Suspected myocardial contusion. Emergency investigation and diagnosis

Introduction: Diagnostic criteria and hospitalization indications for suspicion of myocardial contusion are still unclear. Under the ATLS (Advanced Trauma Life Support) principles, the true diagnosis of contusion can only be determined by direct myocardial inspection. Despite recent advances in investigative techniques, myocardial trauma remains an important diagnosis and challenge in therapeutic conduct.
Case report: We present the case of a 46-year-old pati-ent without a pathological history but with heredocola-teral antecedents presenting himself in the emergency service for a first episode of precordial pain during the night. Upon presentation in the emergency room, the patient had tension values of155 / 90 mmHg, 70 heart-beats, 96% oxygen saturation of blood, with slightly improved symptomatology after intravenous NTG and analgesics. The ECG shows discrete T-negative spots in V1-V3, biologically with myocardial enzyme reaction. Echocardiography highlights effective left ventri-cle, minimal fibrin and fine lateral fluid blade on the lateral side of the right ventricle, mild hypokinesia of the medial apical interventricular septum. Biologically without inflammatory reaction, but with leukocytosis. Considering the heredocolateral history, the clinical picture and the evolving ECG, with the development of diffuse negative T-waves, coronarography is performed but does not detect stenotic / thrombotic lesions in the epicardial vessels. In dynamics, decreasing high sensitivity troponin, without recurrence of symptomatology from admission, without evolving echocardiographic changes, but with the progressive widening of T waves. Paraclinical investigations are completed with cardiac MRI.
The particularity of the case: Based on the clinical and paraclinical data obtained in the patient’s emergen-cy assessment, myocardial contusion is discussed, the patient reporting a strong anterior thoracic contusion (elbow stroke) the day before the emergency service, followed by chest pain for two hours.
Although an acute coronary syndrome is initially suspected, normal angiographic coronaries accompanied by a lack of cardiovascular risk factors and absence of suggestive echocardiographic changes exclude it. The reactive high sensitivity Troponin directs us towards a possible contusion, data from the literature supporting the enzymatic reaction as being highly specific for myocardial injury. ECG changes, though initially discrete, become evident in the coming days, with deep T-waves in all derivations. Changes in the ST segment and the T wave can occur in lesions of the left ventricle, with cases described in literature evolving with global T-wave inversion after chest contusions, which is the same in our case.
However, the possibility of a myocarditis is not completely excluded, although the clinical context is lacking. Cardiac MRI is performed to support the diagnosis, which reveals myocardial edema, recent microvascular obstruction, myocardial destruction located strictly at the median and apical interventricular septum. Other cases cited in the literature frequently describe the interventricular septum (often ruptures) in the case of cardiac contusions secondary to thoracic trauma.
Conclusions: Cardiac contusion is the most common heart lesion after chest trauma but precise diagnosis is still provocative because of its variation in clinical presentation. It should be taken into account that a strong impact on the thoracic front often results in myocardial contusions. Nuclear magnetic resonance imaging may be useful in both the diagnosis and the management of cardiac traumatic lesions.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)