Eur J Cardiothorac Surg 2003;23:473-476
© 2003 Elsevier Science NL
Delayed pericardial effusion following stab wounds to the chest
David G. Harris*,
Jacques T. Janson,
Jacques Van Wyk,
Johann Pretorius,
Gawie J. Rossouw
Department of Cardiothoracic Surgery, Tygerberg Hospital, University of Stellenbosch, Cape Town, South Africa
Received 30 September 2002;
received in revised form 16 December 2002;
accepted 29 December 2002.
* Corresponding author. Tel.: +27-21-9762347; fax: +27-21-9385952
e-mail: drdharris{at}yahoo.co.uk
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Abstract
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Introduction: Delayed pericardial effusion following penetrating cardiac trauma has not been commonly reported, and the exact incidence remains unknown. It was more common before 1960, when pericardiocentesis was still a popular treatment for stable patients presenting with a stab wound to the heart. Material and methods: During an 8-year period, 24 patients were diagnosed with delayed pericardial effusions following a recent stab wound over the chest. Nine patients had been initially treated at our trauma unit, and the remaining 15 patients were referred by a peripheral clinic. Results: Diagnosis was confirmed by cardiac ultrasound or echocardiogram. Sixteen patients were adequately treated by subxiphoid drainage. Sternotomy was performed in five patients, left thoracotomy in two and right thoracotomy in one patient. No actively bleeding injuries were found. Three patients had active infection in the pericardial space. Fever, pleural effusions and ascites were common associated findings. Additional procedures performed included laparotomy for acute abdominal pain in two patients (both negative), and simultaneous drainage of a pleural empyema. Two patients with staphylococcal pericardial infections required subsequent pericardiectomy. Summary: The diagnosis of a penetrating cardiac patient may be missed in a stable patient, and patients may present with delayed pericardial effusions and tamponade. Post pericardiotomy syndrome may be the most common cause of delayed pericardial effusion, followed by sepsis. Subxiphoid pericardial window is an adequate form of treatment. Recent literature reveals that occult cardiac injury is not uncommon, thus a case should be made to actively investigate all patients with precordial stab wounds with cardiac ultrasound or echocardiogram.
Key Words: Delayed pericardial effusion • Cardiac ultrasound
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1. Introduction
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Acute pericardial tamponade following penetrating cardiac trauma is common. Delayed pericardial effusion, however, has rarely been described. It has not been commonly reported in the literature since 1960, when pericardiocentesis was still a common treatment for stable patients presenting with acute cardiac tamponade following a stab. Subsequently, penetrating heart injuries have been treated by prompt surgical exploration and repair.
Over an 8-year period, 24 patients were presented to our hospital with delayed pericardial effusion. We discuss the clinical features, diagnosis and treatment of these cases.
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2. Patients and methods
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There were a total of 24 patients from January 1994 to December 2001. There were 23 males and one female, with an average age of 28 years (14–53 years). Twelve patients were initially treated for the stab wound at a peripheral hospital or clinic; seven of these had intercostal drains inserted, and the rest were sutured and discharged. Three patients were referred from the periphery with no mention whether they had been previously seen. Nine patients were originally treated at our trauma unit. They all had a single parasternal or precordial wound, and all were stable, except for one patient who had a blood pressure of 80/40 mmHg for 3 h. Three of these nine patients required initial intercostal drain insertion for haemothorax. The remaining six were sutured and discharged.
Four patients were admitted to our medical ward with a diagnosis of pericardial effusion before the history of trauma became evident. Patients were examined clinically, and the diagnosis was usually confirmed by two-dimensional ultrasound, or preferably by echocardiogram, if it was immediately available. Surgical approach was left to the surgeon's discretion.
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3. Results
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The most common clinical findings were distended neck veins, dyspnoea, pleural effusion and other features of right heart failure (Table 1). Fever occurred in eight patients (33%). A globular heart on chest X-ray was documented in 20 patients, and one patient had a wide mediastinum. The age of the stab varied from 3 to 33 days. Diagnosis was confirmed by cardiac ultrasound in 16 patients, echocardiography in seven and clinically in one patient.
Drainage was performed by subxiphoid window in 16 patients, sternotomy in five, left thoracotomy in two and right thoracotomy in one case. Except for patient 21, there was no specific reason for sternotomy, but surgeon's preference. Not one actively bleeding wound was found.
