Volume 2 Number I H A R R I S : C A R D I A C T A M P O N A D E IN M U L T I P L E INJURIES 5

CARDIAC TAMPONADE IN MULTIPLE INJURIES D. HARRIS

Institute of Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry

Cardiac tamponade in multiple injuries is discussed with reference to the masked presenta- tion, the diagnostic features, and treatment. Central venous pressure monitoring and continuous pericardial drainage are advocated.

REPORTS of cardiac tamponade in closed chest trauma associated with multiple injuries are surprisingly uncommon. The cause is usually a typical high-speed traffic accident and the inci- dence can be expected to rise, checked only by the use of safety devices in vehicles. Neither the mortality (Conn, Hardy, Fain, and Netterville, 1963) nor the morbidity is known with certainty.

It is a curious feature that although bleeding into the pericardial sac develops sufficient pres- sure within it to prevent the atria from filling properly so that the venous side of the heart is obstructed, and the haemopericardium can be shown to be under considerable pressure, most commonly the bleeding does not persist and the site cannot be demonstrated.

DIAGNOSTIC DIFFICULTY AND DELAY Recognition of haemopericardium is not

always easy, even when it occurs as an isolated injury (Williams and Soutter, 1954; Farringer and Carr, 1955). Many of the described physical signs are unreliable for two reasons : - -

1. No distinction is drawn between acute tamponade and chronic pericardial effusions resulting in compression. Consequently some signs typical of the chronic condition are mis- takenly sought for in the acute case. For example, intense peripheral cyanosis is masked by the vasoconstriction produced by sudden blood-loss. An increased area of cardiac dullness, due to expansion of the pericardial sac, does not develop until the relatively inelastic pericardium can dilate. Similarly, enlargement of the radio- graphic heart shadow is said to require a collec- tion of 300--400mi. (Cecil and Loeb, 1955), whereas an acute collection of 300 ml. is said to be lethal.

2. In the context of multiple injuries, other clinical signs are invalidated because of lack of specificity. Thus signs of shock, distant heart- sounds, reduction of arterial and of pulse pressure, tachycardia, and absence of the apex beat lose their significance. Venous engorgement of the head and neck, which may be a striking clinical feature, is sometimes absent or appears late (Williams and Soutter, 1954), possibly because of inadequate venous return due to haemorrhage. Pulsus paradoxus, associated with loss of compliance of the tense pericardium, is also an inconstant finding. Electrocardio- graphic changes are often absent and depend more on the nature and degree of myocardial injury than on compression. Finally, an import- ant cause of delay is lack of suspicion of the condition in the presence of a chest injury which seems relatively trivial, as illustrated in the case report.

CASE REPORT A 63-year-old lorry driver was involved in a head-on

collision. He was given intravenous morphine while being freed from his vehicle. Forty-five minutes later he was admitted to art emergency department, lightly comatose, with a large ' scalping ' laceration, but no localized neurological signs. His colour was grey with slight leaden lividity of the extremities. His skeletal injuries were a closed, grossly comminuted fracture of the right femoral shaft, a compound comminuted fracture of the right tibial plateau with avulsed patellar tendon, and a closed, grossly com- minuted fracture of the left tibial shaft. The chest showed a small area of bruising with slight instability beneath it. The abdomen was silent. Pulse and blood-pressure were virtually unrecordable. Despite vigorous resuscitation measures his condition deteri- orated. After negative aspiration of the peritoneal and pleural cavities, the diagnosis was suggested by the high, rising central venous pressure as intravenous fluids were continued (Fig. 1). Doubtful confirmation

I N J U R Y : T H E B R I T I S H J O U R N A L O F A C C I D E N T S U R G E R Y

was obtained by the difficult withdrawal of a few ml. of blood on pericardial aspiration by needle and by fine-bore intravenous catheter. Continuous drainage for 4 days by a polyethylene urinary catheter (12 F),

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Only two methods, short of thoracotomy, can be used to distinguish these conditions in circum- stances where massive myocardial injury is likely.

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placed through a trocar and cannula, produced a dramatic recovery. No electrocardiographic or clinical evidence of cardiac damage was present at any time during treatment, nor at review after l year.

THE VALUE OF CENTRAL VENOUS PRESSURE MEASUREMENT

The one feature of this condition which appears to be constantly present is a raised venous pressure, although this may not be shown by venous engorgement. The only other condi- tion in which a strikingly high central venous pressure is recorded, rising with continued replacement transfusion, is that of acute failure due to massive myocardial damage from trauma.

This condition, like tamponade, appears to be relatively uncommon and is revealed by electro- cardiographic changes. It is said that E.C.G. changes can sometimes occur in tamponade (Cecil and Loeb, 1955; Farringer and Cart, 1955).

They are aspiration of the pericardium and angio- cardiography (Williams and Steinberg, 1949).

In cases of myocardial contusion not distin- guishable by the E.C.G. tracing, the venous pressure can be expected to start at a low normal level from failing venous return due to haemor- rhagic shock, only rising to high levels after replacement has exceeded the optimum for the impaired heart action, and after a temporary improvement in the general condition. In tamponade the pressure is initially high and becomes higher with intravenous infusions.

