Cardiac Trauma

1. Lateef Wani M, Ahangar AG, Wani SN, Irshad I, Ul-Hassan N: Penetrating cardiac injury: a review. Trauma Mon 17: 230, 2012. [PMID: 24829887] 2. Bellister SA, Dennis BM, Guillamondegui OD: Blunt and penetrating cardiac trauma. Surg Clin N Am 97: 1065, 2017. [PMID: 28958358] 3. Bock JS, Benitez RM: Blunt cardiac injury. Cardiol Clin 30: 545, 2012. [PMID: 23102031] 4. Liu P, Ren S, Qian S, Wang F: Multiple cardiac perforations following radiofrequency catheter ablation: case report and literature reviews. Ann Thorac Cardiovasc Surg 18: 370, 2012. [PMID: 22293306] 5. Schultz JM, Trunkey DD: Blunt cardiac injury. Crit Care Clin 20: 57, 2004. [PMID: 14979329] 6. Marcolini EG, Keegan J: Blunt cardiac injury. Emerg Med Clin Am 33: 519, 2015. [PMID: 26226863] 7. Morse BC, Mina MJ, Carr JS, et al: Penetrating cardiac injuries: a 36-year perspective at an urban, level I trauma center. J Trauma Acute Care Surg 81: 623, 2016. [PMID: 27389136] 8. Asensio JA, Berne JD, Demetriades D, et al: One hundred five penetrating cardiac injuries: a 2-year prospective evaluation. J Trauma 44: 1073, 1998. [PMID: 9637165] 9. Campbell NC, Thomson SR, Muckart DJ, et al: Review of 1198 cases of penetrating cardiac trauma. Br J Surg 84: 1737, 1997. [PMID: 9448629] 10. Talving P, Demetriades D: Cardiac trauma during teenage years. Pediatr Clin North Am 61: 111, 2014. [PMID: 24267461] 11. Gunay C, Cingoz F, Kuralay E, et al: Surgical challenges for urgent approach in penetrating heart injuries. Heart Surg Forum 10: E473, 2007. [PMID: 18187381] 12. Reddy D, Muckart DJ: Holes in the heart: an atlas of intracardiac injuries following penetrating trauma. Interact Cardiovasc Thorac Surg 19: 56, 2014. [PMID: 24659550] 13. Elie MC: Blunt cardiac injury. Mt Sinai J Med 73: 542, 2006. [PMID: 16568196] 14. Pasquale M, Fabian TC: Practice management guidelines for trauma from the Eastern Association for the Surgery of Trauma. J Trauma 44: 941, 1998. [PMID: 9637148] 15. Bansal MK, Maraj S, Chewaprooug D, Amanullah A: Myocardial contusion injury: redefining the diagnostic algorithm. Emerg Med J 22: 465, 2005. [PMID: 15983078] 16. Khorsandi M, Skouras C, Shah R: Is there any role for resuscitative emergency department thoracotomy in blunt trauma? Interact Cardiovasc Thorac Surg 16: 509, 2013. [PMID: 23275145] 17. Asaid R, Boyce G, Atkinson N: Endovascular repair of acute traumatic aortic injury: experience of a level-1 trauma center. Ann Vasc Surg 28: 1391, 2014. [PMID: 24530575] 18. Rodriguez RM, Anglin D, Langdorf MI, et al: NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA Surg 148: 940, 2013. [PMID: 23925583] 19. Jhunjhunwala R, Mina MJ, Roger EI, et al: Reassessing the cardiac box: a comprehensive evaluation of the relationship between thoracic gunshot wounds and cardiac injury. J Trauma Acute Care Surg 83: 349, 2017. [PMID: 28422918] 20. Desouza KA, Desouza NA, Pinto RM, et al: Transthoracic echocardiogram is a useful tool in the hemodynamic assessment of patients with chest trauma. Am J Med Sci 34: 340, 2011. [PMID: 21289503] 21. Chen MY, Miller PR, McLaughlin CA, Kortesis BG, Kavanagh PV, Dyer RB: The trend of using computed tomography in the detection of acute thoracic aortic and branch vessel injury after blunt thoracic trauma: single-center experience over 13 years. J Trauma 56: 783, 2004. [PMID: 15187742] 22. Tyburski JG, Astra L, Wilson RF, et al: Factors affecting prognosis with penetrating wounds of the heart. J Trauma 48: 587, 2000. [PMID: 10780588] 23. Molina EJ, Gaughan JP, Kulp H, et al: Outcomes after emergency department thoracotomy for penetrating cardiac injuries: a new perspective. Interact Cardiovasc Thorac Surg 7: 845, 2008. [PMID: 18653499] 24. Rhee PM, Foy H, Kaufmann C, et al: Penetrating cardiac injuries: a population based study. J Trauma 45: 366, 1998. [PMID: 9715197] 25. Mina MJ, Jhunjhunwala R, Gelbard RB, et al: Factors affecting mortality after penetrating cardiac injuries: 10-year experience at urban level I trauma center. Am J Surg 213: 1109, 2017. [PMID: 27871682] 26. Pauze DR, Pauze DK: Emergency management of blunt chest trauma in children: an evidence-based approach. Pediatr Emerg Med Pract 10: 1, 2013. [PMID: 24432505] 27. El-Menyar A, Al Thani H, Zarour A, Latifi R: Understanding traumatic blunt cardiac injury. Ann Card Anaesth 15: 287, 2012. [PMID: 23041686] 28. Namai A, Sakurai M, Fujiwara H: Five cases of blunt traumatic cardiac rupture: success and failure in surgical management. Gen Thorac Cardiovsc Surg 55: 200, 2007. [PMID: 17554994] 29. Ueda S, Ito Y, Konnai T, Suzuki S, Isogami K: Delayed cardiac rupture occurring two months after blunt chest trauma. Gen Thorac Cardiovasc Surg 59: 45, 2011. [PMID: 21225401] 30. Kanchan T, Menezes RG, Acharya PB, Monteiro FN: Blunt trauma to the chest: a