A strange case of Pericardial Tamponade

[Teperman, Sheldon]

Gentleman and ladies

            We received the following patient in transfer from a nearby
non trauma center.  Jacobi is a level one in the North East Bronx.  Ron
Simon (frequently depicted in these pages) has gone off to make Bellevue
hospital a better place and has handed the Baton off to me (lucky me).
We all wish Ron well and know he will do great things there as he did
for us here.

 

            To the Case: A 22 year male stabbed in the left chest not
far from the PMI ( on Tuesday-midday). Mild hypotension responded to a
fluid bolus and a unit of blood, a left chest tube puts out 500 cc's
initially with a negative FAST.  He is admitted to that hospital's ICU
with an official echo cardiogram showing a small pericardial effusion.
In the morning a routine ECG shows 1 to 2 millimeter ST segment
elevation across the precordium.  And soon thereafter a repeat Echo
show's that the effusion was now moderate in size. At the same time the
patient begins to drop his pressure and they placed an urgent call to us
as they did not have a chest Surgeon on staff. We encouraged an
expedited transfer, which occurs in a non expeditious fashion.

            Pt arrives to us with a BP of 129 over 85, a pulse of 110
and room air Sats of 89%. Our Fast shows a significant pericardial
effusion, esp. when looking transthoracially.  I have attached a cell
phone pic of the Fast and the ECG. The patient is then taken to the OR
in the company of both our trauma service and our Chest Surgeon (full
CTS training). There is a healthy back and forth about a Sternal split
vs. a pericardial window. I make a $1,00,000 bet with my colleague that
she will find blood on the Window, she agrees its likely but wishes to
avoid the embarrassment (and morbidity) of finding a serous effusion and
making an unnecessary Sternotomy .

            In the OR( about 28 hours post injury) the vitals continue
as same, but the Sats are alarming low even with Supplemental O2.
The patient gets a modified induction, after full prep. And the Window
shows 200cc's straw colored (just a bit turbid) fluid.  An organized
linear piece of fibrin with some hemorrhage in it is also removed from
the pericardial sac (a pericardial biopsy is cooking and a drain was
left in place.) 

            The patient is now making a normal recovery with the Sat
issue having gone away.

 

            So to the question.  What is this?

 Our first theory is that the knife wound approached, irritated or
injured the pericardium-causing a rip roaring and rapidly progressive
Pericardiditis ( the first ECG showing it was 18 hours post
injury)-without an actual injury to the heart. One of my younger
colleagues likes this theory saying,..."If it walks like a duck...."

            Less likely is the possibility that the patient was already
sick and that he was walking around with this when he was stabbed. But
he has no antecedent medical history. Another possibility is that this
was some how related to the chest tube. (Always nice to blame someone
else).

            A quick medline search does not yield much in the way of
similar case/or case studies.

 

            See some of You all, next week at the Dr. Mattox show in
Vegas. I will be the guy haplessly sitting by the slots-hoping to hit
the big one and pay back the Cool Mill I now owe my Chest Surgeon
friend:) 

 
 
 
 
 
 
Sheldon Teperman, M.D.
Director of Trauma and Critical Care Surgery
Jacobi Medical Center
1400 Pelham Pkwy.
Rm. 1213
Bronx NY 10461
 
Tel 718-918-5592
Fax 718-918-5593
Email  Sheldon.Teperman at NBHN.net
 


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