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252 25 Accid Emerg Med 1997;14:252-257

SHORT REPORTS

Traumatic pericardial tamponade: relearning old

R Crawford, H Kasem, A Bleetmen

Abstract Case 1
Traumatic pericardial tamponade is a A 23 year old male was brought to the A&E
serious and rapidly fatal injury. As pen- department after having been stabbed in the
etrating chest wounds are becoming more anterior chest wall and the left loin. On admis-
common, early diagnosis of tamponade is sion he was conscious, with a pulse rate of 110
important so that life saving treatment beats/min and a blood pressure 90/60 mm Hg.
can be started. The classical features of Heart sounds were recorded as normal and he
tamponade may be modified by hypovol- had good bilateral air entry into the chest.
aemia and the presence of associated inju- Fluid resuscitation was begun immediately
ries; acute tamponade may also be with 1500 ml of crystalloid solution, and a
precipitated by rapid administration of chest x ray was performed. He was referred to
large volumes of fluid. Pericardiocentesis, the on-call general surgical registrar who saw
while sometimes life saving, is dangerous the patient 40 minutes after admission. At that
and of limited value. Echocardiography is stage he had become cold and clammy and was
limited by availability and operator de- complaining of chest pain; his pulse had risen
pendence. A high degree of clinical suspi- to 150/min and the blood pressure had fallen
cion in patients with chest injuries, to 70/50 mm Hg. His heart sounds were muf-
together with close monitoring and re- fled and neck veins were noted to be distended.
evaluation, particularly during volume His chest x ray revealed no evidence of a pneu-
replacement, is essential. Four cases are mothorax or haemothorax, but the cardiac sil-
described which presented to the accident houette was enlarged. Tamponade was sus-
and emergency department of Glasgow pected and echocardiography revealed a 1 cm
Royal Infirmary, in three of which there rim of fluid in the pericardial space. He was
was a significant delay in the diagnosis. taken to theatre and underwent thoracotomy.
(JAccid Emerg Med 1997;14:252-254) Five hundred millilitres of blood were evacu-
ated from his pericardial space and a 1 cm lac-
Keywords: traumatic pericardial tamponade; chest eration of the right ventricle repaired. The
wounds; treatment postoperative course was uncomplicated and
he was discharged six days later.
The majority of patients who arrive at hospital
following a penetrating injury to the heart will Case 2
have no vital signs.' Among those that do, up to A 49 year old man was brought to the A&E
16% will be relatively stable and there will not department with multiple stab wounds to his
be any indication of their serious underlying occiput, anterior chest, and epigastrium. He
injury.2 Pericardial tamponade is a life threat- was heavily intoxicated with alcohol and had a
ening complication of penetrating cardiac pulse rate of 90/min and a blood pressure of
trauma that will lead to rapid deterioration in a 100/70 mm Hg. The neck veins were not noted
patient's condition and require emergency to be distended and clear heart sound were
treatment.3 It is important to identify and treat heard. Immediate fluid resuscitation was insti-
this group of patients before deterioration tuted and a chest x ray showed no evidence of
Accident and occurs. Classically the diagnosis is suspected intrathoracic injury. As there was some con-
Emergency from the presence of hypotension, distended cern over his abdominal injuries he was taken
Department, Royal neck veins, and muffled heart sounds, known to theatre and underwent exploratory
Infirmary, Glasgow G4 as Beck's triad.4 However, these signs are not laparotomy but no significant organ injury was
OSF present in many patients or are attenuated, found. Postoperatively he became oliguric and
R Crawford making recognition more difficult. We present on re-examination was noted to be hypotensive
H Kasem
A Bleetmen
four patients who attended the accident and with a blood pressure of 90/70 mm Hg and a
emergency (A&E) department of Glasgow pulse rate of 100/min. Central venous pressure
Correspondence to: Royal Infirmary with traumatic cardiac was normal at 7 cm H2O. Despite further
Mr R Crayford, consultant in tamponade in three of whom there was a sig- administration of fluids his urine output
accident and emergency care.
nificant delay in diagnosis and we review the remained poor and his central venous pressure
Accepted for publication difficulties in the management of this clinical rose to 25 cm. A diagnosis of tamponade was
10 April 1997 problem. suspected some 12 hours after admission and
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Short reports 253

