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

2. 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

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

5. 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

6. Differential Diagnosis
What types of injuries might occur?

7. 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

8. Physical Examination
What would you look for?

9. 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

10. Jugular Venous Distension

11. 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.

12. Laboratory
What would you obtain?

13. 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

14. Interventions at this point?

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

16. Tachycardia
Narrow Pulse Pressure
Tachypnea

17. 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:

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

19. AP Chest X-Ray: Patient S.W.

20. Pericardial Ultrasound
Pericardial Fluid
Heart

21. 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?

22. What next?

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

24. 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?

25. Management
Go directly to the Operating Room…

26. Median Sternotomy

27. 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.

28. QUESTIONS ??????

29. 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

30. Acknowledgment
The preceding educational materials were made available through the ASSOCIATION FOR SURGICAL EDUCATION
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