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Subxiphoid pericardial window in traumatic pericardial tamponade
Clinical Notes
Subxiphoid Pericardial Window in Traumatic Pericardial Tamponade PETER A. COURCY, MD,* THOMAS O. STAIR, MD,t SHELDON BROTMAN, MD* Pericardial tamponade resulting from blunt or penetrating injury can rapidly become lethal; it continues to be one of the most demanding diagnostic and therapeutic problems confronting the emergency physician. The clinical presentation of traumatic pericardial tamponade is variable, especially in the blunt trauma victim with multiple injuries. Because physical examination and pericardiocentesis are unreliable in diagnosing and treating traumatic pericardial tamponade, we advocate a direct surgical approach to the pericardium in all patients suspected of acute pericardial tamponade, whether they are in the emergency department or the operating room. We present an illustrative case report in which the patient was treated successfully with subxiphoid pericardiotomy.
CASE REPORT A 26-year-old man stabbed himself in the left hemithorax. The knife entered in the fourth intercostal space in the midclavicular line. On arrival in the emergency room, the patient was disoriented and combative. The blood pressure was initially 100/80 mm Hg, jugular venous distention was absent, and results of cardiac auscultation were normal. A significant paradoxic pulse could not be elicited. A second blood pressure reading of 80/60 mm Hg was recorded as the patient became more lethargic. A left thoracostomy tube was placed, which drained 500 ml of blood. A central venous pressure line was placed percutaneously in the left subclavian vein, and its position was confirmed radiographically. The initial central venous pressure reading was 15 em H 20 with good fluctuation; however, the patient was uncooperative and straining.
From the *Department of Surgery, the Maryland Institute for Emergency Medical ServicesSystems, Baltimore, Maryland, and the tDepartment of Emergency Medicine, Georgetown University Hospital, Washington, DC. Manuscript received June 27,1983; accepted August 29, 1983. Addressreprintrequests to Sandra l.illlcropp: Maryland Institute for Emergency Medical Services Systems, 22 S. GreeneSt., Bal· timore, MD 21201. Key Words:
Pericardial tamponade, subxlphold perlcardectomy.
Following the infusion of 2 I plasmanate solution, the systolic blood pressure remained at 80 mm Hg, and the patient became unresponsive. A presumptive diagnosis of cardiac tamponade was made. Subxiphoid pericardiotomy was performed with the patient under local anesthesia, and a tense, distended pericardium was easily visualized. The pericardial sac was incised, with drainage of 175 ml of partially clotted blood. Following decompression, the systolic blood pressure rose to 110 mm Hg, and the patient became responsive, requiring intubation and paralysis for control. A left anterior thoracotomy was performed, and a small stab wound was found in the apex of the right ventricle. A right ventricular cardiorrhaphy was performed with 4-0 Tycron sutures over Teflon felt pledgets. Formal exploration and closure of the chest followed in the operating room. The patient had an uneventful recovery. An echocardiogram on the seventh postoperative day showed the pericardium to be free of fluid. The patient was discharged on the eighth postoperative day to a psychiatric rehabilitation program.
DISCUSSION Survival from cardiac wounds resulting from penetrating and blunt injury continues to increase. Trinkle) has reported an early and late mortality rate of only 8% in a series of 100 patients with penetrating cardiac wounds. Aggressive resuscitation and rapid transport by paramedic personnel have enabled more patients with potentially lethal cardiac wounds to reach the emergency room alive. The responsibility for the survival of these patients rests directly with the emergency department physician, who must rapidly diagnose and initiate treatment of these potentially lethal injuries. Cardiac tamponade usually follows penetrating cardi~wounds. Blunt thoracic trauma may also cause cardiac tamponade, and severe cardiac injuries, such as coronary artery and myocardial laceration or myocardial rupture, are usually present." As little as 100 ml of blood contained within the inelastic pericardium may cause acute myocardial decompensation. As the intrapericardial pressure rises, it is transmitted to the ventricular cavity. The increase in intraventricular 153
AMERICAN JOURNAL OF EMERGENCY MEDICINE. Volume 2, Number 2
