a b s t r a c t

Introduction: Little is known about the outcomes of deliberate non-surgical management for hemodynamically unstable patients with blunt traumatic pericardial effusion. We evaluated the efficacy of management with pericardiocentesis or subxiphoid pericardial window in hemodynamically unstable patients who reach the hos- pital alive with blunt traumatic pericardial effusion.

Methods: We conducted a review of a consecutive series of patients with pericardial effusion following blunt trau- ma who arrived at Fukui Prefectural Hospital between January 1, 2009 and December 31, 2017. All patients with traumatic pericardial effusion were included, irrespective of the type of blunt trauma.

Results: Eleven patients were identified arrived to the Emergency Department with a pericardial effusion after blunt trauma. Of the eleven patients, five patients had cardiopulmonary arrest on arrival and none survived. Of the other six patients who reached the hospital alive, five were hemodynamically unstable and clinically diag- nosed with cardiac tamponade. One patient was hemodynamically stable and managed conservatively without pericardiocentesis or pericardial window. Otherwise, two patients were managed with pericardiocentesis alone. One patient was managed with pericardial window alone. One was managed with both pericardiocentesis and pericardial window. The remaining patient underwent median sternotomy because of unsuccessful pericar- dial drainage tube insertion. All six patients who reached the hospital alive survived. Five patients did not require Surgical repair.

Conclusion: The results of the present study suggested that non-surgical management of hemodynamically unsta- ble patients who reach hospital alive with blunt pericardial effusion may be a feasible option for treatment.

(C) 2018

Introduction

Blunt traumatic pericardial effusion is a rare injury occurring in about 0.5% of blunt trauma. However, it is highly fatal as it can result in blunt Cardiac rupture [1], which is a potentially life-threatening injury with an overall mortality of approximately 90% [2]. About 80% of cases are estimated to die before reaching hospital [3]. The overall mortality in patients with blunt cardiac rupture who survive to hospital has been reported to be 89% [2]. Most of these patients presented to hospital with shock and signs of tamponade physiology. For these patients, prompt and definitive surgical repair is considered as the first-line treat- ment therapy [4-6]. However, there are some reported cases of blunt cardiac rupture with Nonoperative management in the setting of previ- ous sternotomy or stable hemodynamics [7-10]. Nonoperative

? There are no potential conflicts of interest.

?? This paper has not been presented anywhere.

* Corresponding author at: Medicine, Fukui Prefectural Hospital, 2-8-1, Yotsui, Fukui 910-8526, Japan.

E-mail address: [email protected] (S. Tanizaki).

management has been considered for blunt cardiac rupture with peri- cardial adhesions when patients had severe Associated injuries that in- creased the risk of systemic anticoagulation. However, little is known about the outcomes of deliberate non-surgical management in patients with no history of sternotomy or hemodynamic instability, except via subgroup analysis of non-surgical candidates. The safety of manage- ment with pericardiocentesis or subxiphoid pericardial window alone of hemodynamically unstable patients with blunt traumatic pericardial effusion and its effect on outcomes are poorly documented. During the last decade, our institution has practiced non-surgical management for patients with blunt traumatic pericardial effusion who were alive upon arrival to the hospital. Therefore, the purpose of this study was to evaluate the efficacy of management with pericardiocentesis or subxiphoid pericardial window alone of patients with blunt traumatic pericardial effusion who reach the hospital alive.

Methods

The institutional review board of Fukui Prefectural Hospital ap- proved this retrospective study, and the need for patient consent was

https://doi.org/10.1016/j.ajem.2018.06.066

0735-6757/(C) 2018

1656 S. Tanizaki et al. / American Journal of Emergency Medicine 36 (2018) 1655–1658

waived because of the retrospective study design. We conducted a re- view of a consecutive series of 11 trauma patients with blunt traumatic pericardial effusion who arrived at Fukui Prefectural Hospital between January 1, 2009 and December 31, 2017. The patient data were obtained from the hospital records. Patients with any type of blunt traumatic pericardial effusion were included. Patient data included age, gender, mechanisms of injury, injury severity score (ISS), combined injury, sys- tolic blood pressure (SBP) and heart rate (HR) on arrival, requirement for Packed red blood cells in the initial 24 h, lengths of stay in both in- tensive care unit (LOS-ICU) and in hospital, electrocardiogram (ECG), and the creatine kinase-myocardial band isozyme level (CK-MB) on ar- rival. Additional data regarding the key outcomes measures were also recorded, focusing on whether pericardiocentesis, subxiphoid pericar- dial window, emergency department thoracotomy, and/or cardiopul- monary resuscitation were performed. The follow-up outcomes were also reviewed.

