Tag Archives: cardiac

What’s Wrong With My Patient? Final Answer!

I previously described a young man who was recovering from surgery for repair of a stab to the heart. He presented shortly after discharge with fever, a slightly elevated WBC, some EKG changes, and a small pericardial effusion.

Several people tweeted out the answer, which is post-pericardiotomy syndrome (PPS).

PPS is an inflammatory reaction to traumatic and then surgical injury to the pericardium. It is seen in a relatively small percentage of patients who undergo pericardiotomy for trauma, which is why patients who develop it are such a surprise to trauma professionals. A similar condition can develop after myocardial infarction (Dressler syndrome) and was first described in 1956. The classic paper describing PPS after trauma was published five years later (cited below).

Symptoms typically develop 1-6 weeks after surgery, and usually consist of low grade fevers, malaise, chest pain, and occasionally arthralgia. A pericardial friction rub may be present (and where is that stethoscope, BTW?). The WBC is usually elevated, with some degree of left shift. EKG may show some degree of pericarditis, including global ST elevation and T wave inversion.

Chest x-ray is usually nonspecific, but may show pleural effusion or an enlarged heart due to the presence of some pericardial fluid. Ultrasound may confirm a pericardial effusion, but this is not a reliable finding since the pericardium is typically left open at the end of the operation.

Treatment is symptomatic, usually consisting of NSAIDS or aspirin to tone down the inflammatory response.  These drugs are usually given for 4-6 weeks, then tapered. If the effusion is large, pericardiocentesis may be needed.

Bottom line: If your postop heart injury patient presents with these symptoms, consider infectious etiologies first, but remember that they are typically even less common than post-pericardiotomy syndrome. Reassure your patient, then reach for the ibuprofen to get them through it.

Reference: Postpericardiotomy syndrome following traumatic hemopericardium. Am J Cardiology 7(1):83-96, 1961.

What’s Wrong With My Patient? Part 2

In my previous post, I described a young man who had recovered from a stab to the heart. He did well for a week and a half, but then presented to the ED with significant chest pain. It seems to be substernal and somewhat pleuritic. What should you do to work it up further?

There have been a number of helpful comments. The first order of business is to rule out problems which may prove to be life threatening. In his case, ischemic disease and some failure of the repair must be ruled out quickly. Although ischemia or MI are unlikely in this young man, they are possible and should be evaluated.

I recommend the following:

  • Auscultate the chest and heart (remember this from medical school?)
  • PA chest x-ray
  • EKG
  • CBC
  • Troponin
  • FAST exam focusing on the heart

My list is short and simple, and should help me figure out nearly all significant problems.

In this case, the following findings are present:

  • The lungs are clear, and their is a faint cardiac friction rub
  • The chest x-ray is unremarkable
  • EKG shows ST elevations in two of the lateral leads only. Otherwise, it is normal.
  • CBC is normal with the exception of WBC 14,000
  • There is a trace level of troponin present
  • FAST demonstrates a very small pericardial effusion without clot

So what do you make of all this? What’s the diagnosis? What do you need to do? Tweets and comments please.

Answers Monday!

What’s Wrong With My Patient?

I’ve had several requests for this case recently, so I figured I’d put it out there again.

A 25 year old man is involved in some sort of violent, non-productive interpersonal relationship. He sustains a stab to the left chest, and is brought to your trauma center as a trauma team activation. During the FAST exam, a moderate effusion with visible clot is seen in the pericardium.

Appropriately, you run to the OR and prepare for a left thoracotomy. You perform a pledgeted repair of the ventricle (black arrow) and close.

The patient does well and is discharged home five days later. He returns to your clinic the following week and is doing well. You remove the staples.

One week later, he returns to your emergency department complaining of significant chest pain. He describes it as deep, behind his sternum, and it seems to be exacerbated by breathing.

Now what? What are you thinking about? What additional exam do you need. What labs?

Tweet or comment with your answers and suggestions. More on this tomorrow!

The Cardiac Box: Meaningful For Gunshot Wounds?

A common dogma in trauma training is: “Watch out for the box!” This area on the anterior chest is purported to indicate high risk of cardiac injury in patients with penetrating trauma.

Where is it, exactly? Technically, it’s the zone extending from nipple to nipple, and from sternal notch to xiphoid.

The cardiac box

But is the dogma true? A number of (old) papers mapped out the location and incidence of cardiac injury in stabs to the chest and upper abdomen. And there is a pretty good correlation. For stab wounds. But what about gunshots?

A team at Emory University ran a retrospective review of their trauma registry data over a three year period.

Here are the factoids:

  • They saw nearly 90 patients per year with penetrating chest wounds. Of these, 80% were gunshots (!) Many had more than one penetration.
  •  Of the 233 gunshots inside “the box”, 34% injured the heart
  • The remaining 44 gunshots outside “the box” hit the heart 32% of the time
  • The authors suggest shifting the definition of “the box” toward the left, so that it extends from anterior midline, wraps around the left chest, and ends in the posterior midline (see below)

new-cardiac-box

Bottom line: Here’s the problem. Knives are attached to a handle which tends to stay outside your patient. Thus, it can only go so deep. But a bullet will keep going until something stops it, or it runs out of gas. So it makes sense that the traditional boundaries of “the box” don’t apply. But extending it to include the left lateral chest and exclude everything on the right side? It may make statistical sense in this study, but common sense dictates that the trauma professional needs to think about the heart any time a gunshot goes anywhere near the chest or upper abdomen. Do not limit yourself to any “box!”

Reference: Redefining the cardiac box: evaluation of the relationship between thoracic gunshot wounds and cardiac injury. AAST 2016 Paper #12.

What’s Wrong With My Patient? Part 2

In my previous post, I described a young man who had recovered from a stab to the heart. He did well for a week and a half, but then presented to the ED with significant chest pain. It seems to be substernal and somewhat pleuritic. What should you do to work it up further?

There have been a number of helpful comments. The first order of business is to rule out problems which may prove to be life threatening. In his case, ischemic disease and some failure of the repair must be ruled out quickly. Although ischemia or MI are unlikely in this young man, they are possible and should be evaluated.

I recommend the following:

  • Auscultate the chest and heart (remember this from medical school?)
  • PA chest x-ray
  • EKG
  • CBC
  • Troponin
  • FAST exam focusing on the heart

My list is short and simple, and should help me figure out nearly all significant problems.

In this case, the following findings are present:

  • The lungs are clear, and their is a faint cardiac friction rub
  • The chest x-ray is unremarkable
  • EKG shows ST elevations in two of the lateral leads only. Otherwise, it is normal.
  • CBC is normal with the exception of WBC 14,000
  • There is a trace level of troponin present
  • FAST demonstrates a very small pericardial effusion without clot

So what do you make of all this? What’s the diagnosis? What do you need to do? Tweets and comments please.

Answers tomorrow!