Pericardial haematoma

A 40-year-old man was brought into the Emergency Department after he fell into a dam following a 10 m jump with his motocross bike. He received 3 min of cardiopulmonary resuscitation (CPR) by bystanders, before intubation by paramedics. Initial plain radiograph of the chest (Fig. 1) demonstrated an abnormal cardiac silhouette, which on