The combination of focused assessment by sonography in trauma (FAST) and/or computed tomography (CT) was used as the screening tool to confirm pericardial effusion in blunt trauma cases. Hemodynam- ic instability was defined as SBP <= 90 mm Hg with agitation or after ini- tiation of a transfusion of packed red blood cells. When emergency physicians noted circumferential pericardial effusion and diastolic col- lapse of the right atrium or ventricle on FAST in hemodynamically un- stable blunt trauma cases, cardiac tamponade was considered highly probable. Once cardiac tamponade was suspected, prompt pericardiocentesis was performed in the emergency department by an emergency physician or a cardiovascular surgeon. The pericardial drain- age volume was controlled to stabilize hemodynamic status and prevent excessive elevation of blood pressure. If the hemodynamic status did not improve after pericardiocentesis, prompt subxiphoid pericardial window was performed by the emergency physician or car- diovascular surgeon, and a drainage tube was placed. In contrast, if pericardiocentesis was successful, conservative management with drainage tube placed was performed under close hemodynamic moni- toring in the ICU. If Pericardial drainage was ongoing, pericardial explo- ration was considered. Median sternotomy was indicated in the case with ongoing hemodynamic instability or hemorrhage after subxiphoid pericardial window.

Results

During the 9-year study period, we identified eleven cases of blunt traumatic pericardial effusion. Among these, five presented in cardio- pulmonary arrest and six presented alive. The five patients with cardio- pulmonary arrest upon arrival to the hospital were arrested at the scene and were transported directly. Emergency department thoracotomy with attempted repair of the injury was performed in 3 patients. Of the 5 patients, one had left massive hemothorax. The locations of con- firmed cardiac ruptures included the left atrium, right ventricle, and left ventricle. None of the five patients survived (Table 1).

Of the 6 patients who were alive upon arrival, 5 were male and 1 was female (Table 2). The median age and ISS were 30 years (range, 20-56 years) and 18 (range, 16-34), respectively. Five patients (83%) were injured in motor vehicle accidents, and one patient was injured by being sandwiched between heavy concrete blocks. Of the 6 patients, four patients were transferred from another hospital. The median SBP and HR on arrival were 75 mm Hg (range, 40-128 mm Hg) and 105 beats per minute (range, 60-200 beats per minute), respectively. Five patients were hemodynamically unstable and were clinically diagnosed with cardiac tamponade. A large pericardial effusion of N10 mm and cir- cumferential on FAST was observed in five hemodynamically unstable patients. The stable patients had a moderate pericardial effusion of 5-7 mm and circumferential. Among the patients transferred from else- where, three had pericardial effusion diagnosed by CT at the referring hospital. Associated injuries were common; three patients had pneumo-hemothorax, two had multiple rib fractures, two had lung con- tusions, and two had blunt hepatic injuries. Troponin T and I levels were not available in this study. All patients had no specific medical history. Of the six patients, one hemodynamically stable patient was man- aged without either pericardiocentesis or pericardial window (Table 2, patient 1). Two patients were managed with pericardiocentesis alone (patients 2 and 3). One was managed with both pericardiocentesis and pericardial window (patient 4). One patient was managed with pericardial window alone (patient 6). The remaining patient underwent median sternotomy because of unsuccessful pericardial drainage tube insertion (patient 5). All 6 patients survived. Five patients had no indica-

tions for median sternotomy by local protocol.

The median ICU-LOS and hospital stay duration were 7.5 days (range, 4-12 days) and 24 days (range, 11-48 days), respectively. All 6 surviving patients were followed up for a median of 6.5 months (range, 1-42 months), and no late complications were observed.

Discussion

This study represents a 9-year experience of non-surgical manage- ment of patients with hemodynamically unstable blunt traumatic peri- cardial effusion. The outcomes of patients treated definitively without surgical repair remain obscure. We experienced no cardiac-related complications or deaths over a median follow-up of 6.5 months.

Blunt traumatic pericardial effusion has traditionally been treated as a surgical emergency because of the high possibility of cardiac rupture. Some studies, however, have reported the feasibility of nonoperative management in Hemodynamically stable patients with blunt traumatic pericardial effusion [1, 9, 10]. This raises the possibility of a protocol of deliberate non-surgical management in hemodynamically unstable pa- tients with blunt traumatic pericardial effusion, though supporting evi- dence for this approach needed.

In a study by Huang et al., 27 blunt traumatic pericardial effusion pa- tients were treated with surgical drainage, by subxiphoid, thoracotomy, or sternotomy approach. They found that subxiphoid approach was

Table 1

Characteristics of the patients with cardiopulmonary arrest upon arrival to the hospital with blunt traumatic pericardial effusion

No.	Age (yr)	Gender	Mechanism	ISS	Combined injury	Primary diagnostic method	Emergency department thoracotomy	injury location
1	32	M	MCC	25	Pneumohemothorax lung contusions	FAST	Yes	LA
2	62	M	MVA	34	Lung contusions	FAST	No	Unknown
3	84	M	MCC	75	Brain contusions Pneumohemothorax	Intra-operation	Yes	LV
4	74	M	Pedestrian	75	Rib fractures Rib fractures	Intra-operation	Yes	RV
5	68	F	Fall	45	Hepatic injury Facial fractures	FAST	No	Unknown
					Pneumohemothorax
					pelvic fractures femur fractures

ISS, Injury Severity Score; MCC, Motor cycle crash; FAST, focused assessment by sonography in trauma; LA, Left atrium; MVA, Motor vehicle accident; LV, Left ventricle; RV, Right ventricle.

S. Tanizaki et al. / American Journal of Emergency Medicine 36 (2018) 1655–1658 1657

Table 2

Characteristics of the patients who were alive upon arrival to the hospital with blunt traumatic pericardial effusion

No.	Age (yr)	Gender	Mechanism	ISS	Combined injury	SBP (mmHg)	HR (bpm)	GCS	PRBCs (Units)	LOS-ICU (day)	LOS (day)	ECG	CK-MB (ng/ml)	Injury to arrival time	Primary diagnostic method	Pericardiocentesis or pericardial window
1	48	M	MVA	20	Pneumohemothorax sternal fracture	128	111	14	2	8	23	NSR	10.5	20 h	CT at the referral	No
2	20	F	MVA	16	Rib fractures No	90	200	14	0	4	11	NSR	11.5	3 h	hospital CT at the	Pericardiocentesis
3	31	M	MVA	29	Lung contusion	90	110	15	0	7	32	NSR	N/A	2 h	referral hospital CT at the	Pericardiocentesis
					Hepatic injury clavicle fractures Scapula fracture										referral hospital
4	20	M	MVA	16	Lung contusions	50	101	13	0	6	24	NSR	30.5	2 h	FAST	Pericardiocentesis
5	29	M	MVA	34	Lung contusions	60	100	14	8	8	48	NSR	18.1	10 min	FAST	& window Unsuccessful
6	56	M	Industrial	16	Hepatic injury Rt. femur fracture Ribs fractures	40	60	3	2	12	40	PVC	N/A	30 min	FAST	pericardiocentesis followed by median sternotomy Pericardial window
					Pneumohemothorax

ISS, Injury Severity Score; SBP, Systolic blood pressure; HR, Heart rate; GCS, Glasgow coma scale, PRBCs, Packed red blood cells; LOS-ICU, Length of stay in the intensive care unit; LOS, length of stay in the hospital; ECG, Electrocardiogram; CK-MB, creatine kinase-myocardial band isozyme; MVA, Motor vehicle accident; NSR, Normal sinus rhythm; CT, Computed tomog- raphy; N/A, not available; FAST, focused assessment by sonography in trauma.

performed in approximately 25% and the survival rate was 80% among fifteen patients treated without cardiac repair, including three patients with Hemodynamic collapse before drainage [1]. Huang et al. reported the outcomes of 30 patients with blunt traumatic pericardial effusion [9]. This study showed that 7 out of 19 patients with stable hemody- namic status received nonoperative management. The remaining elev- en patients with hemodynamic instability required immediate surgical intervention. Witt et al. reviewed 75 blunt trauma patients with pericar- dial fluid on admission CT; of these, 68 did not undergo operative inter- vention and 21 (31%) had systolic pressure lower than 90 mm Hg in the emergency department [10]. Moreover, of the seven patients who underwent operative management, five patients (71%) had hypoten- sion. Pericardial window alone was performed in 4 patients. They found a 10.3% mortality rate in the non-operative group compared to no mortality in the operative group. It was concluded that hemodynam- ically unstable patients with blunt traumatic pericardial fluid should un- dergo operative management. However, our data contradict these, indicating that non-surgical management of hemodynamically unstable patients with blunt pericardial effusion may be a feasible option for treatment.

