Late cardiac tamponade after cardiac trauma: A case report and a review
Bruno Jose da Costa Medeiros1, Hugo Marlon de Castro Negreiros2, Luiz da Gama Pessoa2 1 Member of Surgery Institute of Amazonas State ICEA, Titular of Brasilian Society of Trauma Integrated Attendance SBAIT, Manaus, Amazonas, Brazil 2 Resident Physician of General Surgery at Adriano Jorge Hospital Foundation - FHAJ, Manaus, Amazonas, Brazil
Date of Web Publication
15-Dec-2017
Correspondence Address: Bruno Jose da Costa Medeiros Member of Surgery Institute of Amazonas State ICEA, Titular of Brasilian Society of Trauma Integrated Attendance SBAIT, Manaus, Amazonas Brazil
Source of Support: None, Conflict of Interest: None
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DOI: 10.4103/jctt.jctt_6_17
Abstract
The pericarditis is an inflammation process of the pericardium with lots of causes, primary and secondary. It may progress with pericardial effusion and/or constrictive pericarditis. The presentation as late cardiac tamponade due to trauma is a rare clinical condition and may occur days or weeks after trauma. We report a case observed in a trauma hospital of Manaus-Amazonas, Brazil periphery. The patient presented to the hospital 18 days after a chest trauma with signs and symptoms of cardiac tamponade: tachycardia, turgid jugular veins, inferior limbs swollen, presenting breathing difficulties, and supine position not tolerated. He underwent exploratory thoracotomy, and a thick pericardium with purulent effusion was found. It is important to suspect cadiac injury in patients who are victims of trauma on cardiac box, to observe that the focused assessment sonography for trauma is used, but it has its limitations. It is 90%–95% accurate for the presence of pericardial fluid for the experienced operator. Concomitant hemothorax may account for both false-positive and false-negative ultrasound examinations.[2] When necessary, the subxiphoid exploration must be done. The possibility of occult cardiac lesion or silent cardiac wound should always be considered in patients with chest trauma by knife or gunshot on Zieddler area or cardiac box, to prevent a late cardiac tamponade or pericarditis.
How to cite this article: da Costa Medeiros BJ, de Castro Negreiros HM, Pessoa Ld. Late cardiac tamponade after cardiac trauma: A case report and a review. J Cardiothorac Trauma 2017;2:10-3
How to cite this URL: da Costa Medeiros BJ, de Castro Negreiros HM, Pessoa Ld. Late cardiac tamponade after cardiac trauma: A case report and a review. J Cardiothorac Trauma [serial online] 2017 [cited 2023 Mar 27];2:10-3. Available from: https://www.jctt.org/text.asp?2017/2/1/10/220851
Introduction
The pericarditis is an inflammation process of pericardial sac classified according to evolution and clinical presentation:[1]
Acute pericarditis
Chronic pericarditis
Pericardial effusion
Constrictive pericarditis
Recurrent pericarditis.
The pericardial sac is a conic fibrous sac which surrounds the heart and the roots of great vessels such as vena cava and aorta. It contains only a small amount of liquid (30–50 ml) to permit the sliding of heart.
The development of cardiac tamponade depends on the velocity of effusion's installation and the main cause. It can appear with only 100 ml of fluid or up to 2000 ml in chronic cases.[2]
In trauma cases, the cardiac wound may fill the pericardial sac with blood very rapidly, and the patient presents signs of tamponade: low blood pressure, muffling cardiac sounds, and turgid jugular veins, known as Beck's triad. The low blood pressure in this case is resistant to crystalloid infusion, and muffling of cardiac sounds is sometimes difficult to hear in the emergency room due to its noisy characteristic.
The absence of one triad's item does not exclude the cardiac tamponade.[3] Rarely, a cardiac wound may originate a small leak of blood to pericardial sac and the patient remains well and hemodynamically stable. In this case if the surgeon does not have a high index of suspicion the patient may develop a cardiac occult injury and sometimes be relesead home.
Some conditions are predisposed for this kind of clinical evolution:
Patients that remain clinically stable all the time
Concomitant pneumothorax that may predispose to false-negative focused assessment sonography for trauma (FAST)[4]
Unstable patients with left hemothorax but with no thoracotomy criteria that stabilize after fluid resuscitation and chest drainage [5]
The presence of pneumothorax and subcutaneous emphysema that make it difficult to carry out a FAST.[6]
The patient with chest trauma, clinically stable, and with normal examinations in the beginning must remain under clinical observation. The FAST has a high accuracy 90%–95% in experienced doctors' hand.[7] However, it may fail in some instances; that's why, it is necessary to reevaluate the patient systematically.
