Cardiac tamponade

Effect of alcohol intoxication on hemodynamic physiology and outcome in patients with traumatic cardiac tamponade

BACKGROUND

Alcohol intoxication has a detrimental effect on hypovolemic shock. Our aim, was to study its effects on "pure" cardiac tamponade (i.e., without hypovolemia) in patients with penetrating chest injuries.

METHODS

Thirty-five intoxicated and 15 nonintoxicated patients (blood alcohol > and < 17 mmol/L) were studied. Initial vital signs (trauma scores), special investigations (hematologic profiles, blood gases, glucose, lactate, and catecholamines), clinical progress (24- and 72-hour acute physiology and chronic health evaluation II scores) and outcome were compared.

RESULTS

Intoxicated patients were older (p = 0.02) and more tachypneic on admission (p = 0.006), but no other differences were noted. Mortality was proportional to the degree of shock and was greater in patients who had "front-room" thoracotomies (p < 0.001). Despite the higher percentage of intoxicated patients who were "lifeless" or "in extremis" on admission, they fared no worse than nonintoxicated patients.

CONCLUSION

Alcohol intoxication does not have an adverse affect on traumatic cardiac tamponade.

Emergencies in continuous dialysis patients: diagnosis and management

The number of patients undergoing long-term hemodialysis and peritoneal dialysis is growing in the United States. To provide adequate emergent care to these patients emergency physicians must understand the alterations in normal physiologies present in these patients and how this may affect care. Cardiovascular disease and infection (especially Staphylococcus aureus sepsis) are the leading causes of death among dialysis patients. These patients are also subject to a significantly higher incidence of life-threatening electrolyte disturbances, particularly hyperkalemia and hypercalcemia, than the general population. Suicide, cardiac tamponade, intracranial hemorrhage, bleeding disorders, and bowel infarction are also much more frequent. The inability of dialysis patients to excrete drugs, metabolites, toxins, and fluids significantly alters their responses to common emergencies and should directly influence their care. Failure to recognize these differences in physiology may result in the use of standard forms of emergency therapy that may compound, rather than treat, the underlying disorder. Although most dialysis patients who come into an emergency department have conditions that can, and should, be managed by their nephrologist, the presence of a life threatening emergency requires prompt, appropriate therapy by the emergency physician.

Cardiac tamponade as the only initial feature of malignancy: a case report and review of the literature

Cardiac involvement in the form of pericardial effusion or tamponade as the initial feature of extracardiac malignancy is extremely rare. An extensive search of medical literature yielded only 36 such cases. A case is presented and literature reviewed.

Emergency pericardiotomy as primary diagnostic and therapeutic procedure in malignant pericardial tamponade: report of three cases and review of the literature

Three cases are presented in which pericardial tamponade was the first indication of malignant disorder. The diagnosis and therapy of malignant cardiac tamponade was revealed by emergency pericardiotomy. In all cases the tumor was an adenomatous carcinoma and the site of primary tumor was unknown until death. The median survival time after onset of symptoms was 4 months. The primary site was the lungs in two and remained unknown autopsy in one case.

Emergency diagnosis, resuscitation, and treatment of acute penetrating cardiac trauma

The controversy concerning the mode of resuscitation in acute penetrating cardiac trauma has been resolved in recent years. Most large centers are aggressive, and pericardiocentesis is used in life-threatening situations only as a temporary measure until thoracotomy can be performed. There are at least 32 publications which recommended emergency department thoracotomy for resuscitation of the critically injured heart. The physician should be alerted when patients arrive with penetrating chest and upper abdominal wounds. Cardiac injury must be ruled out as soon as possible, for minutes may mean the difference between successful resuscitation and irreversible myocardial damage. Most penetrating chest wounds are easily managed in the emergency department with fluid resuscitation and chest tube drainage. Patients who have an isolated penetrating cardiac injury will have the best prognosis; moribund patients who are suffering from extrathoracic injuries, especially CNS injuries, will have a dismal prognosis. The keys to successful resuscitation of the traumatized heart are a high index of suspicion, early recognition, and rapid intervention.

Experience in the management of 50 consecutive penetrating wounds of the heart

Fifty patients with penetrating wounds of the heart were grouped into three categories, based on the clinical severity of the injuries. Gunshot wounds consistently resulted in a higher mortality than knife wounds. Central venous pressure (CVP) was the single most important means of determining cardiac tamponade. The survival rates in the respective groups were 6, 79 and 100 per cent. The improved survival in our series was due to a rapid transportation system, increased awareness of the significance of cardiac injuries and an aggressive surgical approach.

Influence of elevated pulmonary vascular resistance on the relationship between central venous pressure and pulmonary artery occluded pressure following cardiopulmonary bypass

This study has demonstrated that CVP measurement is an unreliable index of left ventricular filling pressure in unselected patients undergoing A-C bypass procedures. The influence of altered PVR on the disparity between right and left ventricular filling pressures is not of prime importance. The inconsistent relationship between CVP and PAo is primarily a result of ventricular dysfunction and not altered PVR. This suggests that following A-C bypass surgery patients cannot be grouped with respect to altered PVR as the variable which determines whether CVP will be a reliable guide to changes in left atrial pressure. Routine use of Swan-Ganz catheters would improve the precision of monitoring and fluid administration in all patients following CPB. However, it would also increase the cost and complexity of routine care and add a very low incidence of complications to all patients having cardiac surgery. At present, we monitor high risk patients from the time of surgery and advocate early insertion of Swan-Ganz catheters in low risk patients if they are not responding to appropriate management.

Post-infarction cardiac rupture

Three allied conditions are described in this paper: (i) haemopericardium with cardiac rupture (5 cases); (ii) haemopericardium without rupture (2 cases); (iii) pseudoaneurysm (1 case). In the first 2 of these, the significant features were clinical deterioration with shock 3 or more days after infarction, recurrent cardiac pain, cardiac tamponade, and immediate or later ineffectiveness of counterpulsation. An additional feature in the second group was the development of haemopericardium after heparin therapy. In the third group, infarction followed by left ventricular failure and progressive cardiac enlargement was the significant feature. An apical systolic murmur was not present, as a false sac had not been formed. Ante-mortem diagnosis depends upon an appreciation of these features. Without it successful surgery is impossible. There were 4 survivors in this group of 8 patients.