Bedside Echocardiography in the Management of aThoracic Stab Wound with Early Pericardial Tamponade

A 61-year-old male was brought into an urban trauma centerwith a self-inflicted stab wound to the chest, sustained with a 3-inch pocket knife. Two small left-sided anterior chest wall punc-ture wounds were present, lateral to the lower sternal border,but medial to the midclavicular line, in the sixth intercostalspace.

On arrival, the patient was confused, agitated, and mildlytachycardic. His blood pressure and oxygen saturation were

normal. Examination revealed nonlabored breathing with equalbreath sounds. Bedside echocardiography by the emergencymedicine resident demonstrated a large hemopericardium withclotted blood (Video Clip S1, available as supporting informa-tion in the online version of this paper). In the subcostal view,the right ventricle and atrium appear to be collapsing (Figures 1and 2), and the inferior vena cava (IVC) is distended andnoncollapsible with inspiration (Figure 3), indicative of early

Figure 3. Pericardial tamponade with a distended inferior vena cava, subcostal cardiac ⁄ IVC View. IVC = inferior vena cava;LV = left ventricle.

Figure 2. Pericardial tamponade, subcostal cardiac view.RA = right atrium; RV = right ventricle.

ISSN 1069-6563 ª 2008 by the Society for Academic Emergency Medicine1322 PII ISSN 1069-6563583 doi: 10.1111/j.1553-2712.2008.00270.x

Figure 1. Pericardial tamponade, subcostal cardiac view.RA = right atrium; RV = right ventricle.

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tamponade. Normal bilateral sliding lung signs and a negativeFAST exam indicated lack of pneumothoraces and no immedi-ate intraabdominal hemorrhage. The patient was intubated andrapidly bolused with 2 L of crystalloid. Although ultrasounddemonstrated evidence of tamponade, the patient’s vital signsand clinical status appeared momentarily stable, and he wasemergently transferred to the operating room for explorationand definitive repair. Vital signs prior to transfer, 9 minutesafter arrival, revealed increasing tachycardia with a pulse of128 beats ⁄ min and a blood pressure of 105 ⁄ 83 mm Hg.

In the operating room a pericardial window was attempted,but after encountering pulsatile bleeding and pericardial clot,the procedure was converted to a median sternotomy. A largeleft ventricular laceration was repaired, and a probable distalleft anterior descending (LAD) artery injury was identified. Thedistal LAD injury was also confirmed by transthoracic echocar-diography, which revealed a distal apical wall motion abnor-mality and a mildly diminished overall ejection fraction. Thepatient was transferred to the psychiatry service 5 days afterarrival and was discharged from the hospital on HospitalDay 11.

Danielle Hart, MD

(Hartd00@yahoo.com)

Gavin Budhram, MD

Rob Reardon, MD

Joseph Clinton, MD

Department of Emergency MedicineHennepin County Medical Center

Minneapolis, MN

Supporting Information

The following supporting information is available in the onlineversion of this paper:

Video Clip S1. Bedside echocardiography demonstratingearly pericardial tamponade.

The video clip is in QuickTime.Please note: Wiley Periodicals Inc. are not responsible for

the content or functionality of any supporting information sup-plied by the authors. Any queries (other than missing material)should be directed to the corresponding author for the article.

ACAD EMERG MED • December 2008, Vol. 15, No. 12 • www.aemj.org 1323