The patient in the above vignette has had a penetrating injury near the heart and presents with hypotension and muffled heart sounds. He is most at risk of developing cardiac tamponade, which would be treated with a pericardiocentesis.
Cardiac tamponade develops when fluid collects in the pericardial sac and restricts ventricular filling, leading to decreased cardiac output. Risk factors include penetrating trauma (most common), TB, SLE, malignancy, and pericarditis. Consider this diagnosis in any patient that is hemodynamically unstable and that does not respond to fluid resuscitation. Chest pain, Beck's triad (hypotension, distant heart sounds, and distended jugular veins), pulsus paradoxus (>10 mmHg drop in BP on inspiration), and Kussmauls's sign (paradoxical increase in JVP on inspiration) can all be noted on physical exam. Pericardiocentesis & aggressive volume expansion are the initial treatment options.
Geelhoed reports on blunt and penetrating chest trauma. One must be prepared to evaluate and treat several life-threatening conditions when a patient has been identified as a chest trauma victim. Open or closed pneumothorax (with or without hemothorax), flail chest, pericardial tamponade, and injury to the esophagus, trachea, or great vessels must all be suspected and evaluated.
Jones et al. discuss the role of pericardiocenteses in the emergency department setting. It is widely accepted that penetrating cardiac injuries which cause cardiac tamponade should be drained in a timely fashion. However, when surgical intervention is not immediately available, pericardial drainage in the ED is a viable option for stabilization prior to definitive surgery in the hemodynamically marginal patient.
Illustration A is an artist's rendering of pericardial tamponade that causes hemodynamic compromise through increased pericardial pressure, which reduces right-ventricular filling and cardiac output.
Illustration B depicts an overview image of a pericardiocentesis.
Answer 1: Chest tubes are often used for injuries such as a massive hemothorax. These patients will often present with hypotension, tachycardia, and decreased (but not absent) breath sounds. Chest radiographs often show large fluid collections in the thoracic cavity.
Answer 3: Immediate needle decompression is used in situations such as a tension pneumothorax. These one-way valve injuries ultimately lead to an increased intrathoracic pressure which can restrict cardiac output. Chest radiographs are the gold standard and show an absence lung parenchyma with a contralateral mediastinal shift. This injury necessitates needle decompression and possible chest tube placement.
Answer 4: Closing the defect with sterile occlusive dressing and tape on three sides would not improve this patient's hemodynamic instability. This type of treatment is used for open pneumothoraces creating a one-way valve that allows air to escape.
Answer 5: NSAIDs are often used in pericarditis. A pericardiectomy is often reserved for recurrent pericarditis.
Geelhoed GW. Blunt and penetrating chest trauma. Am Fam Physician. 1978 Feb;17(2):100-6.
PMID:622937 (Link to Abstract)
Jones TS, Burlew CC, Stovall RT, Pieracci FM, Johnson JL, Jurkovich GJ, Moore EE. Emergency department pericardial drainage for penetrating cardiac wounds is a viable option for stabilization. Am J Surg. 2014 Jan 3.
PMID:24480233 (Link to Abstract)
USMLE Step 2 CK Qbook 4th ed. Daugherty, Stephen R. New York: Kaplan Publishing, 2008.