TRAUMA Stab Wound to the Chest: Cardiac Tamponade

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TRAUMAStab Wound to the Chest Cardiac Tamponade

• Mary C. McCarthy, MD FACS
• Professor of Surgery
• Wright State University
• Dayton, Ohio

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Patient S.W.

• 45 year-old man presents to the Emergency
  Department after being involved in an altercation
• He states he was stabbed in the chest with a
  knife when he picked up 2 quarters from the edge
  of a pool table

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(No Transcript)
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History

• What other points of the history do you want to
  know?

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History, Patient S.W.

• Chest pain, shortness of breath?
• When was he stabbed?
• What were the circumstances surrounding the
  incident?
• How long was the knife?

• Was he stabbed by a man or a woman?
• Pertinent PMH,
• ROS, MEDS

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Differential Diagnosis

• What types of injuries might occur?

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Differential Diagnosis

• S.W. has a stab wound to the left anterior
  precordium in an area known as the mediastinal
  box bound by the clavicles, the midclavicular
  lines bilaterally, and the costal margins
  inferiorly
• Penetrating wounds to this area have a high
  incidence of cardiac injuries, although wounds of
  the abdomen, lateral chest or back may also cause
  injury to the heart
• A pneumothorax or hemothorax could also occur
• Penetrating injuries below the nipples can cause
  intraabdominal injuries

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Physical Examination

• What would you look for?

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Physical Examination Patient S.W.

• Vital Signs BP 80/P, P 95, R 30
• Appearance Agitated, diaphoretic
• Relevant Exam findings for a problem focused
  assessment

Remaining Examination findings non-contributory
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Jugular Venous Distension
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Would you like to revise your Differential
Diagnosis?

• The classic signs of cardiac tamponadehypotension
  , muffled heart tones, and elevated central
  venous pressure--are known as Becks triad.
• A narrow pulse pressure, and pulsus paradoxus
  have also been described or merely the
  disappearance of the radial pulse when the
  patient takes a deep breath.

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Laboratory

• What would you obtain?

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Labs ordered, Patient S.W.

• Major trauma labs CBC, Chem-6, PT/PTT should be
  obtained
• A Type and Crossmatch for blood should be obtained

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Interventions at this point?
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Interventions at this point?

• Start 2 large bore peripheral IVs with Ringers
  Lactate or similar isotonic crystalloid solution
• Administer antibiotics (first generation
  cephalosporin)

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Tachycardia
Narrow Pulse Pressure
Tachypnea
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Studies, Patient S.W.
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Studies

• Encourage cost-effective approach to ordering
  studies
• Discuss risk/benefits of various diagnostics
• Encourage students to interpret the imaging study

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AP Chest X-Ray Patient S.W.
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Pericardial Ultrasound
Pericardial Fluid
Heart
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Studies Results

• Chest X-ray is normalthere is no evidence of
  hemothorax or pneumothorax
• The FAST shows a hypoechoic rim of blood around
  the heart
• What is the differential diagnosis at this point?

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What next?

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What next?

• Pericardiocentesis a preliminary pericardial tap
  may buy time in a patient who is decompensating
• Risks vs. Benefits

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Management

• Technique of pericardiocentesis 45o aspiration,
  EKG guidance, aim to L scapula
• S.W.s Blood Pressure rises to 110/90 after
  aspiration of blood from the pericardium.
• What should be done next?

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Management

• Go directly to the Operating Room

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Median Sternotomy
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Discussion

• The Trauma Surgeon or Cardiothoracic Surgeon
  opens the chest through a median sternotomy and
  direct repair of the cardiac injury is performed.
  Care is taken to avoid occluding the left
  anterior descending artery.
• Few patients present with all 3 symptoms of
  Becks Triad, and a high index of suspicion
  should be maintained in patients with penetrating
  injuries in the parasternal area.

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QUESTIONS ??????
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Summary

• Trauma ABCs
• Suspect cardiac tamponade in penetrating chest
  trauma
• Becks Triad Hypotension, muffled heart sounds,
  elevated central venous pressure
• Technique of pericardiocentesis
• Definitive Repair of Cardiac Injuries

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