case of delayed cardiac rupture. J Forensic Leg Med 19: 46, 2012. [PMID: 22152449] 31. Kikuchi C, Motohashi S, Takahashi Y, Nakazawa S, Kanazawa H: A successful treatment for concomitant injury of the coronary artery and tricuspid valve after blunt chest trauma. Gen Thorac Cardiovasc Surg 63: 616, 2015. [PMID: 24043608] 32. Sun X, Hong J, Lowery R, et al: Ascending aortic injuries following blunt trauma. J Card Surg 28: 749, 2013. [PMID: 24224744] 33. Harada H, Honma Y, Hachiro Y, Mawatari T, Abe T: Traumatic coronary artery dissection. Ann Thorac Surg 74: 236, 2002. [PMID: 12118767] 34. Velmahos GC, Tatevossian R, Demetriades D: The “seat belt mark” sign: a call for increased vigilance among physicians treating victims of motor vehicle accidents. Am Surg 65: 181, 1999. [PMID: 9926756] 35. Bernardin B, Troquet JM: Initial management and resuscitation of severe chest trauma. Emerg Med Clin North Am 30: 377, 2012. [PMID: 22487111] 36. Brown J, Grover FL: Trauma to the heart. Chest Surg Clin N Am 7: 325, 1997. [PMID: 9156295] 37. Kong VY, Satorius B, Clarke DL: The selective conservative management of penetrating thoracic trauma is still appropriate in the current era. Injury 46: 49, 2015. [PMID: 25102807] 38. Bakovic M, Petrovecki V, Strinovic D, Mayer D: Shot through the heart-firepower and potential lethality of air weapons. J Forensic Sci 59: 1658, 2014. [PMID: 24846815] 39. Mehrota D, Kejriwal NK: Tricuspid valve repair for torrential tricuspid regurgitation after permanent pacemaker lead extraction. Tex Heart Inst J 38: 305, 2011. [PMID: 21720480] 40. Seamon MJ, Haut, ER, Van Arendonk K, et al: Emergency department thoracotomy. J Trauma Acute Care Surg 79: 159, 2015. [PMID: 26091330] 41. Burlew CC, Moore EE, Moore FA, et al: Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg 73: 1359, 2012. [PMID: 23188227] 42. Lockey D, Crewdsen K, Davies GE: Traumatic cardiac arrest: who are the survivors? Ann Emerg Med 48: 240, 2006. [PMID: 17420084] 43. Wise D, Davies GE, Coats T, Lockey D, et al: Emergency thoracotomy: “how to do it.” Emerg Med J 22: 22, 2005. [PMID: 15611536] 44. Coats TJ, Keogh S, Clark H, Neal M: Prehospital resuscitative thoracotomy for cardiac arrest after penetrating trauma: rational and case series. J Trauma 50: 670, 2001. [PMID: 11303162] 45. Shakur H, Roberts I, Bautista R, et al: Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 376: 23, 2010. [PMID: 21702233] 46. Morrison JJ, Dubose JJ, Rasmussen TE, et al: Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg 147: 113, 2012. [PMID: 22006852] 47. Ker K, Edwards P, Perel P, et al: Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ 344: e3054, 2012. [PMID: 22611164] 48. Spencer RJ, Sugumar H, Jones E, Farouque O: Commotio cordis: a case of ventricular fibrillation caused by a cricket ball strike to the chest. Lancet 383: 1358, 2014. [PMID: 24725579] 49. El-Chami MF, Nicholson W, Helmy T: Blunt cardiac trauma. J Emerg Med 35: 127, 2008. [PMID: 17976783] 50. Pasquier M, Sierro C, Yersin B, et al: Traumatic mitral valve injury after blunt chest trauma: a case report and review of the literature. J Trauma 68: 243, 2010. [PMID: 20065781] 51. Shamsi F, Tai JM, Bokhari S: Coronary artery dissection after blunt chest trauma. BMJ Case Rep September 22, 2014. [PMID: 25246456] 52. Plautz CU, Perron AD, Brady WJ: Electorcardiographic ST segment elevation in the trauma patient: acute myocardial infarction vs myocardial contusion. Am J Emerg Med 105: 141, 2005. [PMID: 16032622] 53. Conn A: Chest trauma, in Legome E, Shockley LW (eds): Trauma: A Comprehensive Emergency Medicine Approach. New York: Cambridge University Press; 2011:190. 54. Asensio JA, Garcia-Nunez LM, Patrizio P: Trauma to the heart, in Feliciano D, Mattox K, Moore E (eds): Trauma. New York: McGraw Hill Medical; 2008:569. 55. Mirvis SE: Thoracic vascular injury. Radiol Clin North Am 44: 181, 2006. [PMID: 16500202] 56. Velmahos GC, Karaiskakis M, Salim A, et al: Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma 54: 45, 2003. [PMID: 12544898] 57. Salim A, Velmahos GC, Jindal A, et al: Clinically significant blunt cardiac trauma: role of serum troponin levels combined with electrocardiographic findings. J Trauma 50: 237, 2001. [PMID: 11242287] 58. Skinner DL, Laing GL, Rodseth RN, Ryan L, Hardcastle TC, Muckart DJ: Blunt cardiac injury in critically ill trauma patients: a single centre experience. Injury 46: 66, 2014. [PMID: 25264354] 59. Fanari Z, Hadid M, Hammami S, Qureshi WA: Traumatic myocardial infarction in a young athletic patient after a football game. Del Med J 86: 213, 2014. [PMID: 25244725] 60. Jackson L, Steward A: Best evidence topic report. Use of troponin for the diagnosis of myocardial contusion after blunt chest trauma. Emerg Med J 22: 193, 2005. [PMID: 15735270] 61.


Introduction 1.History of cardiac trauma
The treatment of trauma to the heart has been written about since 3000 BC and had an inauspicious beginning.Until the late 19 th century, the commonly held belief agreed with Boerhaave's sentiments that, "all penetrating cardiac trauma is fatal."Theodore Billroth warned, "The surgeon who should attempt to suture a wound of the heart would lose the respect of his colleagues."Paget believed that "surgery of the heart has probably reached the limits set by nature to all surgery: no new method of discovery can overcome the natural difficulties that attend a wound of the heart."However, reports of successful treatment of cardiac injuries began to surface toward the beginning of the 20 th century.Like many surgical advances, times of war brought about new innovations and techniques for treating injuries.
Around the time of World War II, it was recognized that cardiac tamponade could be successfully managed by pericardiocentesis.With the advent of cardiopulmonary bypass by Gibbon in 1953, repair of more complex injuries became possible.This ushered in the modern era of treating injuries to the heart.Diagnosis of cardiac injury and tamponade has also been facilitated by portable ultrasound becoming the standard of care in the evaluation of trauma patients.The focused assessment with sonography for trauma (FAST) scan allows for simple, quick, and non-invasive assessment and recognition of cardiac trauma [1].
Cardiac trauma, especially penetrating injuries to the heart, still carries a very high mortality, but certainly is no longer considered uniformly fatal and attempt at repair is now the standard of care in patients presenting with signs of life upon arrival to the hospital [2,3].