There were several concerns associated with non-surgical manage-

ment for blunt traumatic pericardial effusion. Anatomic concerns based on the injury site are the most important consideration, with sev- eral mechanisms proposed for blunt traumatic cardiac rupture [11-13]. The most common mechanism is severe precordial impact with com- pression of the heart between the sternum and vertebra. Another re- ported mechanism is rapid deceleration with an arterial tear at the point of fixation to the vena cava. Some have even reported that the right atrium was the most common site of injury [1, 3, 11, 14]. Indeed, the impact on the right heart may be a key consideration, as we outline below.

Based on a recent autopsy review on 96 patients with blunt cardiac rupture by Teixeira et al., the right chambers were the most frequently injured in patients presenting in cardiac arrest or who had cardiac arrest after hospital arrival [3]. Brathwaite et al. retrospectively reviewed 32 patients with blunt cardiac rupture, including 20 patients presenting in cardiac arrest, and reported that the right side was more susceptible to blunt cardiac injury than the left, with right atria and ventricles being involved in 40% and 31%, respectively [11]. Nan et al. retrospectively reviewed 11 patients who arrived at hospital alive with blunt traumatic cardiac rupture, and showed that the most cases of cardiac injury were

in the low-pressure right heart chambers; four in superior vena cava/ right atrium junction, one in right atrial auricle, and four in right ventri- cles [14]. Most patients who arrived at the hospital alive had minor in- juries in the right heart chamber cavity. Bleeding from blunt cardiac injury in patients who presented alive could be stopped temporarily by blood clotting. And the low pressure in the right side of the heart might allow spontaneous closure of injury. Hemodynamic instability could be improved after pericardial decompression, removing the re- quirement of surgical repair. Moreover, drainage is not always manda- tory in stable patients. However, once a traumatic pericardial effusion is detected in hemodynamically unstable patients, prompt drainage re- mains essential. Based on our results, the protocols for clinical manage- ment of blunt traumatic pericardial effusion are suggested in Fig. 1.

A management concern in cases of blunt trauma is the correct and Prompt diagnosis of pericardial effusion. FAST is a quick and safe diag- nostic tool that can be used to identify free intraperitoneal or pericardial fluid in hemodynamically unstable patients [15]. Crucially, it can be per- formed during resuscitation without the requirement to move the pa- tient to a CT suite. Nevertheless, CT is the preferred tool because it can identify not only pericardial effusion but also Occult pneumothorax, solid Organ injuries, Retroperitoneal hemorrhage, Free air in the perito- neal space, and diagram rupture. CT has become the standard method for identifying injuries in hemodynamically stable trauma patients, where it could have a significant role in the decision for surgery or con- servative management. In this study, CT at the referral hospital identi- fied 3 patients with pericardial effusion and FAST detected pericardial effusion in 3 patients who arrived to hospital alive and 3 patients who presented with cardiac arrest.

The major limitation of this study is that the inferences drawn from

these observations were limited by the extremely small sample size and the uncontrolled bias inherent to the retrospective study. Second, this study did not identify factors that might help predict patients who should have surgical management from those who could be safely man- aged by pericardiocentesis and/or a pericardial window. Third, the methods of the record review were missing some of the actions de- signed to assure the reliability of the data. However, this study analyzes non-surgical management of hemodynamically unstable patients who reach the hospital alive with blunt pericardial effusion.

In summary, the present study suggested that non-surgical manage- ment of hemodynamically unstable patients who reach the hospital alive with blunt pericardial effusion may be a feasible option for treatment.

1658 S. Tanizaki et al. / American Journal of Emergency Medicine 36 (2018) 1655–1658

Unstable SBP 90 mmHg

Blunt traumatic pericardial effusion

Emergency department thoracotomy

FAST (+)

FAST/CT (+)

No response

Response

Observation

Resuscitation

Cardiac repair

Pericardial drainage

Unstable

No response

Response

Sternotomy

+ Cardiac repair

To ICU with drainage tube

Stable SBP>90mmHg

Cardiac arrest on arrival

Ongoing drainage

Fig. 1. The proposed protocol for clinical management of blunt traumatic pericardial effusion. SBP, Systolic blood pressure; FAST, focused assessment by sonography in trauma; CT, Computed tomography; ICU, Intensive care unit.

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