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?
Was he stabbed by a man or a
When was he stabbed? woman?
What were the Pertinent PMH,
circumstances surrounding
the incident? ROS, MEDS
How long was the knife?
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 CV: muffled heart
distension 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 CT Scan: Abd/Pelvis
Abdominal Series etc. 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
Acknowledgment
The preceding educational materials were made available through the
ASSOCIATION FOR SURGICAL EDUCATION
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