UMEM Educational Pearls

Title: What's the Diagnosis? Case by Dr. Tejusve Rao

Category: Visual Diagnosis

Posted: 9/8/2016 by Tu Carol Nguyen, DO (Updated: 9/12/2016)
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Question

A 25-year-old male was brought in by EMS with a stab wound to the chest. What's the diagnosis?

Answer

Pneumopericardium

CT Chest was done with the image below:

Penetrating Cardiac Trauma

Initial Assessment of ABC, ATLS primary survey guidelines.
Evaluate for tension pneumothorax or cardiac tamponade in all patients presenting with chest trauma and shock.
Cardiac Box: Surrounded by sternal notch, xiphoid process and nipples.
Order of injury: Right Ventricle --> Left Ventricle --> Right Atrium --> Left Atrium
Beck’s Triad: Hypotension, JVD, muffled heart sounds may not be present initially.
Conduct FAST exam to examine for cardiac tamponade, hemothorax, pneumothorax.
Cardiac Tamponade more common from stab wounds than from gun shot wounds.
Hemodynamically unstable patients require immediate operative therapy after quick bedside assessment (physical exam, ultrasound, chest tube as needed)

Differential Diagnosis: Bronchial injury, Diaphragm injury, Hemothorax, Tension Pneumothorax, Aortic Transection, Esophageal injury, Pneumomediastinum

Evaluation: Ultrasound (FAST Exam), CXR, CTA in stable patients, ECG, troponin.

Management: Penetrating cardiac trauma require emergent thoracotomy, pericardial window.

References

Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S301-6.

El-menyar A, Al thani H, Zarour A, Latifi R. Understanding traumatic blunt cardiac injury. Ann Card Anaesth. 2012;15(4):287-95.

Tintinalli's 7th Edition. Emergency Medicine Manual. Chapter 164: Cardiothoracic Trauma.