Interesting case... of cardiac rupture

A case from the other day... had some great teaching points, and interesting videos to go along with it... thought I would share.
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US teaching case - CARDIAC

34 y/o female to the ED by EMS after jumping from a third floor window, landing on her chest.
-- Hemodynamically stable en route. Complained of severe midsternal chest pain radiating to her back.
-- On arrival she was cool, pale and diaphoretic with a thready carotid pulse.
-- Physical exam was otherwise unremarkable.

-- FAST examination (copy and paste the link)

http://www.youtube.com/v/RfKL3Y94fi4

-- Revealed large pericardial thrombus and right ventricular collapse consistent with pericardial tamponade. No intra-abdominal free fluid was identified.

-- The patient quickly developed refractory hypotension. Emergently intubated.
-- Pericardiocentesis unsuccessful, presumably 2/2 a large amount of clot w/n the pericardium.
-- PEA arrest. -- ED thoracotomy. -- Pericardotomy and clot removal. -- Massive exsanguination from posterior aspect of the heart.
-- Packing was placed, and return of a strong carotid pulse was noted. (Massive volume repletion)
-- To the OR where the left thoracotomy was extended by clamshell sternotomy and right thoracotomy.

* Viewer discretion advised * (copy and paste the link)

http://www.youtube.com/watch?v=MsDEgtXylGM
-- Inspection of the heart demonstrated a large tear extending from the LA to midway down the posterior aspect of the LV.

-- Hemorrhage from this wound proved to be uncontrollable. -- Refractory cardiac arrest before cardiopulmonary bypass could be initiated.
-- Death.


Relevant findings:
o Cardiac tamponade
-- Increased intracardiac pressures -- Limitation of ventricular diastolic filling & ventricular collapse in diastole
-- Reduction of stroke volume and cardiac output -- Significantly influenced by volume & rate of accumulation
** This event is marked sonographically by the collapse of the right atrial and/or ventricular walls during diastole (scalloping) **
** "Swinging heart" -- counterclockwise rotational movement, which occurs in addition to the triangular movement of the heart, producing a dancelike motion

COMMENTARY
This blunt deceleration mechanism could lead to atriocaval disruption, chamber blowout (like this patient had w/ an AV groove disruption -- basically ripping the LA off the LV), rarely a rib/sternal fx with a puncture injury to the myocardium, pericardial sac laceration w/ possible herniation (rumored to be the cause of death of Princess Diana), coronary sinus tears. MOST of these injuries are lethal as they either lead to exsanguination or complete inflow/outflow obstruction.

This case illustrates that pericardiocentesis is ONLY a temporizing move to relieve tamponade --> used to buy time to get this patient to the OR.

Maybe more important if you're in an outside facility without a surgeon, but ultimately the treatment is thoracotomy/sternotomy with direct repair.

Why NOT an ED thoracotomy in this patient ???

-- If this was a penetrating injury & there was evidence of tamponade, then its clear that ED thoracotomy IS indicated for loss of vital signs.

NOTE --> A medical measure is increasing the CVP with crystalloid/blood/clotting factor replacement to counteract the pressure restriction of the tamponade.

• Technical problems of cardiac ultrasound:
o Subcutaneous air o Pneumopericardium o Mechanical ventilation
o Scanning limited by: Pain, immobilization, procedures o Narrow intercostal space, obesity, musculature

• Sonographic pitfalls
o Pericardial vs. pleural fluid o Pericardial clot o Pericardial fat

EM resident & surgery resident with trauma surgeon on the other side of the bed providing guidance due to sphincter tone irregularities in the EM resident

During that 18 seconds of video the bypass machine was being prepped and they were handing one of the most experienced cardiothoracic surgeons in the nation the materials he had requested. Of note, this patient was in PEA/asystole during the video, though it seems the heart is pumping, thus the site of bleeding was very difficult to isolate, moreover to repair.

Further this video was taken without directly involving the care team for this patient, which was made up of two trauma surgeons, two cardiac anesthesiologists, a cardiothoracic surgery fellow, and cardiothoracic surgery attending, along with 4 resident physicians, thus I believe everything was done in an attempt to save this patients life.

I posted the video in an effort for you to see/realize the view you should strive to achieve when performing an ED thoracotomy. Moreover for you to understand what you could be getting yourself into when opening a chest... this type of injury is VERY difficult to isolate, but hopefully after reading this case, and seeing the videos you won't miss it in the future...