Initial assessment and general assessment
The initial care of the trauma patient with cardiac injuries does not vary from standard Advanced Trauma Life Support (ATLS) protocols.The primary priority is ensuring the patency of the airway and establishing adequate oxygenation and ventilation.This may include tube thoracostomy for drainage of hemothorax from the pleural space to allow re-expansion of the lung.Subsequently, the circulatory system is assessed.Priority is given to establishing intravenous access for the administration of crystalloid and/or blood products.If cardiac tamponade is suspected, this should be confirmed with sonographic confirmation of hemopericardium and/or right ventricular collapse during diastole [4].If tamponade physiology is present, treatment for immediate drainage of the pericardial space should be initiated.This can be accomplished percutaneously by pericardiocentesis or via open pericardial window.
The treatment algorithm for cardiac injured patients branches at this point depending on the mechanism of injury and hemodynamic status.As is the standard in all trauma care, cardiac injuries are categorized as either blunt or penetrating and we will explore their assessment and treatment separately.

Penetrating trauma
Penetrating trauma to the heart most frequently occur with trauma to the anterior chest, but should also be suspected with wounds to the upper abdomen, chest, back, and neck [5].Of the patients that do present to the hospital, the majority of the injuries are to the low pressure, anteriorly located right side of the heart (Table 1) [6].Survival following penetrating trauma is often dependent on the state of the pericardial wound.[7] When the pericardial wound is open and blood is able to flow freely into the pleural space, the patient can often be supported with fluid resuscitation and chest tube thoracostomy.Persistent drainage from the thoracostomy tube should warn of possible cardiac injury and surgical exploration is indicated.Conversely, if the blood is retained in the pericardial space, cardiac tamponade and physiology will ensue if not drained immediately.The protocol for treatment of patients with penetrating cardiac trauma can be further subdivided based upon the patient's vital signs upon presentation to the hospital (Figure 1).Management of the stable patient (systolic blood pressure greater than 90 mm Hg) allows for a more complete evaluation including chest x-ray and echocardiography.Unstable patients (systolic blood pressure less than 90 mm Hg) are taken directly to the operating room for exploration while patients with loss of vitals during transport or upon presentation to the hospital are treated with Emergency Department thoracotomy.If the diagnosis of penetrating cardiac injury is suspected but not confirmed, a subxiphoid pericardial window should be performed.Surgeons should be prepared to do a median sternotomy if an injury is identified in order to definitely address the wound.Upon opening the pericardial sac, any blood or fluid should be evacuated to allow the heart to properly fill and contract.The surgeon's finger can be used to apply pressure and temporarily control hemorrhage while further exposure is gained.This will also allow for replacement of blood volume and restoration of tissue perfusion.
Repair of the myocardium should be done with interrupted sutures utilizing pledgets and performed in a horizontal mattress fashion [7,8].Injuries to small coronary arteries can be treated with simple ligation.Larger coronary arteries require either direct repair or bypass and the operating room should be capable of cardiopulmonary bypass (CPB).[7] Intracardiac injuries require CPB to be definitively addressed.
Whatever injury is encountered and method of repair utilized, the operative principles are universal: relieve tamponade, stop the bleeding, and restore circulating volume.[8]

Iatrogenic injuries
Another form of penetrating cardiac injury that has increased in the modern era is iatrogenic injuries.As the fields of interventional and electrophysiology cardiology continue to increase the number of percutaneous procedures performed, there is a concomitant increase in iatrogenic injuries to the heart.Pacemaker and ICD placement, ASD occlusion devices, coronary catheterization, pericardiocentesis, and even central line placement can cause cardiac trauma.Usually the treatment is observational, but sometimes intervention is necessary.Fortunately these are rare complications but the incidence of iatrogenic injury has been reported as high as 6% for certain radiofrequency ablation procedures.[9] Awareness and prompt recognition of an injury are essential to successful treatment.