echocardiography confirmed the presence a, 2 and had great difficulty trying to speak. His
cm fluid rim, with significant compromise of respiratory rate was 28/min and bilateral air
right ventricular function. He was taken to entry into the chest was noted. His pulse rate
theatre where the tamponade was relieved and was 140/min and blood pressure was recorded
a 7 mm wound in the right ventricle repaired. at 150/80 mm Hg. An ECG revealed sinus
Postoperatively he made a good recovery and tachycardia. Arterial blood gases confirmed a
was discharged five days later. profound metabolic acidosis. A diagnosis of
acute cardiac tamponade was made and an
Case 3 immediate chest x ray showed an increased
A 31 year old male was seen in the A&E cardiothoracic ratio with no evidence of a
department with multiple small stab wounds to pneumothorax. While awaiting the arrival of
his anterior chest, upper abdomen, and left the cardiothoracic surgeons and the anaesthet-
arm. He smelt strongly of alcohol and though ist a pericardiocentesis was performed with
conscious was uncooperative and physically ECG monitoring, using the standard tech-
and verbally abusive to staff. His vital signs nique taught by the American College of
were stable with a pulse rate of 90/min and Surgeons advanced trauma life support pro-
blood pressure of 150/70 mm Hg. Arterial gramme. Eighty millilitres of blood were
blood gases revealed no evidence of hypoxia. aspirated, with immediate improvement in the
Chest x rays were normal and he was patient's condition. The pulse rate fell to
transferred to the ward for observation. Three 100/min, the blood pressure fell to 120/80 mm
hours later he complained of increasing left Hg, and his colour improved. The patient was
pleuritic chest pain and repeat radiography then anaesthetised and underwent immediate
showed a haemothorax. A chest drain was emergency thoracotomy through a median
inserted and 900 ml of blood drained out in sternotomy in the resuscitation room. A large
five minutes, with no further drainage. Imme- pericardial tamponade was evacuated and the
diately after this he was given intravenous opi- source of bleeding was found to be a puncture
ates for analgesia, but then had a cardiorespira- wound in the pulmonary artery, which was
tory arrest which responded rapidly to external repaired with a purse string suture. The patient
cardiac compression and naloxone. Tampon- made an uncomplicated recovery and was dis-
ade was suspected, and echocardiography per- charged on the sixth postoperative day.
formed. This revealed a small "sympathetic
effusion" with no evidence of ventricular com-
promise, and the episode attributed to over- Discussion
dose with opiate. Over the next few hours he Penetrating chest wounds are uncommon in
had further short self terminating "apnoeic" the United Kingdom. The incidence varies
episodes. His vital signs remained otherwise between hospitals, but Glasgow Royal Infir-
stable. The on-call general surgical team were mary deals with a large number of cases in
asked to review him and immediately following comparison to other institutions.56 Despite
their arrival he had a cardiorespiratory arrest this, recognition of cardiac tamponade can still
from which he was again successfully resusci- cause difficulty, as these cases illustrate. In a
tated. An intrathoracic injury was suspected review of emergency thoracotomies performed
and the cardiothoracic surgeons were called. over a two and a half year period, four (80%)
Before their arrival he sustained another out of five pericardial tamponades were
cardiac arrest. He was intubated and an emer- initially missed in 16 patients with penetrating
gency thoracotomy performed in the ward. A cardiac injuries.6 This is partly because the
pericardial tamponade was evacuated and a 1.5 patients are relatively stable in the early stages
cm laceration in the left ventricle repaired. and diagnosis may be difficult due to the pres-
Postoperatively he did well and was discharged ence of alcohol or other injuries which mask
five days later. subtle clinical features. The diagnosis requires
experience and a high degree of clinical suspi-
Case 4 cion. Significant hypotension must always be
A 32 year old man was brought to the A&E explained and frequent re-evaluation of the
department by ambulance as a "standby". He patient by experienced medical staff is essen-
had been found in a lift and was noted to be tial.
cyanosed and unable to give a history. The In this hospital patients with blunt and pen-
ambulance crew initially suspected a grand mal etrating chest trauma not requiring thora-
seizure but rapidly recognised he was critically cotomy are usually managed by the A&E
ill and suspected a tension pneumothorax medical staff and admitted under the care of
when they discovered a 4 mm wound in the the A&E consultants. Those patients with con-
anterior axillary fold above and lateral to the tinuing haemorrhage or suspected cardiac
right nipple. It was subsequently discovered trauma are referred directly to cardiothoracic
that the patient had been stabbed with a screw- surgeons. General surgeons therefore have lim-
driver while in the lift with a man he had ited experience of chest trauma and the
apprehended trying to break into a car. They opportunity of general surgical trainees to gain
decided to "scoop and run" and on arrival in experience of these cases is still relatively small.
the emergency department the patient was Despite this, a significant number of patients
noted to be suffused and cyanosed in the upper are treated by general surgeons because of con-
part of his body and pale and white below the comitant or suspected intra-abdominal injury,
nipples. His eyes were bulging and his neck particularly when the initial evaluation fails to
veins were grossly distended. He was agitated reveal an obvious intrathoracic injury.
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254 Short reports

Chest wounds have been divided into two Recently echocardiography has been used as
broad categories-central and peripheral- a non-invasive diagnostic tool.'4 However,
based on the likelihood of injury to the heart though helpful in confirming the diagnosis, it
and other major mediastinal structures. The cannot be relied on completely because the
borders of the central zone are the suprasternal interpretation is operator dependent and false
notch and the medial halves of the clavicle negatives occur.15
superiorly, the midclavicular lines laterally, and The role of emergency room thoracotomy
the xiphoid and costal cartilages inferiorly.7 remains controversial"6 but it is still widely
Wounds within these boundaries should raise accepted that it is of value in penetrating
the suspicion of serious cardiac injury. Three of trauma for patients in extremis' and the best
our cases had stab wounds within this "danger results are achieved in those suffering from
area". However, case 4 shows that the converse cardiac tamponade."'
of this statement is not true, and any chest
wound can result in central organ damage as its CONCLUSION
extent and trajectory cannot be determined by Traumatic pericardial tamponade is relatively
inspection, and local wound exploration is rarely encountered in the United Kingdom and
unreliable and may be dangerous. causes various diagnostic problems. Clinicians
Associated injuries may distract attention must have a high degree of clinical suspicion
from the chest, particularly if the patient when dealing with victims of penetrating chest
appears stable. This was best demonstrated in trauma, particularly if the injury lies in the
the second patient where it was not until the "cardiac danger area". Although associated
development of oliguria, following a negative injuries need to be dealt with appropriately, the
exploratory laparotomy for an abdominal possibility of occult cardiac injury must always
wound, that the correct diagnosis was made. be kept in mind since a significant minority of
The pathophysiology of tamponade is re- patients remain stable and the signs of
lated to the impairment of ventricular filling tamponade may be modified or absent because
caused by the presence of blood in the pericar- of compensatory mechanisms. Decompensa-
dial space, leading to raised end diastolic filling tion can occur rapidly during fluid replacement
pressure and impairment of venous return. and unless the clinical condition of the patient
This should be evident from distension of neck dictates otherwise this should be carried out
veins or raised central venous pressure. In cautiously, with close monitoring. Echocardio-
patients who are hypovolaemic or have periph- graphy may be helpful in confirming the diag-
eral vasodilatation due to alcohol this sign is nosis by non-invasive means but is not
often attenuated or absent until adequate completely reliable.
volume replacement has been given, as hap-
pened in the first case.8 It may be argued that 1 Sugg WL, Rea WJ, Ecker RR, Webb WR, Rose EF, Shaw
RR. Penetrating wounds of the heart: an analysis of 459
standard advanced trauma life support teach- cases. J Thorac Cardiovasc Surg 1968;56:531-45.
ing, which advocates rapid volume replace- 2 Demetriades D, Van der Veen BW Penetrating injuries to
the heart: experience over two years in South Africa. J
ment in trauma patients, may precipitate tam- Trauma 1983;23:1034-41.
ponade in those who would otherwise have 3 Jorden RC. Penetrating chest trauma. Emerg Med Clin
