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
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