Cardiac fistulas
Although hemorrhage and tamponade are the most common injuries seen in penetrating cardiac trauma, cardiac fistulas are another uncommon yet dramatic complication from cardiac trauma (including iatrogenic injuries).Fistulous connections can occur between coronary arteries, aorta, and directly with the cardiac chambers.Patients, if symptomatic, usually present with congestive heart failure and surgical repair is usually required.[10,11].Presentation is variable from acutely after the injury to decades post-injury.Echocardiography and coronary angiography are the cornerstones of diagnosis and necessary to plan surgical repair.Blunt cardiac injury (BCI) is a spectrum of traumatic heart diseases with severity that can range from myocardial contusion and EKG changes to septal rupture and death.Earlier in the century, cardiac contusion or concussion were terms used to diagnose cardiac changes from blunt thoracic trauma.More recently, BCI is the term used to better incorporate and classify the myriad of cardiac injuries that result from blunt trauma.BCI is estimated to occur in 20% of motor vehicle collisions and in greater than 75% of thoracic blunt injuries independent of the mechanism.The primary mechanism of injury to the heart is from high-speed motor vehicle collision, but any injury that applies force in the form of kinetic energy to the chest wall and heart can result in a form of BCI.The following mechanisms of injury may result in BCI: direct precordial impact, a crush injury between the sternum and spine, a deceleration injury causing injury from the fixation points of the aorta and vena cava, a hydraulic effect from an intraabdominal injury that sends force to the great vessels and heart, or a crush injury [12].

Principles and Practice of Cardiothoracic Surgery
Since blunt cardiac injury is a spectrum of injuries to the heart, a classification scheme was developed to allow clinicians to categorize the types of injury based on outcomes and treatment options.These categories are as follows: 1) BCI with free wall rupture, 2) BCI with septal rupture, 3) BCI with coronary artery rupture, 4) BCI with cardiac failure, 5) BCI with complex arrhythmias, and 6) BCI with minor ECG or cardiac enzyme abnormalities.The American Association for the Surgery of Trauma (AAST) has also published a cardiac injury scale (Table 2) that may help to codify injury for diagnosis and research.Injuries sustained with blunt cardiac injury (BCI) include contusion, ruptures, septal defects, valvular injuries, and coronary artery injuries.Table 3 lists each of these types and the incidence seen from both autopsy and clinical series.Contusion is the most common type of injury with left atrial chamber rupture being least common.Injuries can often occur concomitantly; approximately 20% of injuries with chamber rupture will have another chamber involved.The right heart is the most commonly injured as it is closest to the sternum which is impacted anteriorly by the steering wheel in motor vehicle collisions.Besides having concomitant cardiac injuries, the force needed to cause a BCI will often cause associated injuries such as chest pain, rib fractures, pulmonary contusions, and solid organ injuries; the most common associated injuries that occur with BCI are listed in Table 5.

Diagnosis
The best test for diagnosing blunt cardiac injury has been debated for many years.Cardiac enzymes, radionuclide scans, EKG, cardiac ultrasound and continuous monitoring are some of the major methods that have been investigated.Although cardiac enzymes and radionuclide scans have had many supporters these have not shown reliable predictability in diagnosing blunt cardiac injury and have therefore been left out of the Eastern Association for the Surgery of Trauma (EAST) guidelines (figure 6).Cardiac enzymes, specifically serial troponin measurements are mentioned in the suggested BCI algorithm by Schultz and Trunkey 2004 (figure 7) as an adjunct to increase the negative predictive value of the normal EKG when you have a patient who has either a history of cardiac disease or increased age.EKG has emerged as the primary screening tool for blunt cardiac injury.There are no pathognomonic findings; however, the presence of a new arrhythmia is a sign that workup needs to be escalated.If the EKG is negative in a young hemodynamically stable patient without a history of cardiac disease there is no further need for workup [12].If the EKG is abnormal, and the patient has a history of cardiac disease, increased age or hemodynamic instability then continuous telemetry monitoring for 24-48 hours is recommended.Those with hemodynamic instability require continuous monitoring in a surgical ICU.Any arrhythmia may be detected after BCI including sinus tachycardia, supraventricular arrhythmias, ventricular arrhythmias, any type of heart block, ST-T changes or Q waves [13].
Although, these patients are likely to have had a FAST exam in the emergency room, it is important to figure out who needs a formal echocardiogram.The key indication is hemodynamic instability and a possible diagnosis of blunt cardiac injuiry.Anyone meeting these criteria requires a formal echocardiogram.There has been debate over whether to use transthoracic or transesophageal echocardiography.The recommendations are that the patient receive the first available study method.If transthoracic echocardiography is used and adequate imaging cannot be obtained, then a transesophageal echocardiogram should be initiated immediately.
*Advance one grade for multiple wounds to a single chamber or multiple chamber involvement.

