Case Report

Prehospital mechanical ventilation of a critical cardiac tamponade^?,??

Abstract

Mechanical ventilation of a critical cardiac tamponade is a high-risk situation that can lead to asystolic cardiac arrest. We report a prehospital mechanical ventilation of a Penetrating cardiac injury complicated with tamponade. Onset diagnosis of the circulatory arrest allowed by prehospital continuous ultrasonography led to earlier initiation of the resuscitation and might have favored successful outcome. electrocardiographic signs are too late to diagnose circulatory arrest.

Mechanical ventilation of critical tamponade is thought to be a high-risk procedure. However, when it cannot be avoided, no recommendation exist for this situation. We report the management of a prehospital mechanical ventila- tion of a critical cardiac tamponade caused by a Stab wound. During a brawl in a public square, a 26-year-old man sustained a single stab wound to the xiphoid area. On arrival of the medical team, the patient was cyanosed, bradypneic, with no pulse felt, had Altered consciousness (Glasgow Coma Scale of 9), a heart rate of 110 beats per minute, a blood pressure of 70/50 mm Hg, and no detectable oximetry signal. During Intravenous line placement and initiation of massive fluid resuscitation, the physician performed ultrasonography at the scene. Used equipment was a hand-carried battery- powered Ultrasound device (180PLUS, SonoSite, SonoSite Ltd, Hitchin, Herts, UK, with a cardiac transducer). It revealed a significant amount of pericardial effusion associated with right ventricular and Right atrial collapse (Fig. 1). Despite 500-mL intake of 6% hydroxyethyl starch, 130/0.4, the patient status rapidly worsened up to respiratory arrest, requiring mechanical ventilation. Induction of anesthe- sia was performed with etomidate, 30 mg; suxamethonium, 80 mg; and epinephrine, 1 mg, at once intravenously. Trachea was intubated in one attempt, and low-volume ventilation was initiated. A few seconds after this procedure, the

^? Work is attributed to Service d’Aide Medicale Urgente 31, University Hospital of Toulouse, Toulouse, France.

^?? Support was provided solely by institutional source.

continuous ultrasound monitoring revealed a complete heart failure with no beating activity, whereas electrical activity was still present and unchanged. This onset diagnosis led to immediate initiation of chest compressions. continuous monitoring during this procedure showed recovery of an efficient Cardiac activity after 1 minute of resuscitation, allowing transport to the hospital. Blood pressure remained steady around 80/50 during transport with no further need of vasopressive support or fluid intake. The patient was admitted directly to the operating room where a cardiac surgical team awaited for him. Sternotomy was performed 62 minutes after the first medical contact, and a 3-cm right ventricular wound was sutured. The patient left the intensive care unit on day 1 and discharged home on day 8. He made a Full recovery without cardiac or neurologic complications.

Critical cardiac tamponade combined with respiratory failure is a hard dilemma. In one hand, general anesthesia combined with mechanical ventilation is thought to be a high-risk procedure. Anesthetic management avoiding mechanical ventilation is favored [1-4], and most recom- mend spontaneous ventilation to be maintained until the drainage of the pericardial cavity is done [5,6] or at the very least imminent [7]. However, in the other hand, hypercarbia

Fig. 1 Large amount of pericardial effusion on a parasternal short-axis view.

0735-6757/$ - see front matter (C) 2009

1020.e2 Case Report

due to respiratory failure increases pericardial pressure and might be responsible for Hemodynamic deterioration [8].

In the case described, the dilemma was rapidly solved when a respiratory arrest occurred. Thus the attending physician had no other choice than mechanical ventilation. Because there is no guideline or recommendation for the management of this complex situation, we report a strategy based on the manage- ment of a patient requiring mechanical ventilation.

In critical cardiac tamponade, venous return and cardiac output are mostly dependent of the intrathoracic pressure fall during inspiration [9]. When initiating mechanical ventila- tion, this inspiration-generated cardiac output disappears. Cardiac arrest first occurs because there was no filling of right heart and then remains because there was no Myocardial blood flow [10].

In the intricate case of tamponade aggravating concomi- tantly with respiratory failure, mechanical ventilation can lead to cardiac arrest. Because this cardiac arrest was highly predictable, the attending physician used 1 mg of epinephrine together with induction drugs to improve coronary perfusion [10]. Nevertheless, cardiac arrest occurred immediately after initiation of mechanical ventilation while electrocardiogram still showed sinusal rhythm with normal complex.

Prehospital use of portable ultrasound is known to improve diagnostic accuracy without delaying patient management [11,12], and its use in the specific case of cardiac tamponade in penetrating Cardiac injuries has been reported twice, focusing on feasibility and time saving of this procedure [13,14]. In this case, beside the direct admission to operating room allowed by accurate prehospital diagnosis, ultrasound provided continuous monitoring with real-time information on hemodynamic modifications. Without ultra- sound continuous assessment, cardiocirculatory insuffi- ciency would have been diagnosed rather belatedly, with severe electrocardiogram Rhythm disturbances or asystolic cardiac arrest and then would have been associated with a poorer outcome [15].

