Slide 1

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 2

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 3

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 4

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 5

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 6

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 7

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 8

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 9

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 10

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 11

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 12

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 13

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 14

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 15

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 16

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 17

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 18

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 19

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 20

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 21

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 22

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 23

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 24

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 25

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 26

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 27

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 28

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 29

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]


Slide 30

TRAUMA
Stab Wound to the Chest:
Cardiac Tamponade
Mary C. McCarthy, MD FACS
Professor of Surgery
Wright State University
Dayton, Ohio

Patient S.W.
 45 year-old man presents to the Emergency
Department after being involved in an
altercation
 He states he was stabbed in the chest with a
knife when he picked up 2 quarters from
the edge of a pool table

History
What other points of the history do
you want to know?

History, Patient S.W.
 Chest pain, shortness of
breath?
 When was he stabbed?

 Was he stabbed by a man or a
woman?

 What were the
 Pertinent PMH,
circumstances surrounding
ROS, MEDS
the incident?
 How long was the knife?


Differential Diagnosis

What types of injuries might occur?

Differential Diagnosis
 S.W. has a stab wound to the left anterior precordium
in an area known as the “mediastinal box” bound by
the clavicles, the midclavicular lines bilaterally, and
the costal margins inferiorly
 Penetrating wounds to this area have a high incidence
of cardiac injuries, although wounds of the abdomen,
lateral chest or back may also cause injury to the
heart
 A pneumothorax or hemothorax could also occur
 Penetrating injuries below the nipples can cause
intraabdominal injuries

Physical Examination
What would you look for?

Physical Examination: Patient S.W.
 Vital Signs: BP 80/P, P 95, R 30
 Appearance: Agitated, diaphoretic
 Relevant Exam findings for a problem focused assessment

HEENT: Jugular venous
distension

CV: muffled heart
sounds

Chest: Equal breath sounds

Abd: Soft, non-tender

Remaining Examination findings non-contributory

Jugular Venous Distension

Would you like to revise your
Differential Diagnosis?
 The classic signs of cardiac tamponade—
hypotension, muffled heart tones, and elevated
central venous pressure--are known as Beck’s
triad.
 A narrow pulse pressure, and pulsus paradoxus
have also been described or merely the
disappearance of the radial pulse when the
patient takes a deep breath.

Laboratory

What would you obtain?

Labs ordered, Patient S.W.
 Major trauma labs: CBC, Chem-6, PT/PTT
should be obtained

 A Type and Crossmatch for blood should be
obtained

Interventions at this point?

Interventions at this point?
 Start 2 large bore peripheral IV’s with Ringers
Lactate or similar isotonic crystalloid solution
 Administer antibiotics (first generation
cephalosporin)

Tachycardia

Narrow Pulse
Pressure

Tachypnea

Studies, Patient S.W.
Obstruction Series/Acute
Abdominal Series etc.
Flat/Upright Abdomen

CT Scan: Abd/Pelvis
CT Scan: Other
MRI

PA/Lat Chest

PET SCAN

Ultrasound (FAST)

Extremity Film

RUQ US

Bone Scan

Angiogram

US Pelvis

HIDA Scan

MRCP

OTHER:

Studies
 Encourage cost-effective approach to
ordering studies
 Discuss risk/benefits of various diagnostics
 Encourage students to interpret the imaging
study

AP Chest X-Ray: Patient S.W.

Pericardial Ultrasound

Pericardial Fluid

Heart

Studies – Results
 Chest X-ray is normal—there is no evidence of
hemothorax or pneumothorax
 The FAST shows a hypoechoic rim of blood
around the heart

What is the differential diagnosis at this
point?

What next?

What next?
 Pericardiocentesis: a
preliminary pericardial tap
may “buy time” in a patient
who is decompensating
 Risks vs. Benefits

Management
 Technique of pericardiocentesis: 45o aspiration,
EKG guidance, aim to L scapula

 S.W.’s Blood Pressure rises to 110/90 after
aspiration of blood from the pericardium.

What should be done next?

Management
 Go directly to the Operating Room…

Median Sternotomy

Discussion
 The Trauma Surgeon or Cardiothoracic Surgeon opens
the chest through a median sternotomy and direct repair
of the cardiac injury is performed. Care is taken to
avoid occluding the left anterior descending artery.
 Few patients present with all 3 symptoms of Beck’s
Triad, and a high index of suspicion should be
maintained in patients with penetrating injuries in the
parasternal area.

QUESTIONS ??????

Summary
 Trauma ABC’s
 Suspect cardiac tamponade in penetrating chest
trauma
 Beck’s Triad: Hypotension, muffled heart
sounds, elevated central venous pressure
 Technique of pericardiocentesis
 Definitive Repair of Cardiac Injuries

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]