trauma stab wound to the chest: cardiac tamponade mary c. mccarthy, md facs professor of surgery...
TRANSCRIPT
TRAUMAStab 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
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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ASSOCIATION FOR SURGICAL EDUCATIONASSOCIATION FOR SURGICAL EDUCATION
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