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# Blunt cardiac injury

Damage to the heart from a hard blow to the chest, such as hitting a steering wheel. It can cause abnormal heart rhythms or, rarely, a tear in the heart.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Right ventricle](https://durgical.com/en/anatomy/right-ventricle/)
- [Sternum](https://durgical.com/en/anatomy/sternum/)
- [Pericardium](https://durgical.com/en/anatomy/pericardium/)
- [Left ventricle](https://durgical.com/en/anatomy/left-ventricle/)
- [Right atrium](https://durgical.com/en/anatomy/right-atrium/)
- [Interventricular septum](https://durgical.com/en/anatomy/interventricular-septum/)
- [Sinoatrial (SA) node](https://durgical.com/en/anatomy/sinuatrial-node/)
- [Atrioventricular (AV) node](https://durgical.com/en/anatomy/atrioventricular-node/)
- [Tricuspid anterior leaflet](https://durgical.com/en/anatomy/superior-leaflet-of-right-atrioventricular-valve/)
- [Right coronary artery](https://durgical.com/en/anatomy/right-coronary-artery/)
- [Ribs (back part)](https://durgical.com/en/anatomy/ribs/)

## Why it happens

- [How arrhythmias arise](https://durgical.com/en/physiology/how-arrhythmias-arise/)
- [Refractory periods and excitability](https://durgical.com/en/physiology/refractory-periods-and-excitability/)
- [Cardiac troponin as a lab test](https://durgical.com/en/biochemistry/topics/cardiac-troponin-as-a-lab-test/)
- [Cardiac muscle: intercalated discs](https://durgical.com/en/histology/cardiac-muscle-intercalated-discs/)

## What it is

A spectrum of heart injury caused by blunt chest trauma, ranging from a silent myocardial contusion with ECG changes to arrhythmias, valve or septal rupture, free-wall rupture and commotio cordis. The [right ventricle](https://durgical.com/en/anatomy/right-ventricle/) is most often affected because it lies directly behind the [sternum](https://durgical.com/en/anatomy/sternum/).

## Who gets it

Occurs in a meaningful minority of patients with severe blunt chest trauma, but true incidence is uncertain because there is no single diagnostic standard. In Colombia and Latin America the leading mechanisms are motor-vehicle and motorcycle crashes, falls from height and assaults.

## Causes

- Steering wheel or dashboard impact in road traffic crashes
- Falls from height
- Crush injuries and kicks from animals
- Assaults and blows to the chest
- Commotio cordis: a ball or blow to the precordium at a vulnerable moment of the cardiac cycle

## Risk factors

- High-energy frontal impact or rapid deceleration
- Sternal fracture
- Multiple rib fractures or flail chest
- Associated pulmonary contusion
- Pre-existing heart disease (less reserve)

## Pathophysiology

Compression of the heart between the sternum and the [spine](https://durgical.com/en/anatomy/region/spine/), or sudden deceleration, bruises the myocardium with haemorrhage and necrosis similar to an infarct but without a coronary pattern. The injured muscle is an electrical focus for arrhythmias and may contract poorly. Higher energy can tear a valve, papillary muscle or the septum, or rupture a free wall, causing tamponade. In commotio cordis a blow during the repolarisation window triggers ventricular fibrillation without structural damage.

## Classification

- Myocardial contusion with ECG changes or arrhythmia
- Blunt cardiac injury with pump failure
- Septal rupture, valve injury (most often aortic or tricuspid) or papillary muscle rupture
- Free-wall rupture with tamponade or exsanguination
- Coronary artery injury (dissection or thrombosis)
- Commotio cordis

## Symptoms and signs

- Chest pain and chest wall bruising (steering-wheel mark)
- Palpitations
- Unexplained tachycardia
- Shortness of breath
- Often no specific symptoms

## Red flags

- Hypotension not explained by bleeding
- New arrhythmia, conduction block or ST changes on ECG
- Distended neck veins, muffled heart sounds and hypotension (tamponade)
- New murmur with acute heart failure (valve or septal rupture)
- Sudden collapse after a blow to the chest (commotio cordis)

## Diagnosis

**Clinical**
Suspect it in every significant frontal [chest](https://durgical.com/en/anatomy/region/chest/) impact. ATLS primary survey; examine for tamponade, murmur and heart failure.

**Tests**
A 12-lead ECG on arrival in all suspected cases (sinus tachycardia, ectopy, atrial fibrillation, [right bundle branch](https://durgical.com/en/anatomy/right-bundle-branch/) block, ST changes) and serum troponin. A normal ECG together with a normal troponin essentially excludes clinically significant injury.

**Imaging**
E-FAST during resuscitation looks for pericardial fluid and wall motion problems. Formal echocardiography when screening results are abnormal or the patient is haemodynamically unstable. CT of the chest assesses associated injuries such as sternal fracture and aortic injury.

## Differential diagnosis

- Acute myocardial infarction (which may itself have caused the crash)
- Cardiac tamponade from other causes
- Tension pneumothorax
- Traumatic aortic injury
- Hypovolaemic shock from bleeding elsewhere

## Goal of treatment

Detect the patients at risk of arrhythmia or pump failure, monitor and treat them, and recognise and repair the rare structural injuries quickly.

## Treatment

**Acute**
ATLS approach; immediate CPR and defibrillation for commotio cordis; pericardial decompression and emergency thoracotomy or sternotomy for tamponade or rupture.

**Follow-up**
Continuous cardiac monitoring for about 24 hours when the ECG is abnormal or troponin is raised; patients with normal ECG and troponin can be cleared.

**Medical**
Standard treatment of arrhythmias (antiarrhythmics, electrical cardioversion) and of heart failure; inotropes and vasopressors for pump failure, guided by echocardiography.

**Surgical**
Surgical repair for free-wall, septal, valve or papillary muscle rupture; coronary revascularisation for traumatic coronary occlusion.

**Conservative**
Nursing priorities: rhythm monitoring, frequent vital signs, watching for signs of tamponade, analgesia and oxygen.

## Complications

- Ventricular and atrial arrhythmias, including sudden death
- Cardiogenic shock
- Cardiac tamponade
- Ventricular septal defect or valve regurgitation
- Ventricular aneurysm or mural thrombus

## Prognosis

Isolated contusion with minor ECG changes usually recovers fully within days to weeks. Free-wall rupture is often fatal before hospital; patients who reach theatre alive may survive. Commotio cordis survival depends on rapid defibrillation.

## Prevention

- Seatbelts and airbags
- Chest protectors in contact and ball sports
- Automated external defibrillators at sports venues

## Test yourself

Think of the answer, then tap the question to see it.

## Which cardiac chamber is most often injured in blunt chest trauma, and why?

The right ventricle, because it lies directly behind the sternum.

## Which two tests are used to screen for blunt cardiac injury, and what does it mean when both are normal?

A 12-lead ECG and serum troponin; if both are normal, significant blunt cardiac injury is effectively ruled out.

## What is the most common arrhythmia after blunt cardiac injury?

Sinus tachycardia overall; among true arrhythmias, atrial fibrillation and premature beats are frequent.

## What is commotio cordis and how is it treated?

Ventricular fibrillation triggered by a blow to the precordium in a structurally normal heart; treated with immediate CPR and defibrillation.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/conditions/blunt-cardiac-injury/)

## Related conditions

- [Cardiac tamponade](https://durgical.com/en/conditions/cardiac-tamponade/)
- [Atrial fibrillation](https://durgical.com/en/conditions/atrial-fibrillation/)
- [Ventricular tachycardia](https://durgical.com/en/conditions/ventricular-tachycardia/)
- [Blunt traumatic aortic injury](https://durgical.com/en/conditions/blunt-traumatic-aortic-injury/)
- [Pulmonary contusion](https://durgical.com/en/conditions/pulmonary-contusion/)
- [Flail chest](https://durgical.com/en/conditions/flail-chest/)
- [Rib fractures](https://durgical.com/en/conditions/rib-fractures/)
- [Myocardial Infarction (Heart Attack)](https://durgical.com/en/conditions/myocardial-infarction/)
- [Heart failure](https://durgical.com/en/conditions/heart-failure/)
- [Major trauma (polytrauma): ATLS primary survey](https://durgical.com/en/conditions/major-trauma-atls-primary-survey/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Blunt Cardiac Injury - Injuries; Poisoning - Merck Manual Professional Edition](https://www.merckmanuals.com/professional/injuries-poisoning/thoracic-trauma/blunt-cardiac-injury) (Merck Manual Professional Edition, 2025); Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline (Journal of Trauma and Acute Care Surgery, 2012).

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Source: https://durgical.com/en/conditions/blunt-cardiac-injury/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/blunt-cardiac-injury/