Journal of Forensic and Legal Medicine 52 (2017) 30e34

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Journal of Forensic and Legal Medicine

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m

Cardiac injuries caused by trauma: Review and case reports

Luís Leite a, b, *, Lino Gonçalves a, b, Duarte Nuno Vieira a, c
a
Faculty of Medicine, University of Coimbra, Coimbra, Portugal
b
Department of Cardiology, Coimbra Hospital and University Center, Coimbra, Portugal
c
National Institute of Legal Medicine and Forensic Sciences, Coimbra, Portugal

a r t i c l e i n f o a b s t r a c t

Article history: Assessment of suspected cardiac injuries in a trauma setting is a challenging and time-critical matter,
Received 3 November 2016 with clinical and imaging findings having complementary roles in the formation of an accurate diagnosis.
Received in revised form In this article, we review the supporting literature for the pathophysiology, classification and evaluation
28 April 2017
of cardiac injuries caused by trauma. We also describe 4 cardiac trauma patients seen at a tertiary referral
Accepted 23 August 2017
Available online 24 August 2017
hospital.
© 2017 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords:
Heart injury
Cardiac trauma
Blunt cardiac injury
Penetrating cardiac injury

1. Introduction 2. Blunt cardiac injury

Trauma is a major problem in health care and is the leading
cause of death and disability in those younger than 45 years in
developed countries.1 The reported incidence of cardiac trauma
varies greatly, from 8% in an autopsy study to 76% in a clinical se-
ries; this variance results from a lack of standardised diagnostic
criteria.2 Nevertheless, cardiac trauma is highly lethal, and cardiac
injuries are the second leading cause of death among trauma vic-
tims, after central nervous system injuries.3
The primary site of myocardial injury is the right ventricle (RV)
free wall, due to its anterior location within the thoracic cavity. The
mitral and aortic valves are at greater risk for injury than the
tricuspid and pulmonic valves, as mural pressure is higher on the
left side of the heart.1
Cardiac trauma may be classified, based on the mechanism of
injury, into 2 broad categories: non-penetrating (also referred to as
blunt cardiac injury [BCI]) and penetrating.
An online database query was performed using the PubMed
medical database. All relevant articles from the past 20 years were
reviewed.
BCI refers to damage sustained from blunt thoracic trauma and
is the most common type of cardiac trauma.4 Most BCIs occur with
motor vehicle crashes (50%), followed by pedestrians being struck
by motor vehicles (35%), motorcycle crashes (9%) and falls from a
significant height (6%).1 BCI is often part of multisystem trauma and
is most commonly associated with other thoracic injuries such as
rib fracture, sternal fracture, pneumothorax, haemothorax and lung
contusion. External thoracic injury may not always be present, and
a significant BCI may be seen in the absence of external signs of
thoracic trauma.
BCI is the preferred generic term to refer to a non-penetrating
cardiac injury. The term ‘myocardial concussion’ refers to a subset
of BCI that includes wall-motion abnormalities with no proved
anatomic or cellular injury. In contrast, the term ‘myocardial
contusion’ denotes an anatomic injury or tissue damage demon-
strated at surgery or autopsy, or manifested as increased levels of
myocardial necrosis markers.4
An autopsy based assessment showed that the most common
lethal cardiac injuries caused by blunt trauma were transmural
rupture of cardiac chambers (64%), tears occurring at the venous-
atrial confluence (33%), and coronary-artery dissection (2%).5

2.1. Myocardial rupture

* Corresponding author. Praceta Prof. Mota Pinto, Coimbra 3000-075, Portugal.
E-mail address: luispcleite@gmail.com (L. Leite). Complete free-wall rupture, mostly of the RV, is usually fatal,

