Diagnosis Of Myocardial Contusion Research Articles

Doppler Tissue Energy and Stress Echocardiography in the Diagnosis of Myocardial Contusion in Canines

We sought to evaluate the significance of Doppler tissue energy (DTE) and stressed echocardiography for diagnosing myocardial contusion (MC) in canines. Ten adult healthy dogs were anesthetized (3% pentobarbital sodium/i.v.) and impacted by BIM-II biological impact machine to induce MC. Conventional and stressed echocardiographies were used for segmental abnormal ventricular wall motions; DTE was also used to detect the abnormal ventricular wall motions and areas of injured myocardial fibers after MC, and the results were compared with those of triphenyl tetrazolium chloride (TTC) staining. The data show that both conventional and stressed echocardiographies identified ventricular wall segmental abnormal motions or even aneurysms. These segments were mainly distributed over the front and middle interventricular walls and anterolateral ventricular wall. The ventricular wall motion scoring and wall motion segment index (WMSI) increased remarkably after MC induction. Compared with TTC staining, the conventional echocardiography showed 100% sensitivity and 66.67% specificity, whereas the stressed echocardiography displayed 100% sensitivity and 88.89% specificity. DTE showed both the sensitivity and specificity of 100% for MC diagnosis. Thus, DTE has higher specificity than conventional and stressed echocardiographies. In conclusion, both DTE and stress echocardiography have higher clinical value for MC diagnosis in canines.

Dobutamine Stress Echocardiography Assessment of Myocardial Contusion due to Blunt Impact in Dogs

We sought to investigate the role of two-dimensional stress echocardiography in the early assessment of myocardial contusion. For this purpose, 12 dogs, weighing 11.36 ± 1.50 kg, were selected and the myocardial contusion was experimentally induced. Two-dimensional dobutamine stress echocardiography (DSE) was used to detect abnormal myocardial motions segments at time phases of baseline and 0.5, 2, 4, and 8 h post-wounding. Finally, the above results were compared with pathological findings. The data show that after the dogs were induced to have severe myocardial contusion, 122 segments were found with abnormal myocardial wall motions at 0.5 h post-wounding, 133 segments at 2 h post-wounding, and 142 segments, each, at 4 h and 8 h post-wounding. The wall motion score (WMS) and wall motion score index (WMSI) increased (P < 0.001) as compared with the pre-impaction values. Considering the left ventricular axis view as the standard section, in the 60 segments examined by echocardiography, 54 segments were found to have wall motion abnormalities. Comparing with the results of pathological TTC staining, the sensitivity and specificity were found to be 100 and 66.6%, respectively. It was, therefore, concluded that two-dimensional DSE was a valuable technique in the early diagnosis of myocardial contusion due to its better sensitivity and specificity.

Electrocardiographic ST-segment elevation in the trauma patient: acute myocardial infarction vs myocardial contusion

The diagnosis of myocardial contusion in the setting of blunt trauma engenders much discussion and controversy—partly because of the lack of a gold standard for its identification other than histologic findings at autopsy. Furthermore, blunt cardiac trauma represents a spectrum of disorders ranging from transient electrocardiographic change to sudden death from myocardial rupture; hence, no single terminology exists to define such a wide range of scenarios. Here, we present 2 cases of electrocardiographic ST-segment elevation after high-speed motor vehicle crashes resulting in numerous injuries, including blunt chest trauma. Both patients demonstrated electrocardiographic ST-segment elevation, resulting from myocardial contusion and acute myocardial infarction.

Myocardial contusion

Myocardial contusion can be a difficult diagnosis to make. There is currently no gold standard of investigation that allows its accurate diagnosis in the clinical setting. Trauma surgeons need to have a high degree of clinical suspicion when dealing with patients who have received blunt thoracic injuries in order that the diagnosis of myocardial contusion may be made. In this article we discuss the diagnosis, potential complications and investigation of patients with suspected myocardial contusion and also present a fl ow diagram for the possible management of patients with trauma who may have suspected myocardial contusion.