Drainage via the subxiphoid approach was adequate when performed. A pericardial window was made, draining blood clots and blood stained fluid. The whole heart surface could not be examined for injuries with this approach, but it allowed some visualization of the right ventricle, and adequate drainage of the pericardial space was possible. Conversion from subxiphoid to a sternotomy was never found to be necessary. Three patients had positive cultures from pericardial fluid (Staphylococcus aureus in two patients and beta-haemolytic streptococcus in one). One patient had a co-existing empyema and the pericardial effusion and empyema were drained simultaneously by right thoracotomy.
Additional procedures were performed as follows: (Table 2)
- Patient 1 underwent laparotomy at the same time as the subxiphoid drainage, for suspected subphrenic abscess. Two litres of ascitic fluid was drained, and no abdominal injury was found. Staphylococcus aureus was cultured from the pericardial fluid. Two weeks later, the patient underwent sternotomy and pericardiectomy for severe constrictive pericarditis.
- Patient 12 underwent subxiphoid drainage and had a positive culture of Staphylococcus aureus from the pericardial fluid. One week later a right thoracotomy and drainage of empyema was performed. Four months later, the patient underwent sternotomy and pericardiectomy for severe constrictive pericarditis.
- Patient 14 underwent laparotomy for an acute abdomen at the same time as the subxiphoid drainage. Hepatomegaly and ascites were the only abnormal findings.
- Patient 21 had a sternotomy for suspected acute pericardial tamponade. This patient had been stabbed twice, 2 weeks earlier and on the day of admission. Cardiac ultrasound revealed a pericardial effusion and the patient was taken to the operating room with a suspected acute heart injury. Blood stained fluid and old clots were found in the pericardial space and a healing scar was noticed on the right ventricle. The new stab did not penetrate the pericardium and the pericardial tamponade was believed to be caused by the first stab wound.
There was no mortality. Two patients required inotropic support for 2 days and one patient required ventilation for 2 days. Except for the two patients with constrictive pericarditis (following Staphylococcus aureus infection), all the patients had uncomplicated postoperative courses. Two patients had moderate mitral regurgitation at later follow-up as a result of leaflet prolapse.
During the year 2001, 1066 patients were treated at our trauma unit for a stab wound in the chest. Seven hundred and eighty-nine required chest drain insertion for haemothorax or pneumothorax, 249 had only flesh wounds and 61 had surgery for a penetrating cardiac injury.
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4. Discussion
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Delayed pericardial effusion/haemopericardium after chest trauma is uncommon, as suspected cardiac injuries are now-a-days treated by prompt surgical exploration. In our unit, cardiac ultrasound has been useful in diagnosing abnormal pericardial fluid in doubtful cases [1,2].
Some patients presenting with penetrating cardiac injuries may be completely stable, and the diagnosis can be missed [3]. These patients do not present with the classical findings of raised venous pressure, hypotension and muffled heart sounds. The chest X-ray does not always reveal an enlarged heart shadow. In our series of 191 patients with penetrating cardiac injuries, 63 patients (33%) were completely stable after resuscitation with 2 l of fluid. Fifty-six of these 63 patients (87%) had the diagnosis confirmed by cardiac ultrasound. It is interesting to note that during surgery, 27 of the 63 patients (43%) were found to have lacerations which had sealed off [2]. It is in these patients where the diagnosis may be missed during the initial presentation, if ultrasound or echocardiogram is not performed.
The most common clinical presentation of the patients presenting with delayed pericardial effusion was dyspnoea and distended neck veins, as well as pleural effusions, ascites and fever (Table 1). Only two patients (8%) presented with hypotension. Hepatomegaly and abdominal pain were present in about one-third of the patients, and as a result, laparotomy was performed in two of these patients. The clinical presentation may be confusing in patients who have an epigastric stab wound.
Diagnosis was confirmed by cardiac ultrasound in most patients as it is used regularly in the acute setting in our institution, and has been shown to be reliable, in the absence of haemothorax [1,2]. Pericardiocentesis is not used in our trauma unit in the acute setting for diagnosing cardiac trauma, as it has been shown to be inaccurate [2], and this may explain why this was not performed as an initial diagnostic procedure.
