P BLUNT CARDIAC TRAUMA

Risk Management Pitfalls in Blunt Chest Trauma

1. “I always wait 3 hours before obtaining a troponin as part of my BCI workup.”

It would be appropriate to send troponin as part of the initial blood draw, therefore decreasing the duration of workup in the ED. Very few patients with significant BCI will have both a negative initial ECG and troponin. The important concept is to perform both tests initially, and if both are negative, then there is very little value to serial testing.

2. “The chest x-ray was normal, so I felt comfortable ruling out a pericardial effusion.”

A significant amount of fluid may be present in the pericardium despite a normal chest x-ray. If suspicion for a BCI or pericardial effusion remains, both point-of-care ultrasound and CT have high sensitivity and should be considered.

6. “For all patients with BCI, I order a formal echocardiogram and admit them to inpatient telemetry.”

Patients with suspected BCI can be effectively ruled out while in the ED or observation unit. Formal echocardiograms are reserved for patients with hemodynamic instability, persistent new dysrhythmias, and increasing troponin levels, and in symptomatic patients with significant mechanisms of injury. In otherwise stable patients, consideration of discharge home versus observation can avoid an inpatient admission.