Blunt chest trauma producing acute myocardial infarction in a rugby player

A 21-year-old male college student with an 8-year history of insulin dependent iabetes mellitus presented with retro-sternal chest pain. 4 days previously, he had been tackled in a rugby game, and sought treatment for short-lived chest pain. An electrocardiogram (ECG) and echocardiogram done at another hospital showed transient ST-segment elevation and anterolateral hypokinesia. Cardiac catheterisation reportedly showed normal coronary arteries. A diagnosis of myocardial contusion was made and the patient was discharged after 3 days of observation.

Contusion myocardique

Within the framework of blunt cardiac injury, myocardial contusion (MC) is a specific pathological entity. In clinical practice, blunt chest trauma and multiple trauma are the two circumstances when the diagnosis of MC has to be suggested. The ECG abnormalities concerning MC are considered to be early and transient. The poor sensitivity and predictive values of troponins I and T (when ECG and/or echocardiography diagnostic criterions are considered) do not make these markers relevant for improving the biological diagnosis of MC. Echocardiography should be performed in case of ECG abnormalities, increase of enzymatic markers or hemodynamic instability. It allows one to perform the diagnosis of MC in case of abnormalities of the segmental ventricular wall kinetics, which progressively returns to normal. Only the pathological analysis could allow establishing a final diagnosis. In the initial phase of the management, the probability of the diagnosis might be performed with some arguments including clinical, ECG, biological and echocardiographic data. Later, the lability of both the ECG and the echocardiographic data is another criterion for making a final diagnosis of MC. Myocardial contusion has direct arrhythmogenic effects and the seriousness of arrhythmia increases with the level of contusion kinetic energy. The mechanism of arrhythmia is mainly based on the reentrant circuit around a fixed obstacle. There is no paraclinical parameter to reliably discriminate patients at risk of arrhythmia, especially for otherwise asymptomatic patients. In an animal model, lignocaine at low therapeutic concentrations is able to restore contractility after contusion. These results warrant further confirmations for clinical practice.

Diagnosis: heart contusion?

Myocardial contusion can result from blunt thoracic trauma and is commonly suspected in deceleration injuries. Unfortunately, traumatic heart disease is frequently overlook and the diagnosis of myocardial contusion is often unrecognized. Also the frequency and prognostic influence of cardiac injury in patient with blunt trauma is contraversial. Myocardial contusion is reported to be present in as few as 0% of patients and as many as 76% with blunt chest trauma depending on the criteria used for establishing the diagnosis. Diagnosing myocardial damage as a result of trauma may be a problem because there is a lack of a gold standard for establishing the diagnosis. More articles brought no clear results about specifity and signification of these methods. The conventional CKMB activity and CKMB/CK-total ratio are still used in our country even if low specifity of these markers has been demonstrated, especially in American literature. On the contrary echocardiography (and particularly transesophageal echocardiography) is still not fully used and in many hospitals is not accessible at all.

9 Transoesophageal echocardiography in trauma patients

Transoesophageal echocardiography (TOE) is an outstanding tool for the clinical management of trauma patients. It provides valuable information on haemodynamic instability, diagnosis of myocardial contusion, traumatic valve dysfunction, traumatic aortic injuries, intrathoracic bleeding and systemic gas embolism related to pulmonary contusion. The accuracy of TOE in the diagnosis of traumatic aortic injuries is not perfectly determined: the main limitation is the operator dependency. Experience of trauma patients and specific signs of cardiovascular injuries are the keys to the extensive use of TOE in trauma centres. The main interest in TOE is the capability to perform TOE promptly upon admission, in the intensive care unit and in the operative room. In the case of delayed surgery of aortic injuries, TOE examination can participate in the decision-making process.

