American Journal of Emergency Medicine 33 (2015) 600.e5-600.e7

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American Journal of Emergency Medicine

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Case Report

Resuscitative thoracotomy for nontraumatic Pericardial tamponade: case reports and review of the literature?,??,?

Abstract

Nontraumatic cardiac tamponade is a life-threatening process, and pericardiocentesis is the established treatment designed to relieve tamponade physiology during a cardiac arrest. We report 2 cases, where after traditional resuscitation including serial pericardiocentesis failed, a resuscitative thoracotomy was performed.

Cardiac tamponade is a life-threatening condition that results from an accumulation of fluid, blood, pus, clots, or gas in the pericar- dial space leading to compression of the heart and limitations in cardiac output [1]. In nonTraumatic cases, pericardiocentesis is the established modality of treatment and has been shown to be effec- tive in a majority of patients [2]; however, there are circumstances where the procedure fails to correct tamponade physiology. We present 2 cases of pulseless electrical activity arrest secondary to cardiac tamponade; the first being secondary to an inflammatory effusion and the second to a malignant effusion. The patients were managed with resuscitative thoracotomy after traditional resuscita- tion using advanced cardiac life support algorithms, and serial pericardiocenteses proved unsuccessful.

Case #1: A 58-year-old woman presented to a tertiary, academic emergency department with a chief complaint of dyspnea and general- ized weakness. The patient had presented 2 days earlier to the same emergency department with left-sided chest pain and dyspnea but then left against medical advice after a chest x-ray (Fig. 1). On the second pre- sentation, the patient had an initial blood pressure of 127/84 mm Hg, heart rate of 107 beats per minute, respiratory rate of 18 breaths per minute, an oxygen saturation of 99% on room air, and a temperature of 97.4?F. Medical history included Paroxysmal atrial fibrillation, hypertension, and a right Middle cerebral artery aneurysm repair 8 years prior. On physical examination, the patient appeared to be in no acute distress. Lung fields were clear to auscultation, heart sounds were regular and audible, her abdomen was soft and nontender, and the extremities had no significant edema.

Approximately 90 minutes into her emergency department stay, the patient was directly observed by staff to abruptly collapse secondary to a PEA arrest. Chest compressions were initiated; an endotracheal tube was secured; and epinephrine, atropine, calcium, bicarbonate, and normal saline were administered without return of spontaneous circulation (ROSC). The prior chest x-ray obtained before arrest was notable for cardiomegaly (Fig. 1), and an intraarrest Bedside echocardiography showed pericardial tamponade. Ultrasound-

? Funding: None.

?? Previously presented: No.

? Conflicts of interest: All authors have no conflicts of interest.

guided pericardiocentesis was performed using an 18-gauge spinal needle that yielded 20 cm³ of dark clotted blood. The patient was then noted to be in ventricular fibrillation and was defibrillated; however, the patient did not have return of spontaneous circulation. The code continued, and 4 subsequent pericardiocenteses were per- formed yielding 5 to 20 cm³ of blood. In total, approximately 60 cm³ of fluid was aspirated; however, repeated attempts were limited by clotting, and the patient remained in a PEA arrest with visible cardiac contractility on bedside ultrasound.

During the code, a Surgical consultation was obtained. An emer- gent left-sided anterolateral thoracotomy was performed. Upon inci- sion of the pericardium, a large amount of tense bloody fluid was released, and the patient regained Cardiac activity and peripheral pulses. Twenty-eight minutes elapsed from initial PEA arrest to com- pletion of the thoracotomy and ROSC. Of significance, the patient was noted to have inflammatory adhesions in the pericardial sack. Upon further exploration in the operating room, the patient was found to have multiple sources of slowly oozing blood without any lesion that required ligation.

The patient had a 6-week hospital stay complicated by pneumonia and a prolonged ventilator wean. During the course of her care, her antinuclear antibody returned strongly positive, and the etiology of the tamponade was attributed to systemic lupus erythematous. The patient was discharged to a long-term care facility. Approximately 5 months after initial presentation, the patient had recovered to her baseline state of health and was Neurologically intact.

Case #2: A 65-year-old woman was admitted to a community, level 2 trauma center with a diagnosis of chest pain. The patient had a medical history that included lymphoma, congestive heart failure, hypothyroidism, and thrombocytopenia. Several hours after admission, the patient had agonal breathing that progressed to a PEA arrest. Cardio- pulmonary resuscitation (CPR) was initiated, and the patient’s airway was secured.

During the cardiac arrest, the patient received epinephrine, atropine, calcium, bicarbonate, and a normal saline bolus without return of spon- taneous circulation. A simultaneous review of the record noted that a prior computed tomography of the chest (Fig. 2) showed a large pericar- dial effusion. Laboratory data revealed a white blood cell count of 82000 and platelets of 32000. An echocardiogram was immediately obtained which showed a Massive pericardial effusion. An ultrasound- guided percardiocentesis with an 18-gauge spinal needle was per- formed, yielding 50 to 60 cm³ of serous fluid. Cardiac motion was observed to improve marginally with the fluid removal; however, the patient did not regain pulses. A repeat pericardiocentesis was performed yielding 60 cm³ of additional fluid. The echo showed no significant reduction in the size of the effusion, and ROSC was not achieved.

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Fig. 1. A chest x-ray taken 2 years prior and on the day of presentation showing significant cardiomegaly.

