Interactive Cardiovascular and Thoracic Surgery 2:43-45(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Case report - Cardiac general |
Non-perforating pericardial rupture causing cardiac tamponade
Hiroshi Onda,
Yuichiro Kaminishi,
Yoshio Misawa* and
Katsuo Fuse
Division of Cardiovascular Surgery, Jichi Medical School, 3311-1 Yakushiji, Minami-kawachi, Tochigi 329-0498, Japan
* Corresponding author. Tel.: +81-285-58-7368; fax: +81-285-44-6271
tcvmisa{at}jichi.ac.jp
Received August 15, 2002;
received in revised form October 24, 2002;
accepted November 4, 2002
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Abstract
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A 51-year-old auto truck driver was transferred to our hospital after crashing. He had a severe pain on the left anterior chest wall with high central venous pressure of 30cm H2O. Surveillance of the chest revealed cardiac tamponade and the right seventh rib fracture with left pleural effusion. Pericardiotomy through median sternotomy led to extrusive bloody pericardial effusion. Non-perforating pericardial laceration at the site of the adjoining muscular structure of the diaphragm was repaired with direct suture closure. His postoperative course was uneventful.
Key Words: Pericardial rupture; Cardiac trauma; Cardiac tamponade; Diaphragmatic rupture
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1. Introduction
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Vehicular accidents cause various kinds of injuries, from cutaneous excoriations to lethal internal organ damage. Surface or other painful injuries sometimes hide internal organ damage. Fulda and associates reported that blunt traumatic rupture of the heart and pericardium requiring emergency surgery occurred at a rate of 0.3% in more than 20,000 trauma victims, and carried a high mortality rate of 76% [1]. Thus, prompt diagnosis and treatment is needed to rescue such victims with lethal occult organ injuries. We report a case of cardiac tamponade caused by a non-perforating pericardial rupture after a vehicular accident.
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2. Case report
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A 51-year-old truck driver crashed into another truck and was transferred to our hospital. His consciousness was clear, but he had severe pain in the left anterior chest wall, and was greatly agitated. His breath smelled of alcohol. Blood pressure was 160/100mmHg with sinus tachycardia of 118 per minute, and respiration was irregular (18 per minute) without peripheral cyanosis. Hematologic tests revealed a hemoglobin level of 14.3g/dl and a white blood cell count of 23,700 per cubic mm. While the patient was breathing supplemental oxygen, the partial pressure of oxygen was 90.4mmHg and that of carbon dioxide was 40.2mmHg. An electrocardiogram showed a sinus tachycardia of 122 per min. Surveillance of the chest and abdomen by radiography showed a fracture of the right seventh rib associated with slight hemopneumothorax, and transthoracic echocardiography revealed cardiac tamponade. No other injury was confirmed. Central venous pressure was 30cm H2O in the emergency room.
Immediately after getting the definite diagnosis of cardiac tamponade, about 3h after the traffic accident, he underwent an emergency operation for drainage of the pericardial and pleural effusion at the operation theater. His hemodynamic condition was not deteriorated even after the induction of anesthesia. Through median sternotomy, a tense pericardial sac was observed without hematoma in the superior and anterior mediastinum. Pericardiotomy led to extrusive bloody effusion from the pericardium, with a total of 400ml of effusion. The right ventricle had a soybean-sized injury covered with hematoma, which showed no active bleeding and was repaired by direct suture closure. The pericardium had a laceration at the site of the adjoining muscular structure of the diaphragm (Fig. 1). Active bleeding from the injured site was controlled by suture closure of the laceration. It had not perforated into the abdominal cavity or to the left thorax, but had penetrated muscle layers of the diaphragm. No other bleeding point was observed in the pericardial sac. Bloody pleural effusion, which might have been caused by the rib fracture, was simultaneously drained from the left thorax. There was no injury in the abdominal cavity. Sternotomy was closed in the usual way. The postoperative course was uneventful, and he was discharged 2 weeks after operation.
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Fig. 1 Operative findings: non-perforating laceration of the pericardium was found at the site of the adjoining muscular structure of the diaphragm (shown by arrows). Active bleeding from the muscle layer of the diaphragm was controlled by suture closure of the lacerated pericardium and diaphragm.
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3. Discussion
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Blunt chest trauma can cause cardiovascular injuries including a cardiac rupture of the free wall or papillary muscle, coronary artery disruption, pericardial rupture, ventricular septal defect, and aortic rupture [2–6]. Some lead to lethal outcomes rapidly, while others show delayed presentation of apparent symptoms and signs. Vehicular accidents are the most frequent cause of such traumas, followed by motorcycle crashes [1,8]. A definite diagnosis is often established by emergency thoracotomy [9], but patients who underwent emergency thoracotomy because of rapid deterioration of hemodynamic condition can hardly survive. Only one patient survived among Balkan's six patients [10]. Echocardiographic or computed tomographic findings can add major contributions in cases that maintain stable hemodynamic conditions, and the clinical outcomes are better than those in deteriorated cases [9–11]. Diagnosis without delay and prompt surgical interventions can surmount potentially critical conditions.
Because pericardial rupture can be associated with hemothorax or cardiac herniation, it may sometimes prevent clinicians from arriving at correct diagnoses. An associated pericardial rupture could produce pericardial decompression into the mediastinum or pleural space, obscuring any cardiac rupture. Pericardial rupture without massive bleeding might show no apparent clinical symptoms or signs, but some cases have been reported as having delayed presentation of herniation of the heart after blunt chest trauma [8]. Therefore, cardiac herniation, diaphragmatic rupture, and hemothorax are taken into account for differential diagnosis [7,11–13].
Our case required an emergency operation because of cardiac tamponade indicated by transthoracic echocardiographic findings. After the repair of a small rupture of the right ventricle, an active blood accumulation was observed in the pericardium. Careful examination revealed a non-perforating laceration of the pericardium at the site of the adjoining muscular structure of the diaphragm. Suture closure of the laceration stopped the bleeding. The patient's hemodynamic condition was stable during surgery, thus the surgical repair was successfully performed. When the laceration perforates the diaphragm and drains the pericardial effusion, herniation of the heart or abdominal organs could occur without cardiac tamponade. Pericardial laceration has been found mostly at the left pleuropericardial site followed by diaphragmatic, right pleuropericardial, and superior mediastinal sites [1]. The anatomical structure of the left pleuropericardial site with its sharp angle may cause fragility against a barotrauma injury.
Our case indicates that pericardial injury can occur in different forms, such as a perforating one into the thoracic or abdominal cavity or a non-perforating one around the diaphragm, and that this injury can coexist with a myocardial injury.
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4. Conclusions
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A patient developed cardiac tamponade after a vehicular accident. Non-perforating pericardial laceration at the site of the adjoining muscular structure of the diaphragm was the major origin of bleeding and was successfully repaired with suture closure.
doi:10.1016/S1569-9293(02)00096-8
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References
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Abstract
1. Introduction