Cardiac Tamponade from Displaced Rib Fracture and Intercostal Artery injury Via Pleural-Pericardial communication without Heart Chamber or Great Vessel Involvement

Cardiac tamponade occurs when a pericardial effusion leads to shock physiology. The fluid in the pericardium can be exudative, transudative, or sanguineous arising from multiple different etiologies. Furthermore, the faster the effusion develops, the less volume needed for the development of tamponade physiology. This makes prompt diagnosis and treatment of paramount importance, especially in trauma settings where multiple injuries need to be triaged appropriately. This patient was a 91-year-old female who underwent a motor vehicle collision versus tree as a restrained driver. She was stable on arrival but quickly decompensated in the emergency department requiring placement of a chest tube and infusion of blood products. Patient was taken to the operating room for pericardial window after a CT scan identified a moderate sized pericardial effusion. Intraoperatively, large volume bloody pericardial effusion was encountered requiring median sternotomy to control bleeding. The source of the bleed was an intercostal artery bleeding into the Left pleural space that was communicating with the pericardium via a disrupted parietal pericardium violated by a displaced rib fracture.

After obtaining hemostasis, the patient went into ventricular fibrillation and ultimately arrested after extensive resuscitation and cardiac massage. The patient in this situation was treated according to the advanced rauma life support guidelines. Despite placement of a thoracostomy tube to decompress a known hemothorax, the patient decompensated requiring emergent operative intervention. The source of the hemodynamic collapse was cardiac tamponade related to a rare instance of rib fractures from a blunt injury causing a tear of the pericardium without any damage to the chambers of the heart or great vessels. This case emphasizes the need for operative intervention of traumatic cardiac tamponade because appropriate patient care would have been significantly delayed had a bedside/percutaneous approach been attempted first.

Keywords: Cardiac tamponade; blunt cardiac injury; trauma; hemothorax; pericardial effusion

Abbreviations:FAST: Focused Assessment with Sonography in Trauma
CT: Computerized Tomography
MVC: Motor Vehicle Collision
EMS: Emergency Medical Services
ED: Emergency Department
GCS: Glasgow Coma Scale
PEA: Pulseless Electrical Activity
ROSC: Return of Spontaneous Circulation
ATLS: Advanced Trauma Life Support