In this case, sufficient cardiac activity resumed after 1 mg of epinephrine followed by mechanical ventilation and 1- minute chest compressions. No further vasopressive support or fluid intake was needed for 48 minutes until sternotomy. As pericardial pressure is known to be correlated to carbia, mechanical ventilation can also decrease pericardial pressure and then restore cardiac output [8]. Regarding this, we believe that hypercarbia was a major aggravating factor. Our hypothesis is epinephrine associated with chest compres- sions maintained myocardial blood flow until carbia decreased and cardiac output resumed.

If hemodynamics worsen, some would recommend peri- cardiocentesis. We have no experience of this technique, and we believe that this procedure may be time-consuming. Further- more, when caused by a stab wound, acute cardiac tamponade involves active bleeding from heart cavities, and pericardio- centesis might be futile if no surgical suture is done [14].

In conclusion, if mechanical ventilation of critical tamponade is a high-risk procedure, one should keep in

mind that hypoventilation can be deleterious and may sometimes require endotracheal intubation. In this situation, we suggest asystolic cardiac arrest must be anticipated. Prehospital ultrasound provides real-time hemodynamic status of the patient, allowing earlier diagnosis of circulatory arrest than electrocardiogram. Appropriate therapeutics can be initiated, including epinephrine use and chest compres- sions, even if electrical activity is still present. Decrease in carbia might be a worthwhile objective.

Romain Barthelemy MD

Department of Anesthesiology and Intensive Care

University Hospital of Toulouse Paul Sabatier University

Toulouse, France E-mail address: [email protected]

Vincent Bounes MD

SAMU 31, Department of Emergency Medicine

University Hospital of Toulouse Paul Sabatier University

Toulouse, France

Vincent Minville MD

Department of Anesthesiology and Intensive Care

University Hospital of Toulouse Paul Sabatier University

Toulouse, France

Charles-Henri Houze-Cerfon MD Jean-Louis Ducasse MD

SAMU 31, Department of Emergency Medicine

University Hospital of Toulouse

France

doi:10.1016/j.ajem.2008.12.024

References

1. Breen PH, MacVay MA. Pericardial tamponade: a case for awake endotracheal intubation. Anesth Analg 1996;83:658.
2. Aye T, Milne B. Ketamine anesthesia for pericardial window in a patient with pericardial tamponade and severe COPD. Can J Anaesth 2002;49:283-6.
3. Webster JA, Self DD. Anesthesia for pericardial window in a pregnant patient with cardiac tamponade and Mediastinal mass. Can J Anaesth 2003;50:815-8.
4. Rosamel P, Gostoli B, Lehot J, et al. Technique d’anesthesie en ventilation spontanee pour tamponnade. Ann Fr Anesth Reanim 2007; 26:383-4.
5. Shanewise JS, Hug CC. Anesthesia for adult cardiac surgery. In: Miller RD, editor. Miller’s anesthesia. 5th ed. Philadelphia: Churchill- Livingston; 2000. p. 1753-804.
6. Spodick DH. Acute cardiac tamponade. N Engl J Med 2003;349: 684-90.
7. Lehot JJ, Bastien O. Chirurgie cardiaque: anesthesie et reanimation. In: Samii K, editor. Anesthesie-Reanimation Chirurgicale. 3e ed. Paris: Flammarion; 2003. p. 393-411.

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1. Koller ME, Smith RB, Sjostrand U, et al. Effects of hypo-, normo-, and hypercarbia in dogs with acute cardiac tamponade. Anesth Analg 1983;62:181-5.
2. Spodick DH. Pathophysiology of cardiac tamponade. Chest 1998;113:

1372-8.

1. Martins JB, Manuel WJ, Marcus ML, et al. Comparative effects of catecholamines in cardiac tamponade: experimental and clinical studies. Am J Cardiol 1980;46:59-66.
2. Lapostolle F, Petrovic T, Lenoir G, et al. Usefulness of hand-held ultrasound devices in out-of-hospital diagnosis performed by emer- gency physicians. Am J Emerg Med 2006;24:237-42.
3. Busch M. Portable ultrasound in pre-hospital emergencies: a feasibility study. Acta Anaesthesiol Scand 2006;50:754-8.
4. Lapostolle F, Petrovic T, Catineau J, et al. Out-of-hospital ultrasono- graphic diagnosis of a left ventricular wound after penetrating Thoracic trauma. Ann Emerg Med 2004;43:422-3.
5. Byhahn C, Bingold TM, Zwissler B, et al. Prehospital ultrasound detects pericardial tamponade in a pregnant victim of stabbing assault. Resuscitation 2008;76:146-8.
6. Asensio JA, Berne JD, Demetriades D, et al. One hundred five penetrating cardiac injuries: a 2-year prospective evaluation. J Trauma 1998;44:1073-82.