http://dx.doi.org/10.1016/j.jflm.2017.08.013
1752-928X/© 2017 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
 L. Leite et al. / Journal of Forensic and Legal Medicine 52 (2017) 30e34
with death occurring at the trauma scene.2 The few patients who
survive present to the emergency department with signs of pro-
found hypotension or pericardial tamponade. A pseudoaneurysm
can develop if the ruptured myocardium is sealed off by the peri-
cardium and an organised thrombus; this pseudoaneurysm has a
high risk of spontaneous rupture.6 A traumatic ventricular septal
defect (VSD), typically within the membranous portion of the
septum, may occur immediately after the traumatic event or within
the first few days after injury; depending on the size of the defect,
there may be little haemodynamic change or it may cause cardio-
genic shock.7
2.2. Tears at the venous-atrial confluence
A distraction-avulsion injury at the venous-atrial confluence is
believed to result from rapid deceleration in the freely mobile
ventricles, while the posterior veins remain fixed in place. This type
of injury usually occurs at the junction of the inferior vena cava and
the right atrium, and at the junction of the pulmonary veins with
the left atrium.1 This is a highly lethal injury, but small tears at the
venous-atrial confluence can be contained, and the patient may be
initially stable.8
2.3. Valvular injury
Mitral-valve injuries usually result from the rupture of a papil-
lary muscle, a chordae or a leaflet.9 Tricuspid-valve involvement
has the same injury pattern but is less frequent and has a subtler
clinical presentation. Severe tricuspid regurgitation can actually be
well tolerated and may only be diagnosed months or years later.1
Aortic-valve injuries range from mild annulus damage to lacera-
tion or detachment of the cusps leading to acute aortic regurgita-
tion.10 Aortic-valve involvement is often associated trauma to the
with ascending aorta.11 Pulmonary-valve injuries are rare, with
very few cases of valve disruption described.5
2.4. Coronary-artery injury
Acute dissection of the coronary arteries can result from BCI,
leading to myocardial infarction.12 The pathophysiology of this
injury tends to be direct impact, most frequently over the left
anterior descending artery or the left main coronary artery, usually
in a previously diseased portion of the vessel.13 The dissection is
initiated as the intima over the plaque tears, creating a flap that
obstructs the blood flow.14
2.5. Thoracic-aorta injury
The mechanisms of blunt injury to the thoracic aorta include
rapid deceleration, production of shearing forces and direct luminal
compression against points of fixation, especially at the liga-
mentum arteriosum.15 The aortic isthmus (junction of the mobile
aortic arch and the fixed descending aorta) is the most common site
of aortic injury. Many patients die of vessel rupture and rapid
exsanguination, either at the scene or before reaching medical care.
Other resulting injuries include mural hematoma formation,
intimal tear, transection, pseudoaneurysm, and dissection.2
2.6. Dysrhythmias
Premature ventricular and atrial contractions are the most
commonly seen dysrhythmias, but life-threatening patterns may
also occur.2 Atrial fibrillation was reported on the initial electro-
cardiogram (ECG) in 4% of patients with chest trauma,16 but this
arrhythmia may not be due to direct cardiac trauma because a
31
similar incidence was shown in isolated head or abdominal in-
juries.17 The development of right bundle branch block after BCI has
long been reported and should raise suspicion for cardiac
involvement, but it has little clinical relevance by itself, even when
persistent.16
Commotion cordis refers to sudden death caused by ventricular
fibrillation, triggered by a blunt blow to the chest, in the absence of
underlying cardiovascular disease. The trauma occurs without
anatomic damage to the ribs, sternum or heart, most often in
children and young adults participating in recreational and
competitive sports.18 Transmission of the impact to the myocar-
dium during cardiac repolarization, an electrically vulnerable phase
of ventricular excitability, induces ventricular fibrillation.19 Using
personal chest barriers appears to be not totally protective, as
athletes wearing these still die.20
3. Penetrating cardiac injury
In penetrating chest trauma, both ventricles are injured with
similar frequency, but the RV is the most common site of entry
because it forms most of the anterior surface of the heart.3 The most
frequent trauma scenario is a young man who presents with a
precordial stabbing or thoracic gunshot wound.21 The initial
manifestation is commonly cardiac tamponade and, depending on
the haemodynamic stability of the patient, immediate surgical
intervention may be necessary without further evaluation.
Penetrating cardiac injury is one of the most lethal medical
emergencies, with an estimated pre-hospital mortality rate of 94%
and a subsequent in-hospital mortality rate of 50% among initial
survivors.22 The 2 most significant causes of death, as reported in
autopsy studies,23 are haemorrhagic shock and cardiac tamponade.
4. Diagnostic modalities
The symptom-based diagnosis of cardiac trauma, particularly in
non-penetrating injury, is usually difficult to make because the
symptoms, such as chest pain, are common in patients with
thoracic trauma and often arise from a non-cardiac source. Signs of
congestive heart failure, pulmonary oedema, a pericardial friction
rub or a new cardiac murmur are less common but, when present,
should prompt evaluation for cardiac injury.2
ECG should be routinely performed in all patients with sus-
pected cardiac trauma. Although it has low sensitivity and speci-
ficity when used alone,24 patients with abnormal ECG findings had
more significant complications that required treatment.25
Cardiac biomarkers, namely serum cardiac troponin levels, also
have an important role in cardiac-trauma screening. High-
sensitivity cardiac troponin assays with improved analytical per-
formance have lower limits of detection, allowing patient with
blunt chest trauma to be safely discharged home if their levels are
normal.26 However, even these novel assays have shown cross-
reactivity with diseased skeletal muscle.27 In other words,
elevated cardiac troponin in a patient with chest trauma may
originate from skeletal-muscle injury, not necessarily from cardiac
trauma or from associated ischaemic injury.
Transthoracic echocardiography (TTE) is a very useful tool for
detecting BCI and represents the primary screening tool in unstable
patients with either penetrating or non-penetrating chest trauma.
Transoesophageal echocardiography may help to define intracar-
diac anatomy and function in some cases, such as when traumatic
valve injury or a ruptured septum is present.28
Thoracic computed tomography (CT) allows an accurate exam-
ination of the entire chest, including the heart, pericardium and
great vessels. CT is currently recommended as the initial imaging
modality in haemodynamically stable trauma patients.3
32 L. Leite et al. / Journal of Forensic and Legal Medicine 52 (2017) 30e34

5. Medicolegal implications

The assessment of post-traumatic damage from a medicolegal

point of view (for compensation purposes in civil and work law) is
based on each country's law. Assessment of injury should consider
the aetiology, the cause-effect relation based on pathophysiological
considerations, and the clinical, laboratory and imaging findings. To
establish that a cardiovascular injury is permanent, the injury
should persist after medical and surgical therapy has been opti-
mised, and after a reasonable period of time to allow for physio-
logical recovery.29

6. Case reports

We present 4 examples patients with cardiac trauma, admitted

to the emergency department of a tertiary referral hospital over the
last 5 years.