Given the lack of response to aspiration, an emergent left-sided anterolateral thoracotomy was performed. Upon dissecting through the intracostal muscles, the distended pericardium was incised, as parts of it were adherent to the chest wall. An estimated 500 cm³ of serosanguineous fluid was released, and after a brief period of cardiac massage, the patient regained spontaneous circulation. The time elapsed between the initial PEA arrest and completion of thoracotomy was 29 minutes. The cardiothoracic surgeon was consulted, and the patient was further resuscitated with blood transfusions, vasopressors, and normal saline, while the operating team was assembled.

Operative exploration showed fibrinous matter inside the pericardi- um without active bleeding consistent with a malignant effusion. The patient survived the initial arrest and operation; however, at 48 hours postoperatively, she remained on multiple vasopressors in the cardio- thoracic intensive care unit. At this time, Resuscitative efforts were with- drawn per family request, and the patient died.

Fig. 2. A computed tomography of the chest showing a massive pericardial effusion on the day of admission.

Resuscitative thoracotomy is widely accepted and recommend as a Treatment modality for patients with penetrating and, under some cir- cumstances, blunt traumatic arrest [3]. A large meta-analysis reviewing 25 years of trauma data with 4620 patients showed a combined survival rate of 7.4%. Among the subset, where the location of Major injury was cardiac, the rate increases to 19.4% [4]. Open chest cardiac massage was a common and accepted practice for nontraumatic arrest during the first half of the 20th century [5]. In 1953, Stephenson et al [6] presented a case series of 1200 arrests managed with open chest car- diac massage; 28% of the patients survived to discharge with a favor- able neurologic outcome. The practice became less popular in 1960 when Jude et al [7] showed that closed chest compressions were an effective alternative. Since this time, the research has been limited to a handful of clinical trials, case reports, and animal models.

Research in Canine models provides the most substantial sup- portive evidence for the use of Open Chest CPR (OCCPR). Bircher et al [8] showed that when the dogs received 30 minutes of OCCPR before defibrillation, nearly all survived with a Favorable neurologic outcome, compared with standard CPR, where nearly all died or had a Poor neurologic outcome. Because OCCPR is a deviation from what is currently accepted to be Standard care, most human studies are limited to patients who have failed standard CPR or have had prolonged resuscitations. A clear criticism of this data is that the op- portunity to intervene when the physiologic conditions may be ame- nable to OCCPR is missed. This was substantiated in a canine study that showed if OCCPR was initiated within the first 20 minutes of un- treated ventricular fibrillation, all animals were resuscitated, com- pared with poor long-term survival in a 20 to 40-minute window and 100% mortality after 40 minutes [9].

Contemporary data from human clinical trials are limited. A 1995 study that enrolled 10 patients who failed standard CPR (aver- age arrest time, 54 minutes) showed that the mean coronary perfu- sion pressures were 4.5 times higher in patients receiving OCCPR [10]. Notably, this study had 3 OCCPR survivors who were initially considered to be unsalvageable. A subsequent study underscored the limitations of using OCCPR as a Rescue therapy, where there was 100% mortality associated with prolonged delays in initiation of the resuscitative efforts [11].

More recently, there are case reports documenting successful re- suscitative thoracotomies for medical arrests, all secondary to cardi- ac tamponade physiology. One report documents a patient who 24 days after admission to a trauma service developed constrictive pericarditis leading to a PEA arrest who regained ROSC with

K.A. Corl et al. / American Journal of Emergency Medicine 33 (2015) 600.e5-600.e7

thoracotomy after pericardiocentesis failed [12]. Two subsequent reports describe tamponade refractory to pericardiocentesis sec-

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David G. Lindquist, MD, FACEP

Department of Emergency Medicine

ondary to a type-A aortic dissection [13] and as a complication of cardiac ablation [14]. Both patients were managed successfully with resuscitative thoracotomy.

We present 2 cases, where patients in PEA arrest secondary to tamponade, who failed serial pericardiocentesis, were managed with a resuscitative thoracotomy. Both patients survived the initial PEA arrest and subsequent operative management; however, only the first patient survived until discharge. Although pericardiocentesis remains the first- line treatment for nontraumatic PEA arrest secondary to tamponade, we believe that these cases support the use of resuscitative thoracoto- my in select cases that are refractory to standard care. Moreover, these cases and a review of the literature suggest that if thoracoto- my and OCCPR are to be viable options, these must be initiated early in the resuscitation effort. A preplanned and coordinated effort be- tween the emergency department and surgical service is necessary to obtain optimal outcomes.

Keith A. Corl, MD, FACEP

Department of Critical Care Medicine The Warren Alpert Medical School of Brown University

Rhode Island Hospital, Providence RI

Corresponding author. Department of Critical Care

593 Eddy St, Providence RI 02903

Tel.: +1 401 793 4501

E-mail address: [email protected]

Wade N. Sears, MD, FACEP

Fremont Emergency Medicine Services and ACES

Sunrise Hospital, Las Vegas NV

Shea C. Gregg, MD

Section of Trauma, Burns, and Surgical Critical Care

Bridgeport Hospital, Bridgeport CT

The Warren Alpert Medical School of Brown University

Rhode Island Hospital, Providence RI

http://dx.doi.org/10.1016/j.ajem.2014.09.015

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