Drainage via subxiphoid window was adequate in our experience. Treatment by aspiration alone has been shown to be inadequate in the acute setting, as recurrent pericardial effusions may occur, requiring numerous aspirations [4,5]. Some patients may have blood clots in the pericardium (Table 2), which may not be amenable to aspiration. However, the rest could possibly have been treated by aspiration and the insertion of an indwelling drainage catheter, as we have not demonstrated any actively bleeding lacerations. Thoracoscopy has been useful in stable patients with acute penetrating cardiac wounds [6], and could be another option in patients with delayed tamponade. Sternotomy was performed in three of our patients as a result of surgeon preference early on in our experience, before it became evident that actively bleeding wounds were never found. In two cases, sternotomy was performed for a suspected acute injury. Sternotomy should not be necessary as the initial management, and in fact, should be avoided if infection is suspected. In the presence of pyogenic infection within the pericardial and/or pleural spaces, thoracoscopy or thoracotomy should be a better approach. If pus is found within the pericardial space, it is possibly best to perform pericardiectomy via thoracotomy during the same setting, because of the risk of constrictive pericarditis developing. Alternatively, these patients should be carefully followed up for constrictive pericarditis.
Secondary bleeding, clot lysis with hyperosmosis of the clot with fluid accumulation into the pericardium and post-pericardiotomy syndrome are all possible causes of delayed pericardial effusion. When aspiration was the favoured treatment of stable patients with acute haemopericardium, delayed haemopericardium was a common finding [4,7,8]. Some of these patients had pain, fever and residual pericardial effusions for up to 30 weeks [4]. Two of these patients responded well to corticosteroids, and it was noted that bilateral pleural effusions were common, probably the result of hypersensitivity to blood in the pericardial space. Two patients developed constrictive pericarditis [4].
In our series, pleural effusions were common, occurring in ten of 24 patients (41.6%). These usually contained clear fluid in longstanding cases, and were associated with ascites. In addition, no patient had actively bleeding lacerations, and this strengthens the case for post-pericardiotomy syndrome being the principle cause of delayed pericardial effusion. Three cases of infection were proven to contribute to or cause the effusion.
A case should be made to actively investigate all patients initially presenting with penetrating precordial wounds. In one study, echocardiogram was performed in 31 stable patients with precordial injuries. There were 16 positive echocardiograms, and all underwent subxiphoid exploration, which yielded 12 positive and four negative results. Three of the positive explorations demonstrated only pericardial injuries [9]. Another group performed subxiphoid exploration in all patients with juxtacardiac injuries, and revealed an occult injury rate in 12 of 51 stable patients (17.6%) [10]. Some of the cardiac injuries were not actively bleeding.
The largest review of patients with delayed pericardial effusions since 1950 revealed eight patients [5]. Four were treated by sternotomy, two by thoracotomy, one by pericardiocentesis (five aspirations) and one was diagnosed post-mortem. Since then there have been isolated reports in the literature [11–14].
Missed injuries leading to delayed haemopericardium with tamponade or death may be more common than initially thought. One report comparing hospital and post-mortem records of stab heart victims revealed that 70 of 1198 patients (5.8%) reached the hospital alive. However, a further seven patients who had been admitted to hospital with a chest wound and discharged, were amongst the group of patients identified in the mortuary [15]. This reflects a missed stab heart rate of 9% (seven of 77 patients), and this is further evidence that all asymptomatic patients with precordial wounds should undergo cardiac ultrasound or echocardiogram to exclude a haemopericardium.
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5. Conclusion
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Delayed pericardial effusion/haemopericardium following a precordial stab wound has not been commonly described, but has been identified at our hospital where a large volume of stab wounds are treated. An average of three cases per year were diagnosed at our hospital, where about 1000 cases of stab wounds to the chest are managed annually. Missed stab wounds to the heart may occur if routine cardiac ultrasound or echography is not performed in all stable patients presenting with a stab wound in the precordial area. Treatment by subxiphoid pericardial window is adequate. Severe abdominal pain and ascites may be an associated finding, leading to laparotomy. Patients with septic pericarditis should be followed up for the possible development of constrictive pericarditis at a later stage, or could be initially drained by left thoracotomy with pericardiectomy.
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References
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Abstract
1. Introduction
