A 62-year-old otherwise healthy man was transferred to the ER about 30 min after a motor vehicle accident. He had been wearing a seatbelt and the airbag deployed. Examination at the scene showed a systolic blood pressure (BP) of 80 mmHg, heart rate of 120 beats/min, and a Glasgow Coma Scale of 12/15 with anterior chest bruising. On arrival in the ER, his blood pressure was non-recordable with a palpable radial artery and a heart rate of 127 beats/min (normal sinus rhythm). His jugular vein was not distended. A focused assessment with sonography in trauma (FAST) showed pericardial fluid with right ventricular collapse consistent with cardiac tamponade in the subxiphoid view [Fig. 1]. A chest x-ray revealed a widened mediastinum.
A subxiphoid pericardiotomy was performed simultaneously with tracheal intubation and fluid resuscitation [Fig. 2A]. The hemodynamic instability did not improve after evacuating blood from the pericardial sac (systolic BP 56 mmHg). Repeat FAST investigation following the subxiphoid pericardiotomy showed a pericardial clot. Because of the ongoing hemodynamic instability, a left anterolateral thoracotomy was made to perform a pericardiotomy, considering the possible need for open-chest cardiac massage. Although he developed cardiac arrest just after the thoracotomy, a few seconds of open-chest cardiac massage resumed the spontaneous circulation. On making the incision, blood and a clot were seen within the pericardial space, resulting in hemopericardium. The heart stroke and hemodynamic status (BP 148/117 mmHg) recovered on removing the clot. Despite continuous oozing within the pericardial sac, his hemodynamic status stabilized following this procedure.
The initial chest x-ray showed a widened mediastinum, so we also considered an occult aortic injury. We could not perform transesophageal echography immediately in our ER. We could not get a good operative view for assessing the aortic injury via a left anterior thoracotomy. His hemodynamic status was stabilized following the pericardiotomy. Considering the effort involved in a repeat thoracotomy for aortic injury, we transferred the patient to the computed tomography (CT) room adjacent to the ER following temporary chest closure using sterile iodine-impregnated adhesive drapes [Fig. 2B]. Contrast-enhanced CT showed bilateral multiple rib fractures with no aortic or lung injury.
We repaired the cardiac injury via the left thoracotomy site after the patient returned from the CT room. Continuous oozing was noted from an isolated non-penetrating traumatic rupture of the left ventricular free wall. Hemostasis was achieved with digital pressure and a horizontal mattress suture with 3-0 polypropylene and pledges without cardiopulmonary bypass [Fig. 3]. The patient was concurrently transfused 12 units of packed red blood cells and 12 units of fresh frozen plasma and was transferred to the intensive care unit (ICU) for further resuscitation.
Right thoracic drainage was required because of a gradually increasing right hemothorax during his ICU stay. On postoperative day 1, the serum cardiac enzyme marker troponin I was elevated at 4095 (normal < 0.040) ng/L. This resolved spontaneously. The mechanical ventilation was protracted due to respiratory complications following massive fluid resuscitation. On postoperative day 10, the patient was weaned from mechanical ventilation and extubated. He remained in the ICU for 12 days and was then transferred to a clinical ward. He was discharged without any complications 43 days postoperatively.