Blunt trauma cardiac tamponade: What really counts in management

See also pp. 494–9 Survivors from acute rupture of the heart from blunt trauma are few and far between, most dying at the scene, or en route to hospital. In an interesting paper in this issue, Fitzgerald et al. describe the successful management of two such patients and illustrate several lessons in so doing.1 This is an instructive paper that sets the scene very well for the pathology, diagnosis, ED management and definitive surgical care of this relatively rare type of case. It is easy to understand that most patients with rupture of the heart will rapidly demise and that, as pointed out by the authors, several of the survivors had ruptures in low-pressure areas, such as atria, where the bleeding was less. Emphasis was placed upon the fact that most survivors had vital signs present on reaching the ED; indeed, the two patients reported on were capable of talking at that time. In South Africa, where much trauma is seen, these patients are few in number. Based on past experience, patients reaching ED who have had blunt chest trauma and who have no vital signs or are undergoing cardiopulmonary resuscitation, are seldom considered for emergency thoracotomy, as successes have been minimal. Cases such as this began to appear in the literature in the 80s. A series of seven cases was reported by Williams et al.2 Features included hypotension and signs of cardiac tamponade. Measures advocated included maintaining a high index of suspicion, leading to early thoracotomy. In a paper alluded to by Fitzgerald et al. Martin et al. presented a series of cases managed by a trauma centre.3 Of the seven survivors, four had atrial injuries. In a series of three cases reported by Leavitt et al. in 1987, the patients had pericardiocentesis followed by emergency thoracotomy.4 By 1990, more cases were being taken to thoracotomy without preliminary pericardiocentesis, as evidenced in a paper from shock trauma in Baltimore by Brathwaite et al.5 As our authors indicated, a variety of survival rates began to be published, varying from 41% in a unit in Portland, USA in 19956 to 71% in Cape Town in 19987 and even better after that. More recently, the importance of preliminary pericardiocentesis has been downplayed, this often being reserved for overwhelming haemodynamic collapse before surgery could be instituted. There has also been evidence of the increasing use of echocardiography for preoperative confirmatory diagnosis such as in the paper by Malaspina et al. in 2000.8 By 2002, the use of ultrasound was emphasized and pericardiocentesis, if employed, was often by a subxiphoid approach.9 Today, ultrasound is in widespread use and there is less need for pericardiocentesis, except in extremis, especially if the patient has reached the operating theatre and immediate thoracotomy can be embarked upon. Many of these points are brought out very well in this article by Fitzgerald et al.1 As mentioned above, both patients reported upon had vital signs on arrival, indeed both were able to talk. There was a high index of clinical suspicion and the first patient had clinical signs of cardiac tamponade, including raised neck veins. It is here that the value of ED ultrasound is clearly demonstrated, as the correct diagnosis was obtained immediately and the appropriate action taken. It is becoming clearer and clearer internationally that this diagnostic modality must be available in all ED and that emergency physicians should be conducting this themselves. Training in ED ultrasound should not be optional in emergency medicine training programmes, but should be a required skill, with emergency physicians coming to be regarded as the leaders in this form of emergency diagnosis. The diagnosis having been made in this way, the patient should have only necessary resuscitation on the way to immediate thoracotomy. Pericardiocentesis prior to this should probably only be considered if there is collapse during resuscitation or on the way to theatre. The splendid illustration in Fitzgerald et al.'s paper shows the rupture of the ventricle in the first patient beautifully. With regard to the second patient, some might ask why, when the patient was already in theatre, the operation was commenced with laparotomy and subxiphoid decompression, when what he really required was immediate thoracotomy, when the same cardiac decompression could have been done. There might have been good reasons. The authors are to be congratulated on their excellent management of the reported patients. They illustrate the necessity for rapid assessment, rapid diagnosis, appropriate resuscitation and rapid progress to thoracotomy. The patient outcomes demonstrate the efficacy of this. None declared.

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