Monitoring the central venous pressure, which is a routine procedure in resuscitation, thus presents the best guide to the diagnosis of cardiac tamponade masked by multiple injuries.

The established value of monitoring in follow- ing the changing requirements in blood-volume replacement is particularly great when, .after

Volume 2 Number I

relief of compression, the pressure falls immedi- ately and dramatically (McDermott and Douglas, 1967). Further urgent deficits may be revealed and in cases with myocardial damage, replace- ment may be carefully titrated.

TREATMENT BY CONTINUOUS DRAINAGE

Initial management by needle aspiration, repeated if necessary, has become the accepted form of treatment since the 1939-45 war, with thoracotomy reserved for cases not controlled by aspirations and occasionally for open penetrating wounds. This method has the advantage of being at once diagnostic and therapeutic in emergency conditions. Although the procedure is potenti- ally hazardous, damage to the heart has not often been recorded and can be guarded against by E.C.G. monitoring during needling, as contact with the myocardium produces an immediate pattern of injury in the tracing (Bishop, Estes, and McIntosh, 1956). While aspiration of the initial collection in a pericardial sac fully dis- tended and free from blood-clot is unlikely to result in injury to the heart, repeat aspirations present a greater danger.

Only one other report has been found in the literature of the use of continuous drainage of the pericardial sac by plastic catheter (McDermott and Douglas, 1967). An Intracath polyethylene tube of fine bore, introduced through a needle, had been left in situ for 3 days without complica- tions. In this case an Intracath failed to provide adequate drainage, but a larger bore catheter was left in situ for 4 days, also without complications.

The advantages of continuous drainage are that repeated needling is avoided, that the wider catheter can be directed to the back of the peri- cardial cavity via the apical or wide parasternal routes, ensuring dependent drainage to mini- mize residual clot organization and scarring, and most importantly, it is a continuous guide to the rate of bleeding and therefore the severity of the cardiac trauma. In both cases it proved a satis- factory definitive treatment.

TECHNIQUE OF PERICARDIAL CANNULATION

Three routes are described for needle aspira- tion of the pericardium. The simplest is the wide parasternal route, where the needle is passed directly backwards through the fourth left inter- costal space, a good inch from the left border of the sternum in order to avoid the internal mammary vessels, which can cause serious bleeding if damaged. Underlying this point is

HARRIS: CARDIAC TAMPONADE IN MULTIPLE INJURIES

the thinner walled of the two ventricles, the right. For this reason, the apical route is sometimes preferred, through the same intercostal space lateral to the mid-clavicular line, with the left ventricle deep to the needle. However, the pleura may be transgressed in this way. Finally, the subxiphoid approach through the left costo- xiphoid angle upwards and backwards passes through the rectus muscle and the central tendon of the diaphragm to the base of the pericardium. It is a longer, more oblique approach requiring some delicacy. Needle aspiration is performed first to confirm the diagnosis and, ira fine catheter can be introduced through the needle to provide adequate drainage, this is done and the needle withdrawn. If a larger catheter is required, the subxiphoid route is too long for normal tro- cars, but the other two are satisfactory. A small skin stab is made and the trocar and can- nula advanced slowly until the pericardium is felt to be entered in the direction and at the depth indicated by the preliminary needling. The catheter is inserted and, after removal of the cannula, is connected to some form of closed drainage bag, or underwater seal, in case it should at any time become displaced into the pleural cavity. For this reason it may be sutured to the skin.

A c k n o w l e d g e m e n t s

My thanks are due to Mr. G. K. Rose, Con- sultant Orthopaedic Surgeon, and Dr. J. W. McCloy, Consultant Anaesthetist, to the Royal Salop Infirmary and The Robert Jones and Agnes Hunt Orthopaedic Hospital, for their advice and assistance in the preparation of this paper, and for permission to quote the case reported.

REFERENCES BISHOP, L. H.,jun., ESTES, E. H.,jun., and MCINTOSH,

H. D. (1956), ' Electrocardiogram as Safeguard in Pericardiocentesis ', J. Am. reed. Ass., 162, 264.

CECIL, R. L., and LoEa, R. F. 0955), Textbook o f Medicine, 9th ed., p. 1270. Philadelphia: Saunders.

CONN, J. H., HARDY, J. D., FAIN, W. R., and NETTER- VILLE, R. E. (1963), "Thoracic Trauma: Analysis of 1022 Cases ', J. Trauma, 3, 22.

FARRINGER, J. L.,jun., and CARR, D. (1955), ' Cardiac Tamponade ", Ann. Surg., 141,437.

MCDERMOTT, F. T., and DOUGLAS, M. C. (1967), 'Cardiac Tamponade Resulting from Non-Pene- trating Chest Injury, with Reports of Two Cases ', ,4ttst. N .Z . J. Surg., 37, 147.

WILLIAMS, C., and Soo'r'rER, L. 0954), ' Pericardial Tamponade: Diagnosis and Treatment', Archs intern. Med., 94, 571.

WILLIAMS, R. G., and STEINBERG, I. (1949), ' Value of Angiocardiography in establishing Diagnosis of Pericarditis with Effusion ", Am. J. Roentg., 61, 41.

Requests for reprints shouM be addressed to:--D. Harris, Esq., F.R.C.S., Institute of Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire.