Case #4: Don't go breaking my heart
- 1 day ago
- 5 min read
The Patient*
A 38-year-old male presented following a stab to the left chest approximately one hour earlier.
Primary survey
A - Patent.
B - SpO2 97% on 15 L/min O2 via reservoir mask, slightly tachypneic, but with good air entry bilaterally. A left intercostal drain had been inserted, and 400 mL of frank blood was visible in the drain collection chamber.
C - There was mild haemodynamic instability with a BP of 90/60 mmHg and a HR of 90 bpm.
D - GCS 12/15 (E3 V3 M6)
Secondary survey
A small laceration was visible in the left 5th ICS at nipple level.
An ABG revealed a lactate of 2.3 and an eFAST revealed a small residual haemopneumothorax on the left, and a pericardial effusion on a subcostal view.
What is your next step?
Pericardiocentesis
Prepare for surgical exploration in theatre
Prepare for resuscitative thoracotomy
CTA to investigate for injury to the great vessels.
Click to see the answer
The patient needs surgical exploration in theatre. The patient is at high risk of decompensating, but for now is stable enough to allow for the surgical exploration to be done in the most appropriate setting, which is in the OR.
Pericardiocentesis is not the best option for managing a traumatic tamponade, due to the high risk of failure from clotted blood obstructing the catheter. It might be considered as a temporising procedure in centres where definitive care is not available (and has shown promise in some case series), but is currently considered to be - at best - a bridge to surgical intervention.
CTA does not add useful information for the acute management of the patient and poses serious risk due to the need for time-consuming transport to an area of the hospital with minimal resuscitative capabilities.
While preparing for that next step, the patient deteriorated. His HR climbed to 120 bpm and his BP fell to 65/40 with an accompanying drop in GCS.
Massive transfusion began with PRBC, FFP, and FDP, as well as the autotransfusion of pleural blood from his intercostal drain. Despite these measures, the patient's haemodynamic state continued to deteriorate and an emergency resuscitative thoracotomy (ERT) was performed.
At what point should you secure the patient's airway?
Immediately, given his GCS is 3.
Prior to decompression of the pericardial sac, to allow right endobronchial intubation that will facilitate a better operative view of the left hemithorax.
After decompression of the pericardial sac, to prevent potential deterioration on induction.
Click to see the answer
In patients with obstructive shock, intubation poses great risks. Administering anaesthetic agents reduces RV preload, and positive pressure ventilation not only reduces RV preload, it also increases RV afterload. In acute diastolic dysfunction - with tiny end-diastolic volumes - this additional insult can precipitate cardiac arrest. To minimise this risk, the team should synchronise their airway management to occur alongside the opening of the pleural and pericardial spaces. By opening the pericardial sac, the intrapericardial pressure is relieved and will no longer exceed the right atrial pressure, reducing (but not eliminating) the deleterious effects of positive pressure ventilation on the patient's haemodynamics.
The chest was readily opened via left anterolateral thoracotomy, exposing the pericardial sac. The obstructive shock due to the clotted blood in the pericardial sac was then rapidly relieved, exposing a large laceration involving the lateral wall of the left ventricle. We then proceeded with an RSI using 50 mg IV ketamine, 2 mg IV midazolam, and 100 mg IV rocuronium.
Following pericardiotomy and relief of the patient's obstructive shock, blood began gushing from the cardiac wound, causing him to deteriorate further (BP 40/20 mmHg, HR 30 bpm). We continued massive transfusion and attempted to manage his end-stage shock with rescue boluses of adrenaline.
After several unsuccessful attempts at suturing the myocardial injury, a finger was used to plug the hole, the patient was then transported to the OR. The final ABG taken in the Resuscitation Room found him to have a pH of 7.08, a BE of -19, a lactate of 8.1, and a Hb of 6.8g/L.
In the OR several techniques were attempted in an effort to repair the myocardial defect, including further attempts at direct suture repair. The tissue proved too friable however, and sutures continued to tear through the myocardium. Attempts at closing the defect with a pericardial patch also failed. Despite our best efforts, the patient died.
Take Home Points
1) Prioritise fixing the underlying cause of the patient's critical illness - the relevant one of the H's & T's is tamponade, not hypoxia. In a patient who is in extremis, anaesthetic induction and positive pressure ventilation risks cardiac arrest. Prioritise the patient's haemodynamics.
2) Everything should be attempted in order for the patient to have definitive care in the best possible setting, but be prepared for a change of course if the patient rapidly deteriorates. Have a Plan B.
3) Sometimes even your best efforts aren't enough.
*Note that patient details have been changed for the purposes of de-identification.
Dr Valentina Beux is an emergency medicine specialist. She currently works for the Santa Croce and Carle Hospital in Cuneo, North-West of Italy. Passionate about everything, expert in nothing, when not at work you can find her cycling or rock climbing in her beloved mountains.
Dr Marco Francesconi is an anaesthetist and intensivist currently working in the ICU in Cuneo, Italy. He has a special interest in trauma, pre-hospital care, and perfectly cooked lasagne.
Dr Devorah Wineberg is the deputy director of the trauma unit and co-ordinates the international doctors programme. She began her career as a paramedic before completing a BSc in physiology and subsequently her MBBCh at Wits, and later her Fellowship from the College of Surgeons. After first working as a general surgeon, she returned to her first love and completed her Certificate in Trauma and Critical Care. She is an ATLS and DSTC instructor and has interests in mass casualty and disaster management.
References
[1] Seamon MJ, Haut ER, Van Arendonk, et al. An evidence-based approach to patient selection for emergency department thoracotomy: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;79(1):159-73.
[2] Assaf M, Abdalla A, Shaltout AE, et al. Pericardial tamponade in trauma: a systematic review of diagnosis, emergency management, and surgical outcomes. Cureus. 2025;17(9):e91921.
[3] Qandil M, Ransom P, Abu Shammala M, et al. Pericardiocentesis, drainage and instilled tranexamic acid: definitive management in a 25-case series of penetrating cardiac tamponade. Injury. 2026;57(5):113106.
[4] Ho AM, Graham CA, Ng CSH, et al. Timing of tracheal intubation in traumatic cardiac tamponade: a word of caution. Resuscitation. 2009;80(2):272-4.
