Blunt chest trauma associated cardiac injury diagnosis in the emergency department: A systematic review

 Corresponding author: Mazi Mohammed Alanazi. Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Blunt chest trauma associated cardiac injury diagnosis in the emergency department: A systematic review Mazi Mohammed Alanazi 1, *, Raghad A. Alibrahim 2 and Rawan Saad M Alshahrani 3 1 Saudi and Jordanian Board Emergency Medicine, Head of Emergency Research Unit, Emergency Department, First Health Cluster, Riyadh, Saudi Arabia. 2 Saudi board emergency medicine resident, Aseer Central Hospital, Abha, Saudi Arabia. 3 Saudi board emergency medicine residents, Armed forces hospital southern region (AFHSR), Khamis Mushayt, Saudi Arabia. World Journal of Advanced Research and Reviews, 2025, 26(02), 2251-2257 Publication history: Received on 02 April 2025; revised on 11 May 2025; accepted on 13 May 2025 Article DOI: https://doi.org/10.30574/wjarr.2025.26.2.1881 Abstract Background: Diagnosing cardiac contusions from forceful chest trauma is still difficult due to the non-specific symptoms it produces and the absence of reliable diagnostics to identify myocardial damage. This study's aim to assess how well diagnostic techniques identify blunt heart damage and its consequences. Method: PRISMA criteria were followed in the conduct of this systematic review study. Two reviewers searched the MEDLINE, Scopus, and Embase databases to locate relevant works from 2014 to 2024. The search was limited to publications written in English. We considered case series, observational studies, and prospective or retrospective cohort studies that look at ways to diagnose blunt cardiac damage. Studies that evaluate biomarker-based diagnostics or imaging modalities. We incorporate research that reports on the diagnostic modalities' sensitivity, specificity, and accuracy. Research assessing the clinical results of using these diagnostic instruments. Result and conclusion: The complexity of BCI diagnosis and treatment indicated the necessity for an all-encompassing diagnostic strategy. Although CMR and DECT provide excellent diagnostic accuracy, they are occasionally unsuitable in situations involving severe trauma. TEE has become a very useful bedside technique, particularly for patients who are unstable. Troponins and ECG are screening tests that can be used to rule out BCI because of their moderate sensitivity and high specificity. Keywords: Blunt Chest Trauma; Diagnosis; Myocardial Contusions; Emergency Department 1. Introduction Fifteen percent of emergency department admissions globally are due to blunt chest injuries (BCI), which are linked to high rates of morbidity and death (El-Chami et al. 2008; FRAZEE et al. 1986; van Wijngaarden et al. 1997). They might happen after a car crash, a fall from a height, a violent attack, or an injury sustained in sports. Decelerating forces applied on the anterior portion of the chest wall are believed to be the cause of the damage to the heart, which puts the heart's viscoelastic qualities to the test (FRAZEE et al. 1986). Following the impact, the heart is free to travel along the anteriorposterior axis of the thoracic cavity. It may then be crushed just against the posterior of the sternum or, in the case of a more forceful impact, "squashed" between the sternum and the anterior aspect of the thoracic spine. World Journal of Advanced Research and Reviews, 2025, 26(02), 2251-2257 2252 It is clear that the clinical appearance of individuals with BCI varies widely since these injuries include a wide range of causes and intensities. A silent clinical finding or varying physiological instability degrees are possible presentations, but in some cases, injuries to key structures like the pericardium, valves, chordae tendinae, papillary muscle, coronary artery, or ventricular septum may be "catastrophic" (El-Chami et al. 2008; FRAZEE et al. 1986; Sade et al. 2017). The words "cardiac contusion" and "BCI" are frequently used interchangeably in the literature. The phrase myocardial contusion should no longer be used as a diagnostic for admission or rating of injury severity (andNA; 1992). This study's main goal is to assess how well diagnostic techniques identify blunt heart damage and its consequences. 