Cardiac Troponin I in Myocardial Contusion

Myocardial contusion (MC) is defined as cellular damage that results from nonpenetrating chest trauma. MC is the most common cause of morbidity and mortality in patients who have had chest trauma. Diagnosis of MC is laborious, and chest pain, dyspnea, and nonspecific electrocardiograph changes are commonly present in patients with chest injury. Although transesophageal echocardiography (TEE) can provide high quality images for diagnosis (1)(2), noninvasive diagnosis of this lesion has been always problematic. Cardiac enzyme activity is not commonly used for MC diagnosis. In recent years, the development of assays using new, highly cardiac-specific proteins has opened new frontiers for the diagnosis of myocardial cell damage. Cardiac troponin I (cTnI) is a small filament-associated regulatory protein of muscle, uniquely specific for the heart (3). cTnI is not expressed by developing or diseased …

Circulating Cardiac Troponin T in Myocardial Contusion

Myocardial contusion may induce life-threatening complications, but its diagnosis is difficult. Circulating cardiac troponin T is considered a highly sensitive and specific marker of myocardial cell injury. We investigate the value of cardiac troponin T measurement in the diagnosis of myocardial contusion. Prospective study. Level 1 trauma center. We prospectively measured circulating cardiac troponin T and performed echocardiography and continuous Holter monitoring in patients who had suffered blunt trauma. Myocardial contusion was diagnosed in patients who fulfilled one of the following criteria: (1) an abnormal echocardiography compatible with myocardial contusion; (2) severe cardiac rhythm abnormalities; (3) severe cardiac conduction abnormalities; and (4) hemopericardium. One hundred twenty-eight patients were included and myocardial contusion was diagnosed in 29 patients. Patients with myocardial contusion had more severe trauma, experienced more frequently associated thoracic lesions, and had a lower left ventricular ejection fraction area (48 +/- 15 vs 61 +/- 10%; p < 0.001). Elevated circulating cardiac troponin T concentrations were significantly more frequent in patients with a myocardial contusion (31 vs 9%; p < 0.007). An elevated circulating cardiac troponin T concentration (> or = 0.5 microgram/L) was more accurate than MB fraction of creatine kinase (CK) (CK-MB) and CK-MB/CK ratio in the diagnosis of myocardial contusion, as shown by an area under the receiver operating characteristic (ROC) curve (AROC), which was significantly different from 0.50 (AROC = 0.69; 95% confidence interval, 0.56 to 0.80). However, this improvement was not clinically acceptable (sensitivity, 0.31; specificity, 0.91). Circulating cardiac troponin T measurement had a slightly greater diagnostic value than usual biological parameters (CK-MB, CK-MB/CK) in myocardial contusion. Nevertheless, it was concluded that an elevated circulating cardiac troponin T concentration has no important clinical value in the diagnosis of myocardial contusion.

Diagnosis of myocardial contusion.

From July 1988 to July 1990, 159 consecutive cases of major blunt chest injury were evaluated prospectively for myocardial contusion with serial electrocardiographic monitoring, cardiac isoenzyme studies, and two-dimensional echocardiography. One hundred and forty-seven cases in the series were assessable; 97 of the patients were male, and 50 were female. They ranged in age from 2 to 97 years (average, 38.5 years). There were five deaths, none of cardiac origin. Total lactate dehydrogenase (LDH) values were elevated in 115 patients (78%); total creatine phosphokinase (CPK) values were elevated in 100 (68%). Cardiac isoenzyme patterns were consistent with myocardial contusion in 18 patients (12%). Seventy-five patients had abnormal electrocardiograms, and 10 of these had ectopic rhythms. Two-dimensional echocardiograms were completed in 58 cases; 12 of these (21%) were abnormal. Nineteen patients (25%) with abnormal rhythms had elevated LDH values, and 26 (35%) had elevated CPK values. One patient (10%) with ectopy had an abnormal echocardiogram. Two patients (11%) with abnormal isoenzyme patterns experienced dysrhythmias. Costs for hospitalization and studies amounted to $1,886 per patient. Given the poor predictive value of laboratory testing in patients with significant (ie, symptomatic) cardiac contusion, observation alone with electrocardiographic monitoring and treatment of symptomatic dysrhythmias is an adequate and cost-conscious treatment.

Blunt cardiac injury and intraoperative hypoxaemia

A 28-yr-old man sustained blunt chest trauma in a motor vehicle accident. Severe intraoperative hypoxaemia occurred, unresponsive to oxygen and positive expiratory pressure therapy. Trans-oesophageal echocardiography revealed myocardial contusion and tricuspid valve rupture. Dobutamine improved left ventricular function and ejection fraction resulting in an immediate improvement in arterial oxygenation and saturation. Tricuspid injury and the diagnosis of myocardial contusion are discussed. The case highlights the importance of a non-pulmonary mechanism of hypoxaemia.

