TRAUMA Stab Wound to the Chest: Cardiac Tamponade Mary C. McCarthy, MD FACS Professor of Surgery Wright State University Dayton, Ohio

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

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

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

Differential Diagnosis What types of injuries might occur?

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

Physical Examination What would you look for?

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 HEENT: Jugular venous distension CV: muffled heart sounds Chest: Equal breath sounds Abd: Soft, non-tender Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your Differential Diagnosis? The classic signs of cardiac tamponade—hypotension, muffled heart tones, and elevated central venous pressure--are known as Beck’s 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.

Laboratory What would you obtain?

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

Interventions at this point?

Interventions at this point? Start 2 large bore peripheral IV’s with Ringers Lactate or similar isotonic crystalloid solution Administer antibiotics (first generation cephalosporin)

Tachycardia Narrow Pulse Pressure Tachypnea

Studies, Patient S.W. Obstruction Series/Acute Abdominal Series etc. CT Scan: Abd/Pelvis CT Scan: Other Flat/Upright Abdomen MRI PA/Lat Chest PET SCAN Ultrasound (FAST) Extremity Film RUQ US Bone Scan Angiogram US Pelvis HIDA Scan MRCP OTHER:

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

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound Pericardial Fluid Heart

Studies – Results Chest X-ray is normal—there 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?

What next?

What next? Pericardiocentesis: a preliminary pericardial tap may “buy time” in a patient who is decompensating Risks vs. Benefits

What should be done next? 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?

Management Go directly to the Operating Room…

Median Sternotomy

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 Beck’s Triad, and a high index of suspicion should be maintained in patients with penetrating injuries in the parasternal area.

QUESTIONS ??????

Summary Trauma ABC’s Suspect cardiac tamponade in penetrating chest trauma Beck’s Triad: Hypotension, muffled heart sounds, elevated central venous pressure Technique of pericardiocentesis Definitive Repair of Cardiac Injuries

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