Review Question - QID 106357

This patient with a stab wound to the chest, hypotension with a narrowed pulse pressure, muffled heart sounds and jugular venous distention has likely developed cardiac tamponade from a traumatic pericardial effusion. The most appropriate next step in management is to perform a pericardiocentesis.

Cardiac tamponade develops when fluid collects in the pericardial sac and restricts ventricular filling, leading to decreased cardiac output. Risk factors include penetrating trauma (most common), TB, SLE, malignancy, and pericarditis. Consider this diagnosis in any patient that is hemodynamically unstable and that does not respond to fluid resuscitation. Chest pain, Beck's triad (hypotension, distant heart sounds, and distended jugular veins), pulsus paradoxus (>10 mmHg drop in BP on inspiration), and Kussmauls's sign (paradoxical increase in JVP on inspiration) can all be noted on physical exam. Pericardiocentesis and aggressive volume expansion are the initial treatment options.

Appleton et. al review the pathophysiology, clinical manifestations and management of cardiac tamponade. They discuss the distinction between pericardial effusion and tamponade physiology. They recommend that hemodynamically unstable patients with suspected or confirmed tamponade be treated with pericardiocentesis.

Figure A demonstrates ultrasound findings consistent with pericardial effusion. Note the hypoechoic collection surrounding the pericardium.

Illustration A is an artist's rendering of pericardial tamponade that causes hemodynamic compromise through increased pericardial pressure, which reduces right-ventricular filling and cardiac output.
Illustration B depicts an overview image of a pericardiocentesis.

Incorrect Answers:
Answer 1: Chest tube placement would be appropriate for a suspected tension pneumothorax. While tension pneumothorax also presents with jugular venous distention, unilateral diminished breath sounds and hypoxemia would be expected. It is not appropriate for the management of cardiac tamponade.

Answer 2: Emergent thoracotomy is indicated for patients with penetrating trauma to the chest who develop cardiac arrest. While it may be appropriate for some patients who develop cardiac arrest from suspected traumatic pericardial effusion with tamponade, it would not be appropriate for this patient who has not had cardiac arrest.

Answer 3: Needle thoracostomy would be an appropriate initial stabilizing procedure if tension pneumothorax was suspected. While tension pneumothorax also presents with jugular venous distention, unilateral diminished breath sounds and hypoxemia would be expected. It is not appropriate for the management of cardiac tamponade.

Answer 5: Placement of occlusive dressing is sometimes utilized as an initial stabilizing measure, generally in the prehospital setting, for patients with chest wounds. It would not definitively address this patient's cardiac tamponade.

Bullet Summary:
For patients with cardiac tamponade, the most appropriate initial step is to perform a pericardiocentesis to remove pericardial fluid and restore cardiac output.