Posttraumatic Cardiac Tamponade

1
Post-traumatic Cardiac Tamponade

• ??????R1
• ??????V.S
• 91-11-30

2
Delayed post-traumatic tamponade together with
rupture of the tricuspid valve in a 15 year old
boy

• HEART
• Volume 86(5)             1 November 2001         
     
• Department of Cardiology, AZ Middelheim,
  Lindendreef 1, 2020 Antwerp, Belgium
• Accepted for publication 11 July 2001
• Correspondence to Dr Vermeersch
  Pvermeersch_at_tijd.com

3

• A 15 year old boy with no medical history was
  admitted in August 1999 to hospital following a
  road traffic accident
• bilateral extensive pulmonary contusion, liver
  laceration, and a fracture of the fifth
  metacarpal bone
• no signs of cardiac involvement were noted and
  there was no evidence of major vessel disruption

4

• Four months after the accident
• progressive tiredness and dyspnea during
  exercise.
• suffering from flu like symptoms
• discovered a systolic murmur.
• patient's temperature raised to 39degreesC and
  he had severe dyspnea at rest

5

• On arrival at a second hospital
• pale, tachypnea, and tachycardic, his blood
  pressure was 110/70 mm Hg, a pulsus paradoxus was
  noted, and central venous pressure was increased
• Echocardiography showed a large pericardial
  effusion.
• immediately referred to our department for
  emergency pericardiocentesis
• Transoesophageal echocardiography
• severe tricuspid regurgitation
• Left ventricular function was completely
  normal.
• Severe dilatation of the right ventricle

6

• A total of 650 cm3 (sero) sanguineous fluid (with
  obvious signs of haemolysis) was removed
• Lactate dehydrogenase and total protein content
  in the pericardial fluid were, respectively, 4369
  U/l and 51 g/l (concentrations in serum 856 U/l
  and 55 g/l, respectively).
• CRP 108 mg/l (normal lt 1) and fibrinogen (5.21
  g/l, normal range 1.8-4.0)
• a rupture of the posterior papillary muscle and
  partial laceration of the chordae tendineae,
  causing deinsertion of anterior and posterior
  leaflets

7
Discussion

• report two unusual complications of blunt chest
  trauma
• 1.delayed cardiac tamponade
• 2.severe tricuspid regurgitation
• Post-traumatic hemopericardium
• 1.coronary artery laceration
• 2.cardiac rupture
• 3.diffuse myocardial hemorrhage

8

• delayed cardiac tamponade
• 1.the displacement of thrombus that had
  temporarily
• closed the cardiac wound
• 2.adhesion that formed at the time of injury
  was torn
• 3.exudative non-hemorrhagic pericardial
  effusions
• autoantibodies against the pericardium or
• myocardium
• 4.pericardial effusion has gradually developed
  and
• that hemolysis of an earlier pericardial
  hematoma
• is responsible for accumulation of
  additional fluid in
• the pericardial space

9

• Because of its position in the chest (immediately
  behind the sternum), the right ventricle has a
  predisposition for an anteroposterior compression
  type of injury

10
Conclusion

• Follow up examination of all patients with chest
  trauma for several months after the injury
• instructed to return when symptoms of chest pain
  or dyspnea become evident.

11
Delayed Cardiac Tamponade after Blunt Chest
Trauma in a Child

• Trauma
• Murillo, Carlos A. MD Owens-Stovall, Sharla K.
  MD Kim, Sunghoon MD Thomas, Robert P. MD
  Chung, Dai H. MD
• From the Department of Surgery, University of
  Texas Medical Branch, Galveston, Texas
• (C) 2002 Lippincott Williams Wilkins,
• Inc.Volume 52(3)             March 2002       
       

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• 10-year-old boy
• awake and alert with normal blood pressure (BP)
  and a heart rate (HR) of 124 beats/min
• denied any shortness of breath or chest pain
• equal bilateral breath sounds and heart tones
  were audible without murmur or gallop
• Fifty minutes after the accident, his vital signs
  remained unchanged, with HR of 126 beats/min and
  BP of 138/78 mm Hg

13

• At this point, the patient vomited
• Shortly thereafter, apnea, and he was immediately
  intubated orally
• Advanced cardiac life support protocol
• pronounced dead 105 minutes after arrival to the
  emergency room

14

• At autopsy
• he was found to have approximately 240 mL of
  blood in the pericardium with a cone-shaped
  rupture in his left ventricle.
• He was also found to have a 1.5-cm laceration of
  liver and multiple lacerations of the spleen,
  with approximately 450 mL of hemoperitoneum

15
Discussion

• Thoracic trauma accounts for one fourth of all
  pediatric trauma deaths
• blunt thoracic trauma
• pulmonary and cardiac contusions,
  tracheobronchial
• tears, aortic disruptions, and cardiac
  ruptures
• 64 of patients with a history of blunt cardiac
  injury had some variable degree of cardiac
  laceration, and only 10 to 20 of those patients
  survived long enough to undergo resuscitative
  efforts

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• frequently lack obvious external injuries.
• Visible evidence of chest wall injury may be
  observed in less than 30 of patients
• Fortunately, cardiac injury after blunt trauma is
  seen in lower frequency in children
• 1.because of protective seating in the vehicle
• 2.children's mediastinal structures are much
  more mobile and therefore more easily displaced,
  rather than torn, at the time of a rapid
  deceleration

17

• Beck's triad (jugular venous distention, low
  blood pressure, and muffled heart tones)
• Right atrial rupture, occurring in 40 to 50 of
  reported series, is the site most commonly found
• Left ventricular rupture, with a reported
  incidence of 9 to 13, is the least frequently
  seen injury in survivors
• however, left ventricular lacerations have the
  potential to seal off spontaneously

18

• Arrhythmias on electrocardiograms
• An elevated creatinine phosphokinase isoenzyme is
  usually consistent with a cardiac contusion
  however, these laboratory data are not
  immediately available.
• A widened mediastinum
• Mediastinal CT scanning a poor diagnostic option
  with which to rapidly determine pericardial
  tamponade

19

• In conclusion, a high index of suspicion for
  cardiac injury along with ultrasound evaluation
  of the heart may help to detect cardiac