Cardiac Tamponade is a condition where the heart become compressed by excess fluid in the pericardium. Compression causes reduced diastolic filling of the heart, which can cause cardiac arrest.

The pericardiac sac is normally a virtual space. This is enclosed by the pericardium.

Causes of Cardiac Tamponade

• Traumatic injury – particularly penetrating injury – can lead to accumulation of blood in the pericardial sac. This compresses the heart, and prevents diastolic filling, which leads to cardiac arrest. Cardiac Tamponade in a trauma setting an emergency and can quickly become life-threatening.
• Pericarditis
• Cancer
• Iatrogenic – can occur after cardiothoracic surgery

Presentation

• Becks Triad – occurs in about 1/3 of patients with cardiac tamponade
  • Hypotension
  • Distended Neck Veins
  • Muffled Heart Sounds
• Tachycardia
• Shortness of breath
• Chest pain
• Pulsus Paradoxus – systolic BP decreases >10mmHg on inspiration
• Have a high index of suspicion in any patient with penetrating chest injury – especially they are not responsive to IV fluids and other basic investigations
• FAST / bedside echo can diagnose without the need for other imaging (which may be time consuming)
• It quickly causes cardiac arrest!

Management

• Pericardiocentesis can be performed in the emergency setting in the peri-arrest scenario
  • Use a long 14 or 16G cannula attached a syringe
  • Insert at the angle of the xiphisternum and the left rib border – and aim for the ipsilateral (same side) scapula. Aspirate as you slowly advance. In reality this would often be performed US guided in the emergency department
  • Pericardiocentesis is sometimes attempted for suspected cardiac tamponade in the pre-hospital setting – but is rarely successful
• Surgery may be indicated in some patients – this may be the formation of a pericardial window or could involve a pericardiectomy
• Conservative management – may be attempted in some patients – albeit under very close monitoring (e.g. in the intensive care setting in a trauma patient)
• Involving the cardiothoracics team (and trauma team if indicated) early in management and decision making is imperative

References

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Trauma is managed by teams in the Emergency Department. There is often a defined set of individuals on a ‘Trauma Team’. This might include:

• Team Leader – often an Emergency Physician / Registrar
• Anaesthetist
• Anaesthetic assistant
• Trauma (General) Surgeon / Registrar
• Orthopaedic Surgeon / Registrar
• Additional Emergency Doctors
• Radiographer
• Scribe
• Several Nursing Staff

Allocating Roles

Before the patient arrives then the roles of the team will usually be allocated. Often a ‘Trauma Code’ is sent out to the pagers of the members of the team with pre-defined roles once the message comes in from the ambulance that a trauma patient is expected.

Team leader, scribe, and other roles such as managing airway, circulation, taking blood will be discussed and allocated usually before the arrival of the patient.

Deaths in Trauma

Death in trauma can be divided into:

• Immediate – caused by major disruption or large blood vessels or body cavities
• Early – can occur in minutes to hours after the trauma. Caused by failure of oxygenation of the vital organs – often secondary to cardiovascular collapse.
• Late – occurs days to weeks after the injury. Often due to sepsis and multi-organ failure.

Training of critical care staff – such as with the ATLS (Advanced Trauma Life Support) and EMST (Early Management of Severe Trauma) protocols is aimed at reduced the number of deaths of the ‘late’ category.

The aims of the critical care team in severe trauma are to:

• Stabilise the trauma patient
• Identify life-threatening injuries
• Initiate organ saving interventions

Management of Trauma

Care in the emergency department usually begins with handover from the transporting team (usually ambulance crew). When taking this handover, you should think about the MIST pnemonic

• M – Mechanism
• I – Injury
• S – Symptoms
• T – Treatment

Primary Survey

This is based on the ABCDE approach – with an extra emphasis on the c-spine at the start of the survey. It is a very rapid assessment conducted as soon as the patient arrives in the Emergency Department designed to catch any immediately life-threatening injuries. The patient should be lying flat on their back in bed.