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pressure precludes venous return and ventricular filling. The trans myocardial oxygen gradient decreases, leading to subendocardial ischemia and myocardial dysfunction, evident clinically as tachycardia and shock. These pathologic changes of tamponade occur within minutes of acute injury.? When cardiac tamponade is suspected, the diagnosis must be made rapidly and accurately. The standard diagnostic signs-Beck's traid of hypotension, muffled heart tones, and distended neck veins-are present in less than 40% of patients with surgically proven tamponade," Ewart's sign (dullness to percussion and tubular breath sounds at the angle of the left scapula due to lung compression), Dressler's sign (increased dullness to sternal percussion along with paradoxic pulse), and Kussmaul's maneuver (increasing central venous pressure with inspiration) are virtually uselessin cases of trauma. Chest radiographs are also frequently misleading in acute tamponade. Doubleday? has pointed out that 300 ml of pericardial fluid may be present without detectable increase in the cardiac silhouette. Electrocardiographic changes may occasionally be 'helpful if they are consistent with pericarditis or electrical alternans. Pericardiocentesis has been relied upon as both a diagnostic and a therapeutic maneuver and has been used safely and accurately in chronic pericardial effusions. However, in the trauma victim, pericardiocentesis produces false-positive or false-negative results in approximately 50% of cases 1.2,4,6-8 and is also unreliable for treatment because (1) an acute hemopericardium may have little or no defibrinated liquid blood and (2) clots preclude adequate needle de154
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compression. 1,2,4,7,8 Even when pericardiocentesis does produce clinical improvement, the acute trauma victim, unlike the chronic pericarditis patient, is likely to rebleed immediately into the pericardial sac and require repeat pericardiocentesis. That occurred in 35 of 85 patients reported by Breaux et al,? who recommend placing a soft catheter for continued drainage until a formal thoracotomy can be performed. Pericardiocentesis itself is associated with significant morbidity in the acute-care setting. The risks of doing a blind procedure include coronary artery and myocardial laceration, valve damage, hemothorax, pneumothorax, and diaphragmatic injuries. 2 The subxiphoid approach to pericardiotomy was first described by Larrey'? in 1829. We use a technique described by Fontenelle et aFI in 1970 and used by Arom et al6 in 1977 and Alcan et at'? in 1982. The chest and upper part of the abdomen are prepped and draped. Xylocaine (0.5%, 10-20 ml) is used to infiltrate the skin, subcutaneous tissue, and perichondrium of the xiphoid and costal cartilage. A 10 em vertical midline incision is made, extending from the lower sternum to the superior epigastrium (Fig. 1). The xiphoid is exposed, and the fibromuscular attachments of the posterior aspect are removed by finger dissection. The xiphoid then is elevated with a clamp and excised. Blunt finger dissection is again used to remove subxiphoid fatty areolar tissue. This maneuver allows visualization and palpation of the pericardiodiaphragmatic junction (Fig. 2). Two 1-0 polyglycolic acid sutures then are placed through the junction, 0.5 em apart. To obtain entry into the pericardial sac, a small vertical incision is placed between
COURCY ET AL • SUBXJPHOID PERICARDIAL WINDOW
the sutures (Fig. 3). When a hemopericardium is encountered, a left anterior thoracotomy is performed immediately. If exploration reveals no injury, the subcutaneous tissue and skin are closed. No attempt is made to close the pericardium. Antibiotic coverage and wound drainage are used selectively as conditions dictate. This technique for subxiphoid pericardiotomy is well established as a simple, reliable means of diagnosing and decompressing pericardial tamponade. 6 , IO,12 Pericardiocentesis is also intended to accomplish the same goal, but it is often unsuccessfuI. 1,2,4,6- 8 Compared with pericardioccntesis, subxiphoid pericardiotomy requires more time and surgical expertise but provides far greater diagnostic and therapeutic reliability. Although it has been previously described only as an operating room procedure, subxiphoid pericardiotomy should not be difficult for emergency physicians to learn and perform when circumstances require it. Where, then, does the subxiphoid pericardiotomy fit into the emergency department treatment of the patient with suspected pericardial tamponade? At one end of the clinical spectrum is the patient in stable condition who has a penetrating wound in the cardiac silhouette or clinical signs of a well-compensated tamponade, for whom the physician can deliberately proceed to a formal, exploratory thoracotomy in the operating room. At the opposite end of the spectrum is the dying patient with chest trauma who has no vital signs and requires emergency thoracotomy for open-chest cardiopulmonary resuscitation and control of bleeding, In the middle of the spectrum is the patient whose precarious condition may need confirmation or temporary drainage of a pericardial tamponade . Blood pressure and central venous pressure trends can aid diagnosis, and intravenous fluids , pressors, and antishock trousers can aid treatment. Pcricardiocentesis has been a dubious mainstay.' When the clinical
course suggests a developing pericardial tamponade, there may still be a place for pericardiocentesis. However, if pericardiocentesis shows no abnormality, if it does not adequately decompress the tamponade, or if the physician wishes to avoid its uncertainty, he should proceed directly to subxiphoid pericardiotomy, either in the emergency department or in the operating room. Subxipho id pericardiotomy is a proven, straightforward, and valuable adjunct to the repertoire of the emergency physician.
