Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury.
BACKGROUND
Uncertainty about the definition and diagnosis of blunt cardiac injury (BCI) leads to unnecessary hospitalization and cost while trying to rule it out. The purpose of this study was to examine whether the combination of two simple tests, electrocardiography (ECG) and serum troponin I (TnI) level, may serve as reliable predictors of BCI or the absence of it.


METHODS
Over a period of 30 months (September 1999-February 2002), 333 consecutive patients with significant blunt thoracic trauma were followed prospectively. Serial ECG and TnI tests were performed routinely and echocardiography was performed selectively. Clinically significant BCI (SigBCI) was defined as the presence of cardiogenic shock, arrhythmias requiring treatment, or posttraumatic structural deficits.


RESULTS
SigBCI was diagnosed in 44 patients (13%). Of 80 patients with abnormal ECG and TnI, 27 (34%) developed SigBCI. Of 131 with normal serial ECG and TnI, none developed SigBCI. Of patients with abnormal ECG only or TnI only, 22% and 7%, respectively, developed SigBCI. The positive and negative predictive values were 29% and 98% for ECG, 21% and 94% for TnI, and 34% and 100% for the combination of ECG and TnI. The admission ECG or TnI was abnormal in 43 of 44 patients with SigBCI. Only one patient had initially normal ECG and TnI and developed abnormalities 8 hours after admission. Forty-one patients without other significant injuries stayed 1 to 3 days in the hospital only to rule out SigBCI and could have been discharged earlier. Besides ECG and TnI, other independent risk factors of SigBCI were an Injury Severity Score > 15, the presence of significant skeletal trauma, and history of cardiac disease.


CONCLUSIONS
The combination of normal ECG and TnI at admission and 8 hours later rules out the diagnosis of SigBCI. In the absence of other reasons for hospitalization, such patients can be safely discharged.
Velmahos
George C
GC
Department of Surgery, University of Southern California, and the Los Angeles County and University of Southern California (LAC+USC) Medical Center, Los Angeles, CA 90033, USA. velmahos@usc.edu.
Karaiskakis
Marios
M
Salim
Ali
A
Toutouzas
Konstantinos G
KG
Murray
James
J
Asensio
Juan
J
Demetriades
Demetrios
D
D000328:Adult; D015415:Biomarkers / Q000097:blood; D004452:Echocardiography / Q000379:methods / Q000592:standards; D004562:Electrocardiography / Q000592:standards*; D005260:Female; D006335:Heart Injuries / Q000097:blood / Q000175:diagnosis* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D007902:Length of Stay / Q000706:statistics & numerical data; D015141:Los Angeles / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors; D014193:Trauma Centers; D014218:Triage / Q000379:methods; D019210:Troponin I / Q000097:blood*; D014949:Wounds, Nonpenetrating / Q000097:blood / Q000175:diagnosis* / Q000401:mortality
D015415:Biomarkers; D019210:Troponin I