• C-Spine – is it immobilised? Does it need to be immobilised? Are there injuries that may have caused c-spine damage? If there is any doubt – assume c-spine injury
• A – Airway – can air pass in and out of the lungs? Is the patient conscious and breathing for themselves? Are there any visible obstructions (foreign body, vomit, secretions, patient’s tongue). Initiate airway management techniques as required – this might be anything from simple airway manoeuvres like chin lift (beware of head tilt in c-spine injury), to intubation or even performing a surgical airway!
• B – Breathing – the ability to ventilate. Is the patient breathing? Auscultate the chest. Check for chest rising and equal air entry. Look for gross chest wall defects or injuries. Check the trachea for any deviation. Be wary for pneumothorax or haemothorax – patients might need a chest drain. Flail chest segments often require mechanical ventilation.
• C – Circulation – check the BP and get an ECG if indicated. Make sure blood is sent, including FBC, Urea and Electrolytes, a blood gas, group and save and clotting. Check for signs of hypotension. Look for any signs of external bleeding. Check the heart sounds – think about cardiac tamponade. Check the abdomen for sources of bleeding, including palpating the abdomen for intra-abdominal bleeding. Try to get two large bore IV lines (if someone hasn’t done this already). Control any external bleeding with direct pressure until surgery. Consider a FAST scan to look for sources of intra-abdominal blood. Try to get two large bore cannulas into two large veins as soon as possible. 
• D – Disability – Check gross mental status. Do GCS. Check pupils. Quickly check for peripheral neurological signs
• E – Expose the patient – completely remove clothes and check for any injuries. Consider a log-roll to be able to check for spinal tenderness and rule out injuries on the back, the back of the head and the neck. You should also briefly check peri-anal sensation and anal tone. Once you have finished, make sure to put some blankets (or warmer) on the patient to avoid hypothermia.

Usually, whilst all this is going on, members of the team will be taking blood test, attaching leads for ECG, and getting IV access.

Don’t forget to repeat your survey frequently to keep on top of any changes in the patient’s condition.

Secondary Survey

This will vary a great deal depending on the condition of the patient – are they conscious and able to give a history? Is there a collateral history available?

You could base your history around the AMPLE acronym:

A – Allergies

M – Medications

P – Past History

L – Last meal – important for anaesthetic risk!

E – Event – how did it occur?

The physical examination is a full ‘top to toe’ examination

• Head – fully examine the soul and head for any evidence of injury. Examine the cranial nerves. Check the ears (haemotympanum for evidence of basal skull fracture) and nose for evidence of bleeding.
• C- Spine – check the c-spine for tenderness. Remove the collar for this, but make sure that the head is stabilised (usually by another member of staff) whilst you check the spine. Maintain full spinal precautions until the c-spine has been cleared. 
• Chest – palpate the chest wall checking for instability, rib fractures, areas of flail chest, evidence of subcutaneous emphysema. Listen again to the heart and lungs. Don’t forget to check the axilla and the back – especially in patients with any penetrating chest wounds. If any chest tubes have been places – make sure they are in place correctly and are having output. Make sure a CXR has been ordered +/- performed.
• Abdomen / Pelvis – palpate the abdomen. Check for tenderness or distension. If there is any suspicion of pelvic injury – apply a pelvic binder. Don’t forget to examine the genitals and anus for evidence of bleeding or other trauma.
• Limbs -check all 4 limbs for deformity or other evidence of injury. Split and/or reduce long bone fractures. Check for peripheral pulses. 
• Don’t forget to check the spine if it wasn’t; already done on in the primary survey
• Neurological examination – depending on the conscious level and injuries of the patient you should attempt to perform a neurological examination of the limbs
• Don’t forget to cover the patient up again at the end!

Your hospital may have a trauma pro forma that is filled in as part of the secondary survey (often with lots of diagrams and pictures to help injuries be described).

