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cardio.cardiac-tamponade.blunt-chest-trauma.v1

Cardiac tamponade — blunt chest trauma (MVA, fall, sternal blow)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.cardiac-tamponade.core.v1 — narrowed to blunt cardiac trauma (MVA steering-wheel impact, fall from height, direct sternal blow, crush injury) with traumatic hemopericardium and obstructive-shock physiology. Uses ATLS framework (primary survey first → E-FAST in C step) per ATLS 10th edition §Thoracic. EAST 2012 (Clancy J Trauma 2012 PMID 23114492) Class I admission ECG + troponin for blunt cardiac injury screen. WSES 2019 (Sartelli WJES 2019 PMID 31867050) defines ED resuscitative thoracotomy indications — blunt arrest <10 min only (penetrating > blunt). CRASH-2 (PMID 20554319) tranexamic acid within 3h. Damage-control resuscitation principles (PRBC:FFP:plt 1:1:1, permissive hypotension SBP 80-90 until source control). Pericardiocentesis is BRIDGE ONLY (5-15 min temporizing); definitive control requires surgical sternotomy or thoracotomy. Reversal of pre-injury anticoagulation per Bhatt 2018 + RE-VERSE AD (Pollack NEJM 2017 PMID 28793172) + ANNEXA-4 (Connolly NEJM 2019 PMID 30730782). Sister-differentiated from cardio.post-arrest.commotio-cordis.v1: commotio cordis is PURELY ELECTRICAL R-on-T arrest in structurally normal heart with NO pericardial fluid (pericardium intact); this engine is for STRUCTURAL injury with hemopericardium. Sister-differentiated from cardio.cardiac-tamponade.post-procedural.v1: same drainage/reversal regimen but trauma context adds ATLS damage-control + concurrent-injury workup (aortic isthmus injury ~25% co-occurrence in high-mechanism MVC). Manifest pointer reuses cardio.cardiac-tamponade.core.v1 manifest. Design-brief pointer reuses parent (trauma-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated reversal-agent codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (6)

  • history
    High-speed MVC with steering-wheel impact + chest pain / dyspnea / hypotension → blunt cardiac injury screen (ATLS §Thoracic; EAST 2012 PMID 23114492)
    high_speed_mvc_with_steering_wheel_impact
  • history
    Fall from height >3 m with thoracic landing + new hypotension or muffled heart sounds → traumatic hemopericardium suspected (ATLS)
    fall_from_height_thoracic_landing
  • history
    Direct sternal blow (assault, sports, low-velocity MVC) + new dyspnea/hypotension → blunt cardiac injury workup (Stafford Ann Thorac Surg 2017)
    direct_sternal_blow_with_decompensation
  • imaging
    Pericardial fluid on E-FAST (subxiphoid view) in blunt-trauma context — assume traumatic hemopericardium until proven otherwise (Rozycki Ann Surg 1998)
    fast_efast_pericardial_fluid_in_trauma
  • vital_abnormality
    Beck triad (hypotension + JVD + muffled heart sounds) in blunt-trauma patient → emergent echo + surgical activation (ESC 2015 §Trauma)
    beck_triad_post_blunt_chest_trauma
  • lab_abnormality
    Elevated troponin + abnormal admission ECG in blunt-trauma context → blunt cardiac injury (EAST 2012 Class I screen)
    troponin_elevation_post_blunt_chest_trauma

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Older patients have higher mortality from blunt cardiac injury; pediatric blunt cardiac injury rare but distinctive (ATLS)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension is part of Beck triad + obstructive-shock physiology in tamponade; blunt-trauma + hypotension demands immediate FAST (ATLS C step)
  • hrrequired
    vital • used at CONTEXT
    Compensatory tachycardia in tamponade physiology; bradycardia in late tamponade is pre-arrest (ESC 2015)
  • mechanism_of_injuryrequired
    history • used at CONTEXT
    MVC vs fall vs sternal blow vs crush — drives pre-test probability + concurrent-injury workup (steering-wheel sign, sternal/rib fracture, aortic isthmus injury) (ATLS §Thoracic)
  • efast_pericardial_viewrequired
    imaging • used at INITIAL_WORKUP
    Subxiphoid pericardial view of E-FAST identifies hemopericardium with very high sensitivity in trained hands; the C-step adjunct in ATLS for any blunt-trauma hypotension (Rozycki Ann Surg 1998)
  • echo_or_tee_for_definitiverequired
    imaging • used at INITIAL_WORKUP
    Confirmatory imaging — RV diastolic collapse, IVC plethora, swinging heart; TEE if obese, mechanically ventilated, or prosthetic chest wall barriers (ESC 2015)
  • ecg_admissionrequired
    imaging • used at INITIAL_WORKUP
    Admission ECG is the EAST 2012 Class I screen for blunt cardiac injury — combined with troponin determines downstream workup vs discharge (Clancy J Trauma 2012 PMID 23114492)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Combined with admission ECG per EAST 2012; positive troponin + abnormal ECG mandates admission + monitoring; type-2 MI from contusion / coronary tear (4th UDef MI PMID 30153967)
  • hemoglobinrequired
    lab • used at INITIAL_WORKUP
    Hemorrhagic loss quantification + transfusion threshold; blunt cardiac trauma often co-exists with major hemorrhage from other sources (ATLS)
  • inrrequired
    lab • used at INITIAL_WORKUP
    Trauma-induced coagulopathy quantification; pre-injury anticoagulants drive reversal strategy (Bhatt Circulation 2018)

