Trauma represents the leading cause of death in males younger than 40 years in the United States. Cardiothoracic injuries are a primary or contributing factor in up to 75% of all traumatic deaths. Cardiac trauma occurs most commonly in the setting of motor vehicle accidents, interpersonal violence, cardiopulmonary resuscitation (CPR), falls from great heights, as well as sporting and industrial accidents. Cardiac trauma can be easily overlooked in the presence of distracting injuries, as it can occur in the absence of chest pain or visible wounds. Emergency department physicians lead the initial management, while contemporary trauma teams are typically led by surgical subspecialists. However, cardiologists play an important consultative role in the diagnosis and management of cardiac trauma.

A. Cardiac trauma is divided into blunt trauma (i.e., motor vehicle accidents and falls) and penetrating trauma (i.e., primarily, knife and gunshot wounds).

B. As many as 50% of people with cardiac injuries die in the field, but advances in diagnostic testing and surgical techniques have improved the prognosis of patients who reach emergency centers alive. Definitive management requires rapid mobilization of the surgical team and transport to the operating room.

C. Initial attention is focused on the airway, breathing, and circulation, and the primary survey is performed according to the published Advanced Trauma Life Support (ATLS) guidelines. The cardiac physical examination should assess vital signs, peripheral pulses, murmurs, signs of heart failure, distended neck veins, and the presence of pulsus paradoxus. Routine laboratory evaluation should include cardiac
biomarkers, and a portable chest radiograph should be performed rapidly. Transthoracic echocardiography (TTE) at the bedside is the preferred modality for the initial assessment of cardiac trauma. Focused Assessment with Sonography for Trauma is a widely applied technique using bedside ultrasound to rapidly assess blunt trauma at multiple body sites, including the heart. An electrocardiogram (ECG) is indicated to evaluate for suspected coronary dissection or traumatic coronary thrombosis. The role for cardiac computerized tomography (CT) using intravenous contrast is expanding, and it remains the diagnostic study of choice to evaluate suspected trauma and/or dissection of the aorta and great vessels, along with transesophageal echocardiography (TEE).

A. Blunt cardiac trauma generally occurs in the setting of motor vehicle accidents, but it may also be related to falls, blows from blunt objects, or CPR.

B. Blunt trauma may injure the pericardium, myocardium, valves or subvalvular apparatus, coronary arteries, or the great vessels. The clinical presentation is generally one of tamponade or hemorrhage, depending on whether the pericardium is intact. Although hypotension and tachycardia are seen in both scenarios, tamponade is suggested by elevated neck veins, muffled heart sounds, and pulsus paradoxus and is easily confirmed by a bedside echocardiogram. A new murmur coupled with signs of heart failure should raise clinical suspicion for injury to the valves or subvalvular apparatus.