REFERENCES 1. Trinkle JK, Toon RS, Franz YL, et al. Affairs of the wounded heart . Penetrating cardiac wounds. J Trauma 1979;
19:467-472. 2. Callaham M. Acute traumatic cardiac tamponade : Diagnosis and treatment. JACEP 1978;7:306-312. 3. Shoemaker WC. Algorithm for early recognition and management of card iac tamponade. Crlt Care Med 1975;3 :59. 4. Trinkle JK, Marcas J, Grover FL , et al. Management of the wounded heart . Ann Thorac Surg 1974;17:230-236. 5. Doubleday LC. Rad iological aspects of stab wounds to the heart. Radiology 1960;74:26. 6. Arom KV, Richardson JD, Webb G, et at, Subxiphoid pericardlal window In patients with suspected traumatic parlcardial tamponade. Ann Thorac Surg 1977;23:545-549. 7. Harvey JL , Pacifico AT. Primary operative management: Method of choice for stab wounds to the heart. South Med J 1975 ;68:149-52. 8. Evans J, Gray LA, Rayner P, et al. Principles for the management of penetrating cardiac wounds. Ann Surg
1979;189:777-783. 9. Breaux EP, Dupont JB , Albert HM, et al. Cardiac tamponade following mediast inal injuries: Improved survival with early perlcardioce ntesis. J Tra urna 1979; 19:461 - 466. 10. Larrey DJ, New surgical procedu re to open the pericardium and determine the cause of fluid In its cavity. Clin Chir
1829;36:303. 11. Fontenelle LJ, Cuello L, Dooley BN. Subxlphoid pericardiai window. Am J Surg 1970;120:679-680. 12. Alcan KE, Zabetakis PM, Marino NO, et al. Management of acute cardiac tamponade by subxlphoid pericardiotomy. JAMA 1982;247:1143-1148.
155
Subxiphoid Pericardial Window in Traumatic Pericardial Tamponade PETER A. COURCY, MD,* THOMAS O. STAIR, MD,t SHELDON BROTMAN, MD* Pericardial tamponade resulting from blunt or penetrating injury can rapidly become lethal; it continues to be one of the most demanding diagnostic and therapeutic problems confronting the emergency physician. The clinical presentation of traumatic pericardial tamponade is variable, especially in the blunt trauma victim with multiple injuries. Because physical examination and pericardiocentesis are unreliable in diagnosing and treating traumatic pericardial tamponade, we advocate a direct surgical approach to the pericardium in all patients suspected of acute pericardial tamponade, whether they are in the emergency department or the operating room. We present an illustrative case report in which the patient was treated successfully with subxiphoid pericardiotomy.
CASE REPORT A 26-year-old man stabbed himself in the left hemithorax. The knife entered in the fourth intercostal space in the midclavicular line. On arrival in the emergency room, the patient was disoriented and combative. The blood pressure was initially 100/80 mm Hg, jugular venous distention was absent, and results of cardiac auscultation were normal. A significant paradoxic pulse could not be elicited. A second blood pressure reading of 80/60 mm Hg was recorded as the patient became more lethargic. A left thoracostomy tube was placed, which drained 500 ml of blood. A central venous pressure line was placed percutaneously in the left subclavian vein, and its position was confirmed radiographically. The initial central venous pressure reading was 15 em H 20 with good fluctuation; however, the patient was uncooperative and straining.
From the *Department of Surgery, the Maryland Institute for Emergency Medical ServicesSystems, Baltimore, Maryland, and the tDepartment of Emergency Medicine, Georgetown University Hospital, Washington, DC. Manuscript received June 27,1983; accepted August 29, 1983. Addressreprintrequests to Sandra l.illlcropp: Maryland Institute for Emergency Medical Services Systems, 22 S. GreeneSt., Bal· timore, MD 21201. Key Words:
Pericardial tamponade, subxlphold perlcardectomy.
Following the infusion of 2 I plasmanate solution, the systolic blood pressure remained at 80 mm Hg, and the patient became unresponsive. A presumptive diagnosis of cardiac tamponade was made. Subxiphoid pericardiotomy was performed with the patient under local anesthesia, and a tense, distended pericardium was easily visualized. The pericardial sac was incised, with drainage of 175 ml of partially clotted blood. Following decompression, the systolic blood pressure rose to 110 mm Hg, and the patient became responsive, requiring intubation and paralysis for control. A left anterior thoracotomy was performed, and a small stab wound was found in the apex of the right ventricle. A right ventricular cardiorrhaphy was performed with 4-0 Tycron sutures over Teflon felt pledgets. Formal exploration and closure of the chest followed in the operating room. The patient had an uneventful recovery. An echocardiogram on the seventh postoperative day showed the pericardium to be free of fluid. The patient was discharged on the eighth postoperative day to a psychiatric rehabilitation program.
DISCUSSION Survival from cardiac wounds resulting from penetrating and blunt injury continues to increase. Trinkle) has reported an early and late mortality rate of only 8% in a series of 100 patients with penetrating cardiac wounds. Aggressive resuscitation and rapid transport by paramedic personnel have enabled more patients with potentially lethal cardiac wounds to reach the emergency room alive. The responsibility for the survival of these patients rests directly with the emergency department physician, who must rapidly diagnose and initiate treatment of these potentially lethal injuries. Cardiac tamponade usually follows penetrating cardi~wounds. Blunt thoracic trauma may also cause cardiac tamponade, and severe cardiac injuries, such as coronary artery and myocardial laceration or myocardial rupture, are usually present." As little as 100 ml of blood contained within the inelastic pericardium may cause acute myocardial decompensation. As the intrapericardial pressure rises, it is transmitted to the ventricular cavity. The increase in intraventricular 153
AMERICAN JOURNAL OF EMERGENCY MEDICINE. Volume 2, Number 2
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pressure precludes venous return and ventricular filling. The trans myocardial oxygen gradient decreases, leading to subendocardial ischemia and myocardial dysfunction, evident clinically as tachycardia and shock. These pathologic changes of tamponade occur within minutes of acute injury.? When cardiac tamponade is suspected, the diagnosis must be made rapidly and accurately. The standard diagnostic signs-Beck's traid of hypotension, muffled heart tones, and distended neck veins-are present in less than 40% of patients with surgically proven tamponade," Ewart's sign (dullness to percussion and tubular breath sounds at the angle of the left scapula due to lung compression), Dressler's sign (increased dullness to sternal percussion along with paradoxic pulse), and Kussmaul's maneuver (increasing central venous pressure with inspiration) are virtually uselessin cases of trauma. Chest radiographs are also frequently misleading in acute tamponade. Doubleday? has pointed out that 300 ml of pericardial fluid may be present without detectable increase in the cardiac silhouette. Electrocardiographic changes may occasionally be 'helpful if they are consistent with pericarditis or electrical alternans. Pericardiocentesis has been relied upon as both a diagnostic and a therapeutic maneuver and has been used safely and accurately in chronic pericardial effusions. However, in the trauma victim, pericardiocentesis produces false-positive or false-negative results in approximately 50% of cases 1.2,4,6-8 and is also unreliable for treatment because (1) an acute hemopericardium may have little or no defibrinated liquid blood and (2) clots preclude adequate needle de154
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FIGURE 2 (center). FIGURE 3 (right).
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FIGURE 1 (left).
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compression. 1,2,4,7,8 Even when pericardiocentesis does produce clinical improvement, the acute trauma victim, unlike the chronic pericarditis patient, is likely to rebleed immediately into the pericardial sac and require repeat pericardiocentesis. That occurred in 35 of 85 patients reported by Breaux et al,? who recommend placing a soft catheter for continued drainage until a formal thoracotomy can be performed. Pericardiocentesis itself is associated with significant morbidity in the acute-care setting. The risks of doing a blind procedure include coronary artery and myocardial laceration, valve damage, hemothorax, pneumothorax, and diaphragmatic injuries. 2 The subxiphoid approach to pericardiotomy was first described by Larrey'? in 1829. We use a technique described by Fontenelle et aFI in 1970 and used by Arom et al6 in 1977 and Alcan et at'? in 1982. The chest and upper part of the abdomen are prepped and draped. Xylocaine (0.5%, 10-20 ml) is used to infiltrate the skin, subcutaneous tissue, and perichondrium of the xiphoid and costal cartilage. A 10 em vertical midline incision is made, extending from the lower sternum to the superior epigastrium (Fig. 1). The xiphoid is exposed, and the fibromuscular attachments of the posterior aspect are removed by finger dissection. The xiphoid then is elevated with a clamp and excised. Blunt finger dissection is again used to remove subxiphoid fatty areolar tissue. This maneuver allows visualization and palpation of the pericardiodiaphragmatic junction (Fig. 2). Two 1-0 polyglycolic acid sutures then are placed through the junction, 0.5 em apart. To obtain entry into the pericardial sac, a small vertical incision is placed between
COURCY ET AL • SUBXJPHOID PERICARDIAL WINDOW
the sutures (Fig. 3). When a hemopericardium is encountered, a left anterior thoracotomy is performed immediately. If exploration reveals no injury, the subcutaneous tissue and skin are closed. No attempt is made to close the pericardium. Antibiotic coverage and wound drainage are used selectively as conditions dictate. This technique for subxiphoid pericardiotomy is well established as a simple, reliable means of diagnosing and decompressing pericardial tamponade. 6 , IO,12 Pericardiocentesis is also intended to accomplish the same goal, but it is often unsuccessfuI. 1,2,4,6- 8 Compared with pericardioccntesis, subxiphoid pericardiotomy requires more time and surgical expertise but provides far greater diagnostic and therapeutic reliability. Although it has been previously described only as an operating room procedure, subxiphoid pericardiotomy should not be difficult for emergency physicians to learn and perform when circumstances require it. Where, then, does the subxiphoid pericardiotomy fit into the emergency department treatment of the patient with suspected pericardial tamponade? At one end of the clinical spectrum is the patient in stable condition who has a penetrating wound in the cardiac silhouette or clinical signs of a well-compensated tamponade, for whom the physician can deliberately proceed to a formal, exploratory thoracotomy in the operating room. At the opposite end of the spectrum is the dying patient with chest trauma who has no vital signs and requires emergency thoracotomy for open-chest cardiopulmonary resuscitation and control of bleeding, In the middle of the spectrum is the patient whose precarious condition may need confirmation or temporary drainage of a pericardial tamponade . Blood pressure and central venous pressure trends can aid diagnosis, and intravenous fluids , pressors, and antishock trousers can aid treatment. Pcricardiocentesis has been a dubious mainstay.' When the clinical
course suggests a developing pericardial tamponade, there may still be a place for pericardiocentesis. However, if pericardiocentesis shows no abnormality, if it does not adequately decompress the tamponade, or if the physician wishes to avoid its uncertainty, he should proceed directly to subxiphoid pericardiotomy, either in the emergency department or in the operating room. Subxipho id pericardiotomy is a proven, straightforward, and valuable adjunct to the repertoire of the emergency physician.
REFERENCES 1. Trinkle JK, Toon RS, Franz YL, et al. Affairs of the wounded heart . Penetrating cardiac wounds. J Trauma 1979;
19:467-472. 2. Callaham M. Acute traumatic cardiac tamponade : Diagnosis and treatment. JACEP 1978;7:306-312. 3. Shoemaker WC. Algorithm for early recognition and management of card iac tamponade. Crlt Care Med 1975;3 :59. 4. Trinkle JK, Marcas J, Grover FL , et al. Management of the wounded heart . Ann Thorac Surg 1974;17:230-236. 5. Doubleday LC. Rad iological aspects of stab wounds to the heart. Radiology 1960;74:26. 6. Arom KV, Richardson JD, Webb G, et at, Subxiphoid pericardlal window In patients with suspected traumatic parlcardial tamponade. Ann Thorac Surg 1977;23:545-549. 7. Harvey JL , Pacifico AT. Primary operative management: Method of choice for stab wounds to the heart. South Med J 1975 ;68:149-52. 8. Evans J, Gray LA, Rayner P, et al. Principles for the management of penetrating cardiac wounds. Ann Surg
1979;189:777-783. 9. Breaux EP, Dupont JB , Albert HM, et al. Cardiac tamponade following mediast inal injuries: Improved survival with early perlcardioce ntesis. J Tra urna 1979; 19:461 - 466. 10. Larrey DJ, New surgical procedu re to open the pericardium and determine the cause of fluid In its cavity. Clin Chir
1829;36:303. 11. Fontenelle LJ, Cuello L, Dooley BN. Subxlphoid pericardiai window. Am J Surg 1970;120:679-680. 12. Alcan KE, Zabetakis PM, Marino NO, et al. Management of acute cardiac tamponade by subxlphoid pericardiotomy. JAMA 1982;247:1143-1148.
155