of Trauma, 54(1), 45–50. https://doi.org/10.1097/01.TA.0000046315.73441.D8