HPI: 67 yo M with history DM, HTN, presenting as restrained front seat passenger in MVC. + airbag deployment, no head trauma or LOC. Car was going through an intersection and was hit on the rear drivers side, causing the car to spin out. Pt was ambulatory on scene. Now complaining of non-radiating, severe, mid-chest/sternal pain and left-sided lower rib pain. No SOB, no diaphoresis. No blood thinners.

PE: BP 186/92; HR 86; Temp 98.1 °F (36.7 °C); Resp 14; SpO2 100%

Pertinent positives:

Pulmonary/Chest: Effort normal and breath sounds normal. Sternum exquisitely tender to palpation.

+ TTP over left lower ribs in the mid/anterior axillary line. No bruising or abrasions

Initial workup:

FAST exam: negative (notably, negative for hemopericardium) Portable CXR: no obvious fractures. No PTX. Normal cardiac silhouette. EKG: as pictured, RBBB. No prior EKG for comparison.

Portable CXR: no obvious fractures. No PTX. Normal cardiac silhouette.

ECG: as pictured, RBBB. No prior EKG for comparison.

DDx:

• Sternal fracture
• Rib fractures
• Blunt cardiac injury (BCI) with possible:
• Septal and/or valvular injury MI/coronary artery dissection
• Arrhythmia
• Myocardial dysfunction (diminished contractility)
• Myocardial rupture

Clinical course:

• Patient remained hemodynamically stable
• CT of his chest, abdomen and pelvis: negative
• Labs unremarkable, including negative troponins.
• Patient was placed in observation status overnight, remained hemodynamically stable, chest pain improved with NSAIDs and acetaminophen.
• No changes on repeat ECG. Patient was discharged in stable condition with PCP and cardiology follow up.

Take home points:

• Blunt cardiac injury is poorly characterized, with varied presentations and no clear diagnostic criteria
• Arrythmia such as V-fib and V-tachycardia are the most common lethal sequelae 
• ECG findings in BCI may include: persistent sinus tachycardia or other arrhythmia, new bundle branch block, ST depressions or elevations, or premature atrial/ventricular contractions
• Consult surgery immediately for valve injury, or septal or ventricular wall rupture.
• Consider observation on telemetry monitoring for patients with persistent tachycardia, premature beats, sternal fractures, positive troponins, or evidence of hemodynamic instability