2. Method This systematic review study was conducted according to PRISMA guidelines. To find pertinent papers from 2014 to 2024, two independent reviewers examined the MEDLINE, Scopus and Embase databases. Only English-language publications were included in the search. The titles, abstracts, and full texts of the articles were then read in order to filter them. We included prospective or retrospective cohort studies, observational studies, or case series; studies that investigate diagnostic methods for blunt cardiac injury (BCI). Studies that assess imaging modalities (CT, DECT, CMR, echocardiography) or biomarker-based diagnostics (ECG, troponins). We include studies reporting on diagnostic accuracy, sensitivity, and specificity of the above modalities. Studies evaluating clinical outcomes associated with the use of these diagnostic tools (e.g., Major Adverse Cardiac Events [MACE], mortality, or need for intervention). The dispute among the reviewers over eligibility was resolved through discussion. After the discovered records were first sorted by title and abstract, potentially relevant articles were examined in their entirety. The references in the listed papers were screened for eligibility. If the full-text version of the work was not available, an email was sent to the related authors; if they did not respond, a follow-up email was sent. We extract data on a predesigned Google sheet, we extracted data on study characteristics (author, study design, and study area); population and participants characteristics; diagnostic methods; and key findings. Quality assessment of the included studies was performed according to ROBINS-I tool. Burrell et al. (2017) study (Burrell et al. 2017) showed a moderate risk of bias, due to confounding and missing data from a small sample size. Hammer et al. (2015) (Hammer et al. 2016) showed a high risk of bias, in confounding and measurement due to the retrospective nature and CT's poor sensitivity in detecting cardiac contusions. Sade et al. (2017) had a low to moderate risk of bias. Vasileiou et al. (2019) had a high risk of bias, in confounding and measurement because CXR alone is not a dependable diagnostic tool. Audette et al. (2014) had a moderate risk of bias, with concerns over missing data and variability in ECG and troponin measurement. Table 1 Quality assessment of the included studies with the ROBINS-I tool Study (Author, Year) Burrell et al., 2017 Hammer et al., 2015 Sade et al., 2017 Vasileiou et al., 2019 Audette et al., 2014 Bias due to Confounding Moderate High Moderate High Moderate Bias in Selection of Participants Low Moderate Low Moderate Low Bias in Classification of Interventions Low Low Low Low Low Bias due to Deviations from Intended Interventions Low Low Low Low Low Bias due to Missing Data Moderate Moderate Low Moderate Moderate Bias in Measurement of Outcomes Low High Low High Moderate Bias in Selection of Reported Results Low Moderate Low Moderate Moderate World Journal of Advanced Research and Reviews, 2025, 26(02), 2251-2257 2253 Overall Risk of Bias Moderate High Low to Moderate High Moderate 3. Result In this systematic review study, we include 5 articles published in the period from 2014 to 2024. The studies aimed to assess the role of diagnostic methods in detecting cardiac contusions and associated injuries in patients with blunt cardiac trauma. Figure 1 PRISMA consort chart of studies selection Burrell et al. (2017) study examined the use of cardiac magnetic resonance imaging (CMR) in diagnosing blunt cardiac injury (BCI). This prospective cohort study includes 42 major trauma patients, 21 with of chest injury and elevated troponin levels, and 21 controls. The study found that 28% of patients with chest injuries exhibited abnormal CMR findings, such as myocardial edema, regional wall motion abnormalities, and myocardial hemorrhage. Left ventricle was the most commonly affected area. Major adverse cardiac events (MACE), including ventricular arrhythmia and World Journal of Advanced Research and Reviews, 2025, 26(02), 2251-2257 2254 hypotension requiring inotropes, occurred in five patients. The study found that CMR has a 60% sensitivity and 81% specificity MACE prediction, it’s found to be better in the diagnosis of suspected BCI in comparison to conventional methods like electrocardiography (ECG) and troponin. Hammer et al. (2015) retrospective study assessed the use of computed tomography (CT) in cardiac contusions diagnosis in blunt trauma patients. His study includes 42 patients with clinically diagnosed BCI. CT identified abnormalities of the heart or pericardium in 82% of patients with confirmed BCI. However, the detection of myocardial contusions was poor, CT sensitivity was 0% for right ventricular contusions and 22% for left ventricular contusions. The study emphasized that CT disgnosis of severe thoracic trauma indirectly indicate BCI, and myocardial hypoenhancement on CT alone is not a dependable diagnostic tool. The authors advised using CT as a complementary tool with echocardiography or CMR for diagnosing BCI. Sade et al. (2017) study examined the