Case Report
A 19-year-old man, transferred from a rural hospital to our trauma center in Manaus - Amazonas, on eighteenth day after a laparotomy, complaining of abdominal pain. He presented a scar on left chest due to a tube thoracostomy, another scar on miclavicular line on 4 th intercostal space due to a knife injury, a scar on the right side of the neck due to a cervicotomy. The patient is complaining of abdominal pain, breath difficulties, and does not tolerate supine position. On assessment in the emergency department, he had breathing difficulties. There was marked tachycardia. Physical examination showed mild epigastric tenderness with voluntary guarding, but no rigidity. There were turgid jugular veins [Figure 1], swollen inferior limbs, and normal blood pressure. Vital signs were 115 beats per minute, 25 breaths per minute, blood pressure – 140/110 mmHg, and temperature –39°C or 102.2° F. FAST showed liquid in pericardial sac [Figure 2] and [Video 1] and liquid in pelvis [Figure 3]. A left thoracotomy was done and a very thick pericardial sac was found. After opening the pericardial sac, a huge amount of purulent fluid was aspirated [Figure 4] and [Video 2] and a small amount was reserved for laboratory studies. A partial pericardiectomy was performed and the pericardial sac was cleaned with 5 L of saline solution [Figure 5] and [Video 3]. Two chest tubes were placed in the chest cavity, and the pericardial sac was left open. An exploratory laparotomy on the inferior abdomen was performed but only reactive ascites were found. The fluid culture and antibiogram showed growth of Staphylococcus aureus, sensible to Oxacilin. The patient recovered well and was discharged home on day 15 postoperatively. The presentation of pericarditis as late cardiac tamponade due to trauma is a rare clinical condition and may occur days or weeks after trauma. The possibility of an occult cardiac lesion or silent cardiac wound should always be considered in patients with chest trauma by knife or gunshot on Zieddler area or cardiac box, to prevent a late cardiac tamponade. FAST should be performed and subxiphoid cardiac window should be considered in places that do not have ultrasound.
Figure 1: Turgid jugular veins. Note the scar of a right cervicotomy
The pericardial sac has a small amount of liquid, 30–50 ml which serves to allow the sliding of the heart in its interior. The development of cardiac tamponade depends on the speed of installation of the pericardial effusion and the causal factor. The acute cardiac tamponade is common on cardiac injury and may be present in 80 % of all cases, but the late tamponade is a rare condition.[2]
In cases of trauma, a cardiac injury can cause rapid filling of the pericardial sac (fibrous and inelastic consistency) with blood causing the patient to show signs of shock with hypotension, muffling of heart sounds, and distended jugular veins, known as the triad of Beck.
Purulent pericarditis is a rare event, in this case report that we have just presented secondary to trauma (occult cardiac injury), which developed as a late traumatic cardiac tamponade.
The patient had a heart injury 18 days before entering our hospital, underwent closed chest drainage on the left thorax and exploratory laparotomy of the abdomen, was released home, and evolved with signs of cardiac tamponade.
This evolution is uncommon due to the presence of very effective diagnostic methods in emergency trauma rooms. Among these, we can mention the FAST that according to the last revision of the Advanced trauma life support - ATLS is a test with an accuracy of 90%–95% in the hands of experienced examiners.[5] However, some situations such as hemopneumothorax can mask the cardiac lesion when evaluated at the ultrasound and make the diagnosis difficult of hemopericardium.
In 2013, Hommes et al. evaluated 50 patients with thoracoabdominal injury who were stable from the hemodynamic point of view and who underwent exploratory laparotomy. All patients underwent a subxiphoid pericardial window. They found a hidden hemopericardium in 14 of the 50 patients (28%).[3]
In Manaus-AM, Costa et al. evaluated 100 patients with cardiac injury, of these 82 were victims of knife attack and 18 suffered firearms injuries. They proposed continuous reassessment and liberal indication for subxiphoid pericardial exploration when FAST leaves doubts in patients with suspected cardiac injury.[4]
The diagnosis of hemopericardium in stable patients is a rather arduous task; continuous reevaluation protocols have been proposed for this purpose.
Hommes M, Nicol AJ, van der Stok J, Kodde I, Navsaria PH. Subxiphoid pericardial window to exclude occult cardiac injury after penetrating thoracoabdominal trauma. Br J Surg 2013;100:1454-8. [PUBMED]
Costa CA, Biroli D, Araújo AO, Chaves AR, Cabral PH, Lages RO, et al. Estudo retrospectivo de ferimentos cardíacos ocorridos em Manaus/AM. Rev Col Bras Cir 2012;39:272-8. Disponível em. Available from: http://www.scielo.br/rcbc. [Last accessed on 2017 Oct 10].
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