Fluids in Trauma

Be wary of giving large amounts of fluids – this can inadvertently increase the blood pressure and increase blood losses.

• Maintain a MAP (mean arterial pressure) of >65mmHg
• Aim for adequate BP – not normal BP
• Head injury patients should maintain a SBP (systolic blood pressure) of >90mmHg
• Be particularly cautious if there is internal bleeding
• Give small fluid boluses regularly as required – usually boluses of around 200mls. Avoid large amounts of fluid stat (if possible) – if parameters are maintained as above.
• If larger boluses are needed if BP drops – boluses of 10ml/Kg maximum are recommended

Haemorrhage

Defining haemorrhage is difficult. The American College of Surgeons Classification of Haemorrhagic Shock classifies haemorrhage shock in classes I – IV – with IV being the most severe.

• Blood pressure changes are late
• Pulse pressure changes are earlier
• Respiratory rate is an early change
• Mental state is an early change
• DON’T AIM FOR A ‘NORMAL’ BP
  • Aim for MAP >65mmHg
• Send a group and save and crossmatch request ASAP
  • O negative blood can be given immediately
  • Group specific blood takes about 10 minutes to be processed by the lab
  • Crossmatched blood takes about an hour to be process by the lab
• Give O negative blood as soon as possible if required
• Give blood products in the ratio of 1:1:1
  • 1 unit of RBCs
  • 1 unit of FFP (fresh frozen plasma)
  • 1 unit of platelets
• If there are signs of external bleeding – keep pressure on and don’t stop!

FAST Scan

This stands for Focused assessment Sonography in Trauma. The fast scan is an US scan performed at the bedside, usually by an Emergency Registrar or Consultant, or occasionally the Trauma Registrar or Consultant (Gen Surgery).

The scan is usually performed after the secondary survey.

The goals of the FAST scan are to find any intra-abdominal free fluid (which in this circumstance is most likely to be cause by bleeding), to check for cardiac tamponade, and to assess the lungs.

• Visualises three spaces: intra-abdominal, intra-thoracic and pericardial
• Can usually only detect blood if >200mls present
• Good pelvic views by a skilled sonographer in an easily viasulised (usually skinny person) abdomen can detect smaller amounts
• 7 Views in total
  • Subxiphoid 4 chamber (cardiac)
  • Transthoracic long axis
  • Abdominal and lower thoracic
  • Right coronal and intercostal oblique
  • Left coronal and intercostal oblique
  • Pelvic
  • Anterior thoracic

Other Imaging

• Chest XR
• Pelvic XR
• C-spine X-ray

These three scans are usually standard in most trauma patients. Other imaging should be requested based on clinical findings.

A “Pan Scan” is usually a CT scan from the Head to the Pelvis in cases of severe trauma with multiple indicated injuries.

Head Injury in Trauma

The use of fluids in head injury in trauma is a special case. In the absence of head injury – fluids should only be given if the MAP is <65mmHg.

In head injury, we give fluids to maintain a SBP of >90mmHg.

This is to prevent secondary brain injury. 

• Primary brain injury – occurs at the time of the trauma – nothing can be done to reverse this!
• Secondary brain injury – occurs in the hours after the injury and can be prevented by following the ABCDE principles
  • Often caused by hypoxia and hypotension
  • ALWAYS give oxygen and maintain SBP >90mmHg

Prognositc Indicators in Head Injury

• High energy trauma – e.g. fall from height, high speed MVA
• Low level of consciousness at presentation
• Anticoagulation
• Diffuse brain injury on CT
• Hypotension
• Age – worse prognosis in older patients

Disposition of the Trauma Patient

Obviously depends on many factors! Severe trauma will often go straight to theatre and then onto ICU.

Patients with mild trauma, especially those with head injury, will usually be admitted to the trauma ward for observation, and the following day a Tertiary Survey is usually performed.

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