Acute traumatic cardiac tamponade treated solely by percutaneous pericardial drainage

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0 1998

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Irilur!/ by Elsevier

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Vol. 29, No. h, pp. 473-174, 1998 Science Ltd. All rights reserved Printed in Great Britain UU2i~-3383/Y8 !$19.00+0.00

PII: SOO20-1383(98)00053-9

Case reports Acute traumatic by percutaneous C. A. Graham’,

cardiac tamponade treated pericardial drainage

Z. Latif’, E. W. Muriithi*,

solely

P. R. Belcher2r3 and A. J. Ireland’

‘Accident and Emergency Department and ‘Department of Cardiothoracic Surgery, Glasgow Royal Infirmary, Castle Street, Glasgow G4 OSF, Scotland, UK and University of Glasgow, Glasgow G12 8QQ, Scotland, UK

Injury,

Vol. 29, No. 6, 473-474,

1998

Case Report A 32 year old man was brought by emergency ambulance to the Accident and Emergency (A & E) Department at Glasgow Royal Infirmary, arriving at 0349 hrs. He had been stabbed once in the chest with an unknown weapon. On examination there was a wound 2 cm to the left of the sternum in the 6th intercostal space. There were no other external injuries. Initial assessment revealed a clear airway, respirations of 4O/min, pulse rate of 125/min, and blood pressure (BP) of 140/120 mmHg. The trachea was central with normal bilateral air entry. He was drowsy (Glasgow Coma Scale E3 M6 V4) and smelled of alcohol, but was orientated and obeying commands. He was cold, clammy and sweaty and had distended neck veins. Treatment was started with high flow oxygen, two wide bore peripheral intravenous cannulae and a rapid infusion of two litres of crystalloid. Eight units of group specific blood were requested. A cardiothoracic opinion was sought urgently as the likely diagnosis was cardiac tamponade and equipment was prepared for an emergency room thoracotomy. A chest radiograph was normal. A right internal jugular cannula was inserted and a central venous pressure (CVP) of 20 cm H,O was measured as his BP dropped to 85/50 mmHg. An emergency echocardiogram was performed in the resuscitation room, which confirmed cardiac tamponade. A 4 cm effusion was demonstrated anteriorly with right sided chamber collapse. Pericardiocentesis was carried out under echocardiographic guidance using a 14 gauge needle and a single lumen central venous catheter (Leader Cath, Vygon UK Ltd, Gloucestershire, England) was inserted into the pericardium over a guidewire (F@w 2); 150 ml of blood drained in 5 min with an immediate improvement in his haemodynamic status (pulse 98 bpm, BP 98/59 mmHg, GCS E4 M6 V4). He was then transferred to the Cardiothoracic Surgical Intensive Care Unit for observation.

He remained haemodynamically stable over the next few hours. The CVP remained normal and there was no evidence of pulsus paradoxus. He was given intravenous antibiotics and during the first 72 h he drained a further 350 ml of blood (via the catheter) but remained haemodynamically stable. He was transferred to the main cardio-

thoracic ward 28h after admission and the catheter was removed on the third day after a repeat echocardiogram confirmed the absence of pericardial fluid. He was discharged the following day without complication. At outpatient review the heart size was normal and no other abnormality was seen on electrocardiography or the chest radiograph.

Discussion Cardiac tamponade is a frequently lethal complication of penetrating wounds to the mediastinum.

1. Echocardiograph immediately percutaneous drainage catheter.

Figure

after insertion

of

474

Injury: International

may present in extremis and the survival rate for these patients is very poor despite immediate thoracotomy in the A&E Department’, which has brought this treatment under close scrutiny’. A proportion of patients with cardiac tamponade may present with less obvious signs and indeed the diagnosis may be delayed”. The classically described Beck’s Triad -L(muffled heart sounds, distended neck veins and hypotension) is often absent; neck veins may not be distended due to concurrent hypovolaemia. In this patient the neck veins were distended and the diagnosis was readily apparent. It is essential to maintain a high index of suspicion for cardiac tamponade, and it should be remembered that any penetrating wound between the root of the neck and the umbilicus can cause tamponade3 If tamponade is suspected but not clinically apparent, a chest radiograph may show an enlarged cardiac shadow. However, as in this case, the chest radiograph may be normal. Transthoracic echocardiography in the resuscitation room is the diagnostic procedure of choices. It will identify almost all those patients with acute tamponade and facilitates guided pericardial aspiration or drainage. If echocardiography is unavailable or the patient is undergoing laparotomy for other reasons, creation of a pericardial window via the subxiphoid approach is an alternative method of excluding cardiac tamponade”. If cardiac tamponade is confirmed or strongly suspected, emergency left thoracotomy or median sternotomy is usually required to explore the chest and empty the pericardium of blood and clot. The wound to the heart or great vessel involved is sutured and the chest is closed with tube drainage of the pericardium. In order to avert emergency room thoracotomy and in keeping with current cardiological practice in the treatment of tamponade following invasive cardiological procedures, it was decided to drain the haemopericardium percutaneously. If drainage is persistently high and there is haemodynamic instability or ECG changes, further measures must be taken. However, this initial approach is capable of Patients

Journal of the Care of the Injured Vol. 29, No. 6,1998

relieving acute tamponade thus allowing proper assessment of the patient’s volaemic status and the management of other urgent injuries. This case illustrates that a percutaneously placed pericardial drain alone can relieve acute cardiac tamponade without the need for surgical intervention. It is stressed, however, that this approach should only be adopted when the patient can be closely observed in an appropriate cardiothoracic intensive care setting by cardiothoracic surgeons who are skilled in dealing with such injuries. It must be remembered that immediate surgical intervention may be required at any time during the first 48h, and the standard of observation should reflect this.

References 1 Bleetman A., Kasem H. and Crawford

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3

4 5

6

R. Review of emergency thoracotomy for chest injuries in patients attending a UK Accident and Emergency department. Injury 1996; 27(2): 129-132. Asensio J. A., Stewart B. M. and Murray J. etal. Penetrating cardiac injuries. Surgicnl Cliuics UI North America 1996; 76(4): 685-724. Crawford R., Kasem H. and Bleetman A. Traumatic pericardial tamponade: relearning old lessons. Jomud of Accideplt alld Emergency Medicine 1997; 14: 252-257. Beck C. S. Acute and chronic compression of the heart. Americafz Heart Journal 1937; 14: 515. Thakur R. K., Aufderheide T. I’. and Boughner D. R. Emergency echocardiographic evaluation of penetrating chest trauma. Carladiarl jourrlal of Cardiology 1994; lO(3): 374-376. Arom K. V., Richardson J. D. and Webb G. etal. Subxiphoid pericardial window in patients with suspected traumatic pericardial tamponade. Amals uf Thoracic Surgery 1977; 23: 545.

Paper accepted 15 January 1998. Requests

Accident Infirmary,

for

reprints should be addressed to: Dr C. A. Graham, and Emergency Department, Glasgow Royal Castle Street, Glasgow G4 OSF, Scotland, UK.

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