feasibility of dual-energy computed tomography (DECT) in diagnosing cardiac contusions in blunt cardiac injuries. They included 17 patients who underwent DECT within 48 hours of trauma, with a follow-up scan conducted one year later. Contusions were primarily located in the left ventricular free wall, ventricular septum, and apex. In 10 patients, contusion areas resolved completely on follow-up, while in four patients, contusions persisted and showed significant improvement. Findings indicate high interobserver agreement in detecting contusions, suggesting DECT as a potentially effective tool for diagnosing blunt cardiac injuries. Vasileiou et al. (2019) retrospective cohort study examined the clinical significance of a widened mediastinum (WM) on chest X-ray (CXR) following blunt trauma. Among 749 patients analyzed, 67% had a WM. Despite the initial suspicion that WM indicate aortic injury (AI), 26% had positive findings on CT, with just two confirmed cases of AI. The study reported a 100% sensitivity and 33% specificity for CXR in detecting AI, highlighting its limited diagnostic accuracy. Audette et al. (2014) retrospective descriptive study examined the use of ECG and troponin in diagnosing myocardial contusion in trauma patients with sternal fractures. Among 54 patients, 72% underwent initial ECGs, and 33% received follow-up ECGs. Additionally, 30% had troponin testing, and 2% showed elevated levels. A combination of ECG and troponin testing yielded a 100% sensitivity and 45-89% specificity. Table 2 characteristics of include studies Study (Author, Year) Study Design Study Aim Participants Characteristics Outcome Methodology Burrell et al., 2017 Prospective cohort study To evaluate the incidence and severity of blunt cardiac injury (BCI) using cardiac magnetic resonance (CMR) and compare it to standard diagnostic methods 42 major trauma patients (21 with chest trauma and 21 controls), July 2013 - Jan 2015 6/21 (28%) patients with chest injuries had abnormal CMR scans; MACE occurred in 5 patients CMR within 7 days, ECG, Troponin, and echocardiography Hammer et al., 2015 Retrospective study To evaluate CT findings in blunt cardiac injury 42 patients with blunt cardiac injury (Median age: 52, 86% male) CT was poorly sensitive for right ventricular contusions (0%) and left ventricular contusions (22%) Chest CT, ECG, Troponin, and echocardiography Sade et al., 2017 Prospective study To assess the feasibility of dualenergy computed tomography (DECT) for diagnosing cardiac contusion 17 patients (10 men, 7 women, median age 51) DECT identified contusions primarily in the left ventricle; follow-up showed recovery in most patients DECT imaging within 48 hours of trauma, follow-up DECT at ~1 year Vasileiou et al., 2019 Retrospective cohort study To determine the significance of widened 749 blunt trauma patients (67% MVC, 76% male) Only 26% had positive CT findings; sensitivity CXR, Chest CT World Journal of Advanced Research and Reviews, 2025, 26(02), 2251-2257 2255 mediastinum on chest X-ray (CXR) in blunt trauma of WM for aortic injury was 100%, specificity was 33% Audette et al., 2014 Retrospective descriptive study To evaluate the use of ECG and troponin in assessing myocardial contusion in sternal fracture cases 54 trauma patients with suspected sternal fracture (51 years mean age, 54% female) 72% had initial ECGs, 33% had follow-up ECGs, 30% had troponin dosage; ECG + troponin combination had 100% sensitivity ECG, follow-up ECG, Troponin, Chest Xray, Cardiac ultrasound Table 3 Main findings of the included studies Study (Author, Year) Demographics Study Duration Type of Trauma Methods Used for Diagnosis Accuracy of Method (Sensitivity/Specificity) Burrell et al., 2017 42 major trauma patients July 2013 - Jan 2015 Blunt cardiac injury Cardiac Magnetic Resonance Imaging (CMR) Sensitivity: 60%, Specificity: 81% Hammer et al., 2015 42 patients with blunt cardiac injury 2006 - 2013 Blunt cardiac injury Computed Tomography (CT), ECG, Troponin, Echocardiography Myocardial hypoenhancement on CT: Sensitivity: 0% (RV), 22% (LV) Sade et al., 2017 17 patients (10 men, 7 women, median age 51) Feb 2014 - Sept 2015 Mildest blunt cardiac injury Dual-Energy CT (DECT) High interobserver agreement (κ = 1.0) but no clear sensitivity/specificity reported Vasileiou et al., 2019 749 patients with widened mediastinum Jan 2017 - June 2017 Blunt trauma Chest X-ray (CXR), Chest CT Sensitivity: 100%, Specificity: 33% Audette et al., 2014 54 patients with suspected sternal fractures Jan 2007 - Oct 2010 Sternal fracture trauma ECG, Troponin ECG + Troponin: Sensitivity: 100%, Specificity: 45-89% 4. Discussion BCI diagnosis remain difficult due to its