What is the next step in managing a patient with chest pain after a motor vehicle crash, with negative initial CT imaging, normal electrocardiogram (ECG) and troponin level less than 0.1?

Management of Post-Traumatic Chest Pain with Normal Initial Workup

This patient should be admitted for observation on telemetry (Option A). Despite negative initial imaging and cardiac markers, blunt chest trauma from steering wheel impact carries significant risk for delayed cardiac complications that require continuous monitoring.

Rationale for Admission with Telemetry

Blunt cardiac injury requires serial monitoring even with initially negative studies. The American Heart Association guidelines establish that patients with chest pain syndromes and potential cardiac injury warrant telemetry observation with serial ECGs and cardiac biomarkers at 3-6 hour intervals 1. This is particularly critical in trauma patients where:

• Myocardial contusion can present with delayed troponin elevation occurring 6-12 hours after injury, making a single initial troponin insufficient for ruling out cardiac injury 2
• Traumatic arrhythmias may develop hours after the initial impact, with the highest risk occurring within the first 24-48 hours post-trauma 1
• The mechanism of injury (direct steering wheel impact) represents high-energy blunt chest trauma, which carries substantial risk for cardiac contusion, coronary dissection, or pericardial injury even when initial CT imaging appears normal

Observation Protocol

The appropriate management includes 1:

• Continuous cardiac monitoring on telemetry for at least 24 hours to detect arrhythmias
• Serial troponin measurements at 3-6 hour intervals (minimum of 2-3 measurements) to identify delayed myocardial injury 1, 3
• Repeat ECGs at 3,6-9, and 24 hours to detect evolving ischemic changes 3
• Serial clinical assessments for development of hemodynamic instability, new murmurs (suggesting valvular injury), or signs of pericardial effusion

Why Other Options Are Inappropriate

Discharge home (Option B) is unsafe because:

• A single normal troponin drawn immediately after trauma does not exclude delayed myocardial injury 2
• The American Heart Association specifically recommends against immediate discharge in patients with chest pain requiring cardiac evaluation, emphasizing the need for serial markers 1
• Blunt cardiac trauma can manifest delayed complications including arrhythmias, which occurred in the first 24-48 hours in trauma populations 1

Nuclear perfusion study (Option C) is premature because:

• This test is indicated for risk stratification in stable patients with possible ACS after serial markers are negative, not as an initial diagnostic step 1
• In trauma patients, the priority is detecting acute cardiac injury (contusion, arrhythmia) rather than chronic coronary disease 3

Repeat chest x-ray in 4 hours (Option D) addresses pulmonary complications but fails to monitor for cardiac injury, which is the primary concern given the mechanism and symptomatology.

Critical Pitfalls to Avoid

• Never rely on a single troponin measurement in trauma patients - the temporal pattern of troponin elevation is essential for diagnosis, with peak levels often occurring 6-12 hours post-injury 3, 2
• Do not assume normal CT excludes cardiac injury - myocardial contusion and small pericardial effusions may not be visible on initial chest CT, and coronary dissection requires specific imaging protocols
• Recognize that normal ECG does not exclude significant cardiac trauma - ECG changes may be delayed or subtle, particularly with right ventricular contusion 3