North Am 1993;1 1:97-106.
been stable. There is growing evidence to sup- 4 Beck CS. Two cardiac compression triads. JAMA 1935;104:
port this point of view9 and some clinicians 714-6.
5 Steedman DJ, Beard D. Preliminary analysis of the care of
now advocate that victims of trauma who have injured patients in five Scottish teaching hospitals. First
low but stable blood pressure should have report from the Scottish Trauma Audit Group (STAG).
Health Bull 1995;53:55-65.
delayed and controlled volume replacement at 6 Bleetman A, Kasem H, Crawford R. Review of emergency
the time of surgery.'" This practice, however, fhoracotomy for chest injuries in patients attending a UK
Accident and Emergency department. Injury 1996;27:
should be reserved for those patients who are 129-32.
being cared for by an appropriate and experi- 7 Borlase MC, Metcalf RK, Moore EE. Penetrating wounds
to the anterior chest. Am J Surg 1986; 152:649-53.
enced surgical team. 8 Karrel R, Shaffer MA, Franaszek JB. Emergency diagnosis,
In the face of these difficulties, pericardio- resuscitation and treatment of acute penetrating cardiac
trauma. Ann Emerg Med 1982;1 1:504-17.
centesis has been advocated as a reliable 9 Martin RR, Bickell WH, Pepe PE, Burch JM, Mattox KL.
method to diagnose and treat tamponade." Prospective evaluation of preoperative resusitation in hypo-
tensive patients with penetrating truncal injuries: a prelimi-
While this may be a truly life saving procedure, nary report. J Trauma 1992;33:354-62.
as in case 4, it is not without attendant risk, and 10 Westaby S. Resusitation in thoracic trauma. Br J Surg 1994;
81:929-31.
the number of patients in whom it is indicated 11Advanced trauma life support program handbook. Chicago:
is very small. If the blood in the pericardial American College of Surgeons, 1993.
12 Siemens R, Polk HC, Gray LA, Fulton RL. Indications for
cavity is clotted it cannot be adequately thoracotomy following penetrating thoracic injury. J
aspirated, a false negative result may be Trauma 1977;17:493-500.
13 Trinkel JK, Toon RS, Franz JL, Arom KV, Grover FL.
obtained, and the tamponade will not be Affairs of the wounded heart: penetrating cardiac wounds.
relieved. There is also danger of ventricular J Trauma 1979;19:467-71.
14 Reid CL, Kawanishi DT, Rahimtoola SH, Chandraratna
puncture and damage to the coronary arteries. PAN. Chest trauma: evaluation by two-dimensional
For these reasons most agree that this proce- echocardiography. Am HeartJ 1987;1 13:971-6.
dure is of little value in cardiac trauma.'2 15 Freshman SP, Wisner DH, Weber CJ. 2-D Echo-
cardiography: emergent use in the evaluation of penetrating
Subxiphoid pericardiotomy has been advo- precordial trauma. J Trauma 199 1;31:902-6.
cated, although it is a more invasive procedure 16 Arreola-Risa C, Rhee P, Boyle EM, Maier RV, Jurkovich
GG, Foy HM. Factors influencing outcome in stab wounds
and requires more surgical skill.'3 It is more of the heart. Am J Surg 1995;169:553-6.
sensitive than pericardiocentesis but in some 17 Asensio JA, Stewart BM, Murray J, Fox AH, Falabella A,
Gomez H, et al. Penetrating cardiac injuries. Surg Clin
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for the control of bleeding. Injury 1991;22:5-6.
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Traumatic pericardial tamponade: relearning

J Accid Emerg Med 1997 14: 252-254

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