What is the most appropriate initial diagnostic test for a patient with chest trauma after a road traffic accident (RTA), who is hospitalized and found to have premature ventricular contractions (PVCs) and a normal bowel sounds (NBS), with options including echocardiogram (ECHO), electrocardiogram (ECG), serial troponins, or focused assessment with sonography for trauma (FAST)?

From the Guidelines

The most appropriate initial diagnostic test for a patient with chest trauma after a road traffic accident (RTA) who is hospitalized and found to have premature ventricular contractions (PVCs) is an electrocardiogram (ECG). This is because an ECG provides immediate information about cardiac rhythm disturbances, conduction abnormalities, and signs of myocardial injury that may result from blunt chest trauma 1. While an echocardiogram (ECHO) would be useful to assess structural damage, serial troponins to monitor for myocardial injury, and Focused Assessment with Sonography for Trauma (FAST) to detect free fluid in trauma, the ECG is the first-line test for evaluating cardiac electrical activity and rhythm disturbances like PVCs.

Key Considerations

• The patient's presentation with PVCs suggests a potential cardiac rhythm disturbance that requires immediate evaluation with an ECG 1.
• An ECG can quickly identify potentially life-threatening arrhythmias, ischemic changes, or conduction abnormalities that require immediate intervention in this trauma setting.
• The presence of normal bowel sounds (NBS) is not directly relevant to the choice of initial diagnostic test for cardiac trauma.
• The patient's hemodynamic stability is crucial in determining the subsequent diagnostic and therapeutic approach, with hemodynamically unstable patients requiring more urgent evaluation and management 1.

Diagnostic Approach

• The initial diagnostic approach should prioritize the evaluation of cardiac rhythm and function using an ECG.
• If the ECG reveals abnormal findings or if the patient's clinical condition warrants further evaluation, additional diagnostic tests such as echocardiography, serial troponins, or FAST may be considered.
• The choice of subsequent diagnostic tests should be guided by the patient's clinical presentation, hemodynamic stability, and the results of the initial ECG evaluation 1.

From the Research

Initial Diagnostic Test for Chest Trauma

The most appropriate initial diagnostic test for a patient with chest trauma after a road traffic accident (RTA) can be determined based on the patient's symptoms and medical history.

• For patients with premature ventricular contractions (PVCs) and normal bowel sounds (NBS), the following options are available:
  • Echocardiogram (ECHO)
  • Electrocardiogram (ECG)
  • Serial troponins
  • Focused assessment with sonography for trauma (FAST)

Relevant Studies

Studies have shown that:

• ECG findings are significant in nonpenetrating chest trauma, and surface ECG in conjunction with creatinine phosphokinase (CPK) isoenzyme assay has been an accepted standard for diagnosis of posttraumatic cardiac dysfunction 2.
• Helical CT of the chest is most important in the initial work-up of chest trauma, and aortography is only indicated in selected cases 3.
• A systematic approach prioritizing airway, respiration, and circulation is essential for the evaluation of thoracic trauma 4.
• Acoustic cardiography can detect PVC-induced minor electromechanical dysfunction in patients with normal left ventricular ejection fraction (LVEF) 5.

Diagnostic Test Selection

Based on the patient's symptoms, an electrocardiogram (ECG) is likely the most appropriate initial diagnostic test, as it can help identify any cardiac dysfunction or arrhythmias, such as PVCs, which are present in this patient 2. Additionally, a focused assessment with sonography for trauma (FAST) may also be useful in evaluating the patient's chest trauma 3, 4.