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A 23-year-old male is brought to the emergency department after a motor vehicle

accident. He was an unrestrained driver. He was found unresponsive at the scene of
the accident, and was intubated by the paramedics. He has received 2L of normal saline
over the last 20 minutes. His blood pressure is 80/40 mmHg and pulse is 120/min. He
responds to strong vocal and tactile stimuli by opening his eyes. His pupils are equal
and reactive to light. His neck veins are distended. There are multiple bruises involving
the anterior chest and upper abdomen. His chest x-ray shows a small, left-sided pleural
effusion and normal cardiac contours. Which of the following is the most likely diagnosis?

o A. Lung contusion
o B. Aortic rupture
o C. Esophageal rupture
o D. Pericardia! tamponade
0 E. Bronchial rupture

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A 23-year-old male is brought to the emergency department after a motor vehicle

accident. He was an unrestrained driver. He was found unresponsive at the scene of
the accident, and was intubated by the paramedics. He has received 2L of normal saline
over the last 20 minutes. His blood pressure is 80/40 mmHg and pulse is 120/min. He
responds to strong vocal and tactile stimuli by opening his eyes. His pupils are equal
and reactive to light. His neck veins are distended. There are multiple bruises involving
the anterior chest and upper abdomen. His chest x-ray shows a small, left-sided pleural
effusion and normal cardiac contours. Which of the following is the most likely diagnosis?

A. Lung contusion [1 8%]

B. Aortic rupture (11 %]
C. Esophageal rupture (3%]
D. Pericardia! tamponade (64%]
E. Bronchial rupture (3%]

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Explanatio n: User

This patient presents with hypotension (unresponsive to IV fluid bolus), tachycardia, and
elevated jugular venous pressure after blunt thoracic trauma consistent with likely acute
cardiac tamponade. Cardiac tamponade occurs acutely in trauma because of bleeding
into a stiff pericardium that has no elasticity. Only 100-200 mL of blood is needed to
cause a sudden rise in intrapericardial pressure that compresses the cardiac chambers
and compromises both venous return (causing elevated jugular venous pressure) and
cardiac output (causing tachycardia and hypotension). The chest x-ray in these patients
can appear normal without a change in cardiac silhouette size due to the small amount of
pericardia! fluid. The resultant cardiogenic shock must be treated immediately with
decompression by pericardiocentesis or surgical pericardiotomy to remove this small fluid
and reduce the intrapericardial high pressure acutely.

In contrast, chronic processes (such as malignancy or renal failure) cause slow

accumulation of pericardia! fluid that gradually increases the intrapericardial pressure and
allows the pericardia! elasticity to adapt slowly. As a result, it may take 1-2 liters of fluid
before the intrapericardlal pressure reaches a critical point that leads to the same
physiologic changes described above in acute cardiac tamponade. The chest x-ray In
these patients tends to show the classic findings of an enlarged cardiac silhouette in a
globular shape.

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 Item lliJ?M k <J [> jj ~· l!lj , ~
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pericardia! fluid. The resultant cardiogenic shock must be treated immediately with
decompression by pericardiocentesis or surgical pericardiotomy to remove this small fluid
and reduce the intrapericardial high pressure acutely.

In contrast, chronic processes (such as malignancy or renal failure) cause slow

accumulation of pericardia! fluid that gradually increases the intrapericardial pressure and
allows the pericardia! elasticity to adapt slowly. As a result, it may take 1-2 liters of fluid
before the intrapericardial pressure reaches a critical point that leads to the same
physiologic changes described above in acute cardiac tamponade. The chest x-ray in
these patients tends to show the classic findings of an enlarged cardiac silhouette in a
globular shape.

(Choice A ) Blunt thoracic trauma may cause a lung contusion with varying amounts of
blood lost into the pleural space. This patient's chest x-ray does show a small left-sided
hemothorax, but severe blood loss would not cause jugular venous distention.

(Cho ice B) Most patients with aortic rupture die in the field. Those that survive to the
emergency department typically have suffered an injury of the aorta just distal to the left
subclavian artery that may be contained as hematomas within the mediastinum. This
form of aortic rupture typically causes hypertension (due to visceral afferent reflexes and
a pseudocoarctation syndrome) and not jugular venous distention.

(Choice C) An esophageal rupture typically presents with severe retrosternal chest pain
and mediastinal free air on chest x-ray and does not cause massive blood loss or cardiac
pump failure unresponsive to standard fluid resuscitation.

(Choice E) Blunt thoracic trauma can cause bronchial rupture with jugular venous
distention, but this usually is in association with a tension pneumothorax that would be
visible on chest x-ray.

Educat ional objective:

Acute cardiac tamponade occurs due to a sudden rise in intrapericardial pressure and
should be suspected in all adult patients with blunt chest trauma who present with
persistent jugular venous distention, tachycardia, and hypotension despite aggressive
fluid resusc itation. Chest x-ray findings typically reveal a nonnal cardiac silhouette
without tension pneumothorax.

References:
1. Definitive management of acute cardiac tamponade secondary to blunt
trauma

Time Spent: 2 seconds Copyright© UWorld Last updated: (10/07/2016]

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