12-phase flow (10)

  1. 1FRAME
    Blunt cardiac trauma + Beck triad / E-FAST pericardial fluid → traumatic hemopericardium with obstructive shock; ATLS primary survey first then activate cardiothoracic / trauma surgery (ATLS; ESC 2015 §Trauma)
    inputs: sbp
    advance: blunt-trauma context + tamponade physiology suspected
  2. 2ENTRY
    High-mechanism injury (MVC steering-wheel, fall >3 m, sternal blow, crush) with new chest pain / dyspnea / hypotension OR positive E-FAST pericardial view → activate trauma + cardiothoracic teams
    inputs: age, mechanism_of_injury
    advance: mechanism + presentation align with blunt cardiac injury
  3. 3CONTEXT
    Document mechanism details (speed, restraint use, deformity), pre-injury anticoagulants, comorbidities, concurrent injuries (head, abdomen, pelvis, long bones) per ATLS secondary survey (ATLS)
    inputs: mechanism_of_injury, hr
    advance: mechanism + concurrent-injury map captured
  4. 4RED_FLAGS
    Obstructive shock physiology + concurrent hemorrhagic shock from other sources — rate of accumulation > absolute volume drives tamponade physiology (Spodick 2003); peri-arrest patients require ED resuscitative thoracotomy if blunt arrest <10 min (WSES 2019 PMID 31867050)
    inputs: sbp, hr
    advance: shock recognized → emergent drainage prepared with cardiothoracic + trauma surgery on standby
  5. 5INITIAL_WORKUP
    E-FAST (4-view) including pericardial subxiphoid; admission 12-lead ECG + troponin (EAST 2012 Class I); CXR for mediastinal widening (aortic injury screen); CT chest with IV contrast if stable (cardiac contusion + aortic injury + sternal fracture map); type & cross 6 units; coags; lactate (ATLS)
    inputs: efast_pericardial_view, ecg_admission, troponin, hemoglobin, inr
    actions: panel.cardiac, panel.coag, panel.cbc
    advance: pericardial fluid + injury mapped + transfusion + reversal initiated
  6. 6DIFFERENTIAL
    Cardiac contusion (no tamponade) vs atrial/ventricular wall laceration (tamponade) vs coronary artery laceration / type-2 STEMI vs valve disruption vs septal rupture vs concurrent aortic isthmus injury (Stafford 2017; ATLS)
    advance: structural injury identified or excluded; commotio-cordis differential (purely electrical, no effusion) handled by cardio.post-arrest.commotio-cordis.v1
  7. 7TREATMENT
    Step 1: damage-control resuscitation (PRBC:FFP:plt 1:1:1 if MTP activated; permissive hypotension SBP 80-90 until bleeding controlled per damage-control); Step 2: emergent OR for sternotomy or left thoracotomy + repair if hemodynamically unstable + transferable; Step 3: pericardiocentesis is BRIDGE ONLY (5-15 min temporizing maneuver to OR); Step 4: ED resuscitative thoracotomy if blunt-traumatic arrest <10 min per WSES 2019 (very low survival ~2% but >0); Step 5: TXA within 3h per CRASH-2 (PMID 20554319)
    inputs: sbp
    advance: drainage performed + reversal initiated + surgical disposition determined
  8. 8DISPOSITION
    OR for surgical repair (sternotomy preferred for cardiac repair access; left anterolateral thoracotomy if peri-arrest in ED) → SICU post-op; if conservative management → SICU/CICU with serial echo (ATLS; ESC 2015)
    advance: multidisciplinary disposition confirmed (trauma + cardiothoracic surgery + CICU)
  9. 9MONITORING
    Re-accumulation surveillance (echo q4-6h × 24h then q12-24h × 48h); telemetry for blunt cardiac injury arrhythmia surveillance (sinus tachy + AF most common; VT/VF 2-3%); serial troponin q6h × 24h; serial Hb; surgical wound monitoring (ESC 2015; EAST 2012)
    actions: panel.cardiac
    advance: bleeding controlled + no re-accumulation × 48h + arrhythmia surveillance complete
  10. 10FOLLOWUP
    Cardiology + trauma surgery shared follow-up; echo at 4-6 wk for valve / wall-motion follow-up; cardiac MRI at 4-6 wk if persistent symptoms or echo equivocal; sports/return-to-work clearance per cardiology (Stafford 2017)
    advance: late-complication surveillance scheduled (valve disruption may present subacutely)