Focal myocardial injury following blunt chest trauma: A comparison of indium-111 antimyosin scintigraphy with other noninvasive methods

The diagnosis of myocardial contusion is often difficult, as traditional methods such as serial electrocardiograms, cardiac enzyme (creatine kinase [CK-MB]) analysis and echocardiography lack sensitivity and specificity. Recent reports have shown that 111In labelled antimyosin scanning has high sensitivity for detecting cardiac injury. However, no prior studies have been reported for antimyosin imaging with patients suspected of sustaining a cardiac contusion. Accordingly, 17 patients with severe multisystem trauma (intrathoracic vascular injury in eight patients, pneumothorax and pulmonary contusion in 13) underwent antimyosin scintigraphy, echocardiography, 12-lead electrocardiograms, and CK-MB determinations. Arrhythmias were noted in seven patients, four of whom died. All patients had elevated CK levels but CK-MB isoenzyme was >4% in only three. Abnormal ST segments were noted in nine subjects, only one of whom had CK-MB elevation. Echocardiography revealed pericardial effusions in four patients but was technically suboptimal in 53% of the studies. Blinded interpretation of the antimyosin scans revealed only one with focal myocardial uptake; this same patient had the only discrete wall motion abnormality on the echocardiogram and also had ST depression with ectopy but normal CK-MB. Thus in patients with suspected myocardial contusion, echocardiography is frequently limited technically and the electrocardiogram and CK analysis appear to lack diagnostic accuracy. In contrast, monoclonal antimyosin imaging may be performed in patients with trauma without limitation and yields results that are concordant with echocardiograms. In patients with suspected myocardial contusion, focal antimyosin uptake is uncommon despite severe thoracic injury, which suggests that extensive myocardial necrosis is not the primary method of injury.

Contusions myocardiques dans les traumatismes thoraciques fermés : étude prospective

Various laboratory investigations were assessed with respect to their accuracy in detecting myocardial contusion in patients with blunt chest trauma. All patients, aged between 18 and 50 years, admitted to the intensive care unit for flail chest, sternal fracture, pulmonary contusion, pleural or mediastinal lesion not requiring surgery, were included over a twelve month period. A complete cardiac assessment was carried out, including a physical examination, electrocardiogram, chest X-ray, enzyme assay (ALAT, ASAT, LDH, CPK and MB isoenzyme), two-dimensional echocardiography (2D-EC), thallium-201 scintigraphy. Myocardial contusion was diagnosed when an area of drecreased or absent thallium-201 uptake was found in the scintigraphy. These latter results were compared with those obtained with the other investigations. Sixteen patients, mean age 34 years, were included ; two who died before the end of the investigations were excluded. 2D-EC provided the most useful data (pericardial effusions in a third of the cases). The physical examination, enzyme assays, and chest films were of low value. The investigations carried out six months after the initial trauma showed that long term follow-up was not required. All patients were asymptomatic ten months after their trauma. Although the diagnosis of myocardial contusion was made in half the cases using thallium-201 scintigraphy, 2D-EC provided reliable data and had the advantage to be carried out at the patient's bedside.

Value of creatinine phosphokinase isoenzyme determinations in the diagnosis of myocardial contusion: Lindenbaum GA, Carroll SF, Block EF, Kapusnick RA. Ann Emerg Med 1988;17:885-9

Value of creatinine phosphokinase isoenzyme determinations in the diagnosis of myocardial contusion: Lindenbaum GA, Carroll SF, Block EF, Kapusnick RA. Ann Emerg Med 1988;17:885-9

Value of creatine phosphokinase isoenzyme determinations in the diagnosis of myocardial contusion

