Emergency Bedside Ultrasound Diagnosis of Traumatic Cardiac Tamponade—A Case of Blunt Cardiac Rupture

A 34-year-old female presented to the emergency department (ED) by emergency medical services after jumping from a third floor window, landing on her chest. The patient was reported to be hemodynamically stable en route to the ED. However, on arrival she was cool, pale, and diaphoretic, with a thready carotid pulse. Her physical examination was otherwise unremarkable. She complained of severe midsternal chest pain radiating to her back. Focused assessment with sonography for trauma (FAST) examination revealed a large pericardial thrombus and effusion and right ventricular collapse consistent with cardiac tamponade (Figure 1 and Video Clip S1, available as supporting information in the online version of this paper). No intraabdominal free fluid was identified. The patient quickly developed refractory hypotension. She was then emergently intubated. Pericardiocentesis was unsuccessful, presumably secondary to a large amount of clot present within the pericardium. Soon after, the patient went into a pulseless electrical activity arrest. ED thoracotomy was performed. After pericardiotomy and clot removal, massive exsanguination was noted from the posterior aspect of the heart. Packing was placed, and return of a strong carotid pulse was noted. The patient was taken to the operating room where the left thoracotomy was extended by clamshell sternotomy and right thoracotomy. Inspection of the heart demonstrated a large tear extending from the left atrial appendage to a point approximately midway down the posterior aspect of the left ventricle. Hemorrhage from this wound proved to be uncontrollable. The patient developed refractory cardiac arrest before cardiopulmonary bypass could be initiated and died.

Figure 1.  Subxiphoid view of the heart. L = liver; T = pericardial thrombus; E = pericardial effusion; LV = left ventricle; RV = right ventricle; arrow = right ventricular collapse.