Assessment

HISTORY. Elicit a thorough history of the injury event, including the time, place, and description. Determine the point of impact and any weapons (baseball bat, brick, fist) used in an assault. Patients usually describe the most common symptom of cardiac contusion—that is, precordial pain resembling that of myocardial infarction. However, coronary vasodilators have little effect in relieving the pain. It is important to note that many patients may be asymptomatic for the first 24 to 48 hours after the chest trauma. In patients with multiple trauma, physical signs may be masked by associated injuries. Note the presence of blunt chest injuries, such as sternal, clavicular, or upper rib fractures; pulmonary contusion; hemo-thorax; or pneumothorax—all of which raise suspicion for the possibility of a myocardial injury.

PHYSICAL EXAMINATION. Generally, the physical signs of a cardiac contusion are few and nonspecific. Observe the chest wall for the presence of bruising, hematoma, swelling, or the imprint of a steering wheel if the patient has been driving a motor vehicle. Note the presence of pain (chest wall or musculoskeletal), dyspnea, tachycapnea, tachycardia, and diaphoresis. Be alert for the possibility of cardiac tamponade, active bleeding into the peri-cardial space that leads to myocardial compression, and cardiogenic shock. Note the presence of hypotension, muffled heart sounds, a paradoxic pulse, and shock from potential complications (Table 1).

• TABLE 1 Complications Associated with Myocardial Contusion
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