variable clinical presentations and the lack of accepted gold standard for diagnosis. The included five studies (Audette et al. 2014; Burrell et al. 2017; Hammer et al. 2016; Sade et al. 2017; Vasileiou et al. 2019) focused on imaging modalities, including CMR, CT, and DECT to assess BCI. The use of imaging modalities in BCI diagnosis still a topic of debate. CXR always used initial screening tool, but studies found that a widened mediastinum on CXR has low specificity (33%) for detecting aortic injury (Vasileiou et al. 2019), making it an unreliable diagnostic tool on its own (Girón-Arango and D’Empaire 2022). CT has been more widely used due to its ability to detect associated thoracic injuries. Hammer et al. (2015) found that CT has poor sensitivity in myocardial contusions detection, particularly in the right ventricle (Girón-Arango and D’Empaire 2022). Sade et al. (2017) examined DECT as an alternative, finding that it shows a high interobserver agreement in detecting myocardial contusions, with improved accuracy. CMR was highly sensitive imaging modality for detecting myocardial edema and fibrosis. Burrell et al. (2017) found that CMR detected myocardial abnormalities in 28% of patients with suspected BCT and show a strong correlation with clinical outcomes (Girón-Arango and D’Empaire 2022). Despite its diagnostic accuracy, CMR is not practical in the acute World Journal of Advanced Research and Reviews, 2025, 26(02), 2251-2257 2256 trauma setting due to patient instability and limited availability. Shoar et al. (2021) suggested that although CMR and DECT are valuable, their application in emergency settings remains limited. Lieshout et al. (2021) evaluated transthoracic echocardiography (TTE). TTE show a poor sensitivity (45%) for myocardial contusion, and 88% specificity (Van Lieshout et al. 2021). TEE show advantages in perioperative trauma patients, as it provides better imaging quality in hemodynamically unstable patients (Girón-Arango and D’Empaire 2022). A systematic review and meta-analysis, found that TEE had a sensitivity of 86.7% and specificity of 72.1%, which support its use in suspected BCI cases (Kyriazidis et al. 2023). ECG and cardiac biomarkers were used widely as cost-effective screening tools. Audette et al. (2014) tested the role of ECG and troponin in myocardial contusion assessment and found that ECG abnormalities were detected in many patients with suspected BCI, but its specificity varied (Girón-Arango and D’Empaire 2022). The combination of ECG and troponin I (cTnI) had a 100% negative predictive value for clinically significant BCI, making it a highly effective rule-out strategy (Salim et al. 2001). ECG and cardiac biomarkers show high specificity (>80%), and low sensitivity, so they should not be used in isolation for diagnosis (Kyriazidis et al. 2023). The findings of the included studies highlight the need for a multimodal approach to diagnose BCI. Liedtke and DeMuth study provided a historical perspective, show that BCI sometimes goes undiagnosed due to the overshadowing effects of other traumatic injuries (Liedtke and DeMuth 1973). This remains relevant today, as many patients with significant thoracic trauma not exhibit immediate cardiac symptoms, necessitating careful monitoring. Shoar et al. (2021) detected the variability in clinical presentation and the importance of combining multiple diagnostic modalities to improve diagnosis. Early identification of high-risk patients is important to start management. Patients with normal ECG and troponin can sometimes safely discharged (Salim et al. 2001). Patients with persistent ECG abnormalities, elevated biomarkers, or imaging-confirmed structural injuries require close monitoring and possible intervention. Hemodynamically unstable patients, particularly those with tamponade or valvular rupture, should be assessed for the need of urgent surgical management (Girón-Arango and D’Empaire 2022). List of abbreviations • BCI, Blunt Cardiac Injury • CMR, Cardiac Magnetic Resonance Imaging • CT, Computed Tomography • DECT, Dual-Energy Computed Tomography • TEE, Transesophageal Echocardiography • ECG, Electrocardiography • cTnI, Cardiac Troponin I • CXR, Chest X-ray • WM, Widened Mediastinum • AI, Aortic Injury • MACE, Major Adverse Cardiac Events • MVC, Motor Vehicle Collision • PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses • ROBINS-I, Risk of Bias in Non-Randomized Studies - of Interventions • PPV, Positive Predictive Value • NPV, Negative Predictive Value 5. Conclusion Multifaceted nature of BCI diagnosis and management, suggested the need for a comprehensive diagnostic approach. 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