Fig. 2. Chest radiograph showing a widened mediastinum.

6.1. Patient 1

An 80-year-old man presented to the hospital after a head-on
motor vehicle collision at highway speed. On arrival, he was
awake with a Glasgow Coma Scale score of 15. He complained of
chest pain and shortness of breath, but was haemodynamically
stable. He had a sternal fracture but no other remarkable signs of
traumatic injury. Laboratory testing revealed elevated levels of
troponin I (6.51 ng/mL), creatine kinase (CK; 458 U/L), CK-MB
(38.9 ng/mL) and myoglobin (381 ng/mL); the remaining labora-
tory values were within normal limits and there were no electro-
cardiogram abnormalities. Emergent TTE revealed severely
impaired global left ventricular systolic function and no pericardial
effusion. These data confirmed the diagnosis of myocardial contu-
sion. Thoracic contrast-enhanced CT identified extensive bilateral
pulmonary contusions and confirmed the absence of great-vessel
injuries and haemopericardium (Fig. 1).
The patient was discharged home from the intensive care unit
on the 25th hospital day with normal left ventricular systolic
function.
motor vehicle accident. The patient was conscious and had no
significant external signs of traumatic injury but remained hypo-
tensive even after intravenous fluid administration. Chest radiog-
raphy showed a widened mediastinum (Fig. 2), and TTE
demonstrated normal biventricular systolic function with no
valvular injuries or pericardial effusion.
Contrast-enhanced CT revealed a dissection of the descending
aorta with 34 mm of extension, beginning at the aortic isthmus,
without signs of rupture (Fig. 3).
An endoluminal stent graft was placed in the true lumen, and
the patient stabilised without immediate complications.
6.3. Patient 3
A 39-year-old man was admitted to the hospital with a pre-
cordial gunshot injury (from a 6-mm pellet) resulting from a

6.2. Patient 2

A 29-year-old man was taken to the hospital after a high-speed

Fig. 1. Thoracic contrast-enhanced CT showing extensive bilateral pulmonary

contusions. Fig. 3. Sagittal contrast-enhanced CT showing a descending aortic dissection.
 L. Leite et al. / Journal of Forensic and Legal Medicine 52 (2017) 30e34
Fig. 4. Chest radiograph showing a retained intrathoracic gunshot pellet.
suicide attempt. The entrance wound was in the left hemithorax,
3 cm to the left of the sternum, and there was no evidence of an exit
wound. At the time of admission, the patient was conscious and
haemodynamically stable. Chest radiography showed the position
of the gunshot pellet (Fig. 4).
TTE demonstrated normal biventricular systolic function and no
pericardial effusion. Thoracic contrast-enhanced CT showed that
the pellet was located in the mediastinum, below the left pulmo-
nary artery and anterior to the left pulmonary vein. A pulmonary
contusion was associated with the ballistic trajectory (Fig. 5). As the
patient was stable and there was no significant damage to the
intrathoracic structures, conservative treatment was chosen.
6.4. Patient 4
An 18-year-old man was stabbed in the chest with a knife during
a bar fight and was brought to the emergency department 10 min
later. A 2-cm skin wound was identified at the junction of the left
midclavicular line and fifth intercostal space. The patient was
conscious, with stable vital signs. Emergent TTE demonstrated a
moderate pericardial effusion, without echocardiographic signs of
cardiac tamponade. Thoracic CT confirmed a significant pericardial
effusion, measuring 14 mm close to the right ventricle; there was a
small left pleural effusion but no signs of pneumothorax or pul-
monary contusion (Fig. 6).
The patient was immediately transferred to the operating room.
There was significant haemopericardium with several blood clots,
and a defect was found in the anterior wall of the right ventricle;
Fig. 5. Sagittal (A) and axial (B) contrast-enhanced CT showing a retained intrathoracic
gunshot pellet.
33
Fig. 6. Thoracic CT showing a moderate-to-severe pericardia effusion and a small left
pleural effusion.
this was sutured directly.
7. Conclusions
The spectrum of cardiac injuries caused by trauma is wide, and
the mortality is high. BCI is the most common type of cardiac
trauma, and presentation varies greatly. Thus, a high index of sus-
picion and knowledge of the appropriate diagnostic workup are
essential to optimal care. Cardiac biomarkers are useful in blunt
chest-trauma screening, while echocardiography and CT are the
main diagnostic modalities.
Conflicts of interest
None.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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