A strange case of Pericardial Tamponade

[Pradeep Navsaria]

Navsaria and Nicol: Haemopericardium in stable patients after penetrating
trauma; is subxiphoid pericardial window and drainage enough? A prospective
study.

[I know your window was 'turbid', straw coloured....]

Robert Smith wrote:

> Could you tell us the authors and title?
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Pradeep Navsaria
> Sent: Friday, March 23, 2007 2:52 AM
> To: Trauma & Critical Care mailing list
> Subject: Re: A strange case of Pericardial Tamponade
>
> This patient has a penetrating cardiac injury [Grade I - III).  A reference
> that may interest you - Injury 2005:36;p754-750.
>
> P Navsaria
> Trauma Center
> GSH, Cape Town
> SA
>
> "Teperman, Sheldon" wrote:
>
> > 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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