Myocardial contusion is an injury often missed in the patient with severe multisystem trauma. Fifty patients with physical findings or mechanisms of injury that were suggestive of possible nonpenetrating injury to the heart were studied with serial creatine phosphokinase isoenzyme (CPK/MB), continuous arrhythmia monitoring, and ECGs for at least 72 hours. Two-dimensional echocardiograms were obtained on all patients within 48 hours of admission. Seventy-two percent (36 of 50) had detectable CPK/MB. Ten patients had echocardiograms suggestive of cardiac contusion. Of these ten, three had no detectable CPK/MB and six had CPK/MB of less than 5%. CPK/MB had a sensitivity of 70% and a specificity of 27.5%. We conclude that in the patient with multisystem injury, CPK/MB determinations are not reliable. The decision to evaluate the patient with echocardiography should be made on the basis of physical findings and, more importantly, on mechanism of injury.

Creatine phosphokinase-MB assays in patients with suspected myocardial contusion: diagnostic test or test of diagnosis?

To clarify the role of serum CPK-MB assays in the diagnosis of myocardial contusion, we reviewed the hospital records of 182 patients with significant blunt chest trauma and serial CPK-MB determinations. In our laboratory a serum CPK-MB/CPK ratio less than 2.2% is abnormal. The study group was composed of 131 men and 51 women, with a mean age of 35 years. Only six patients had histories of cardiac disease. Of 159 patients injured in vehicular accidents, 143 were drivers, nine were pedestrians, and seven were passengers. There was no relationship between the MB fraction and soft (nonspecific changes) or strongly suggestive (ectopy, focal changes) ECG signs of myocardial contusion. Two of the three patients with power failure had CPK-MB/CPK ratios less than 2.2%. MUGA scans, performed in 18 patients, indicated myocardial injury in seven patients; only 1/7 had abnormal 2D echocardiography, and only 2/7 had elevated MB fractions. In summary, we found no relationship between serum CPK-MB and the presence of clinically significant myocardial contusion. CPK-MB determination in patients with suspected blunt myocardial injury is unjustifiably expensive ($108/assay) and adds confusion to an already vague clinical area.

Myocardial Contusion following Nonfatal Blunt Chest Trauma

Currently available diagnostic techniques for myocardial contusion following blunt chest trauma were evaluated. We investigated 30 patients prospectively over a period of 1 year for the presence of myocardial contusion. Among the 30 patients, eight were found to have myocardial contusion on the basis of abnormal electrocardiograms, elevated creatine phosphokinase MB fraction (CPK-MB), and positive myocardial scan. Myocardial scan was positive in seven of eight patients (87.5%). CPK-MB fraction was elevated in four of eight patients (50%). Definitive electrocardiographic changes were seen in only two of eight patients (25%). It appears that myocardial scan using technetium pyrophosphate and CPK-MB fraction determinations are the most reliable aids in diagnosis of myocardial contusion following blunt chest trauma.

Cardiac contusion in the patient with multiple injuries

We have treated 20 patients with multiple injuries and concomitant myocardial contusion. The diagnosis of myocardial contusion was based mainly on serial ECG tracings which showed arrhythmias, dynamic ischaemic patterns or conduction disturbances. The clinical and laboratory findings of cardiac contusion are sometimes indistinguishable from those found in multiple injuries. Furthermore, they are overshadowed by the overt manifestation of cerebral, thoraco-abdominal and skeletal injuries. Awareness and prompt diagnostic measures are essential in the diagnosis of cardiac injury. Strict cardiac monitoring following multiple trauma will prevent serious or even fatal outcome of cardiac injury.

Radionuclide evaluation of cardiac trauma

Radionuclides were first used in the evaluation of myocardial trauma as a noninvasive means to detect hemopericardium. At present an important use is in the diagnosis of myocardial contusion, which can be difficult to recognize clinically, and often has nonspecific EKG and enzyme alterations. Technetium-99m pyrophosphate scintigraphy has been shown to be of significant value in confirming this diagnosis. Myocardial scintigrams are helpful in determining the degree of damage produced by penetrating wounds of the heart and can also detect electrical injury to the heart from accidental shock or cardioversion. In addition, multiple gated blood pool scans can determine the hemodynamic significance of mycardial trauma and evaluate for late sequelae such as aneurysm formation.