Management
Since blunt cardiac injury describes a spectrum of disease states, the treatment depends on the actual problem.Arrhythmia can be managed medically with the caveat that anticoagulation needs to be used cautiously in trauma patients.Hemopericardium can be seen with or without hypotension or tamponade.If hemopericardium is suspected and the patient is stable a subxiphoid pericardial window can be used to verify the hemopericardium.Once a pericardial window is performed, the surgeon must be prepared to proceed with a median sternotomy.If the patient is hypotensive and tamponade is expected then either a subxiphoid pericardial window or a thoracotomy can be performed.As a rule free wall rupture is more common in the atria than the ventricles and more common on the right than the left.This is thought to be due in part to the position of the heart in the chest.The method of repairing the atria is to grasp each side of the atrial wound, place a vascular clamp across the defect, and sew it closed.The method of repair of the ventricle is to place a finger of the non-dominant hand over the injury occluding the wound and stopping the blood loss.Then pledgeted mattress sutures are placed under the finger in order to approximate the wound without tearing through the injured myocardium.Septal rupture requires the patient to be placed on bypass.Coronary artery injury, valve injury and papillary muscle rupture are all very rare.These entities generally

A. Level I
1.An admission EKG should be performed on all patients in who there is suspected BCI.

C. Level III
1. Elderly patients with known cardiac disease, unstable patients, and those with an abnormal admission EKG can be safely operated on provided they are appropriately monitored.Consideration should be given to placement of a pulmonary artery catheter in such cases.
2. The presence of a sternal fracture does not predict the presence of BCI and, thus, does not necessarily indicate that monitoring should be performed.
3. Neither creatinine phosphokinase with isoenzyme analysis nor measurement of circulating cardiac troponin T are useful in predicting which patients have or will have complications related to BCI.
Screening of Blunt Cardiac Injury.Pasquale, N K and Clark, J. s.l.: The Eastern Association for the Surgry of Trauma, 1998.Outcomes of emergency department thoracotomy for blunt trauma are universally poor.The salvage rate of patients with or without vital signs on arrival to the emergency department is 1%-2% [14].This low survival rate mandates that before an emergency department thoracot-  omy is undertaken both the mechanism of injury and the length or presence of CPR be taken into consideration.

Figure 1 .
Figure 1.Algorithm for the Management of Penetrating Cardiac Injury

Figure 4 .
Figure 4. Various maneuvers used to repair penetrating wounds of the heart.Suturing of cardiac wound underneath the wound-occluding finger (A).Wound sutured (A').Placement of horizontal mattress sutures through the myocardium underneath the cardiac wound-occluding finger and underneath the coronary artery adjacent to the wound (B).Wound sutured (B').Control of atrial bleeding with a vascular clamp (C).(From Symbas PN: Cardiothoracic Trauma.Philadelphia, WB Saunders Co, 1989, p 42. Used by permission.)

Figure 6 .
Figure 6.EAST guidelines for Blunt Cardiac Injury

Figure 7 .
Figure 7. Algorithm for treatment of suspected BCI

Table 1 .
Anatomic Location of Penetrating Cardiac Injuries

Table 2 .
Cardiac Injury Scale

Table 3 .
BCI Patterns of Injury

Table 4 .
Injuries Associated with BCI 1.If the admission EKG is abnormal (arrhythmia, ST changes, ischemia, heart block, unexplained ST), the patient should be admitted for continuous EKG monitoring for 24 to 48 hours.Conversely, if the admission EKG is normal, the risk of having a BCI that requires treatment is insignificant, and the pursuit of diagnosis should be terminated.2. If the patient is hemodynamically unstable, an imaging study (echocardiogram) should be obtained.If an optimal transthoracic echocardiogram cannot be performed, then the patient should have a transesophageal echocardiogram.3. Nuclear medicine studies add little when compared to echocardiography and, thus, are not useful if an echocardiogram has been performed.