Pediatric emergency medicine trisk 3708 3708

pressure will decrease, causing a narrowing of the pulse pressure and subsequent
hypotension and cardiogenic shock.

Clinical Considerations
Clinical Recognition
Blunt cardiac injury occurs more commonly with other associated injuries than in
isolation. Unlike adults, pediatric patients with blunt cardiac injury often have
few presenting signs or symptoms. In one pediatric study, less than half of the
awake patients with blunt cardiac injury complained of chest pain, and external
evidence of thoracic injury was present in only 60% of these patients. In the same
study, cardiac examination was abnormal in less than one-quarter of the patients.
Additional findings that should prompt evaluation for cardiac injury include a
cardiac arrhythmia, a new murmur, or evidence of congestive heart failure (e.g.,
an enlarged liver, a gallop heard on cardiac examination, or rales with
auscultation of the lungs).
Myocardial contusion, ventricular or atrial rupture, and valvular disruption may
produce cardiogenic shock. Circulatory compromise results from a decrease in
cardiac output, usually from impaired myocardial contractility.
Pericardial tamponade, due to air or blood inside the pericardium, will also
decrease cardiac output and cause circulatory collapse. If the patient is
decompensating and a pericardial tamponade is suspected, a pericardiocentesis
should be performed emergently and prior to any further diagnostic evaluation,
with the exception of bedside US when available to confirm the diagnosis and
facilitate the procedure ( Fig. 115.5 ).
Triage
Children with blunt trauma to the sternum or left hemithorax from a high-energy
mechanism should be placed on a cardiac monitor and evaluated immediately.
While the stable patient is unlikely to deteriorate, providers should be prepared to
correct any arrhythmias by both pharmacologic and electrical means. Signs of
cardiogenic shock should be addressed immediately by rapid evaluation and
correction of the cause.

Initial Assessment
Patients with cardiac injuries may complain of chest or sternal pain. Physical
examination may reveal tachycardia, an irregular heart rhythm, a new heart
murmur, signs of congestive heart failure, or in the case of cardiac tamponade,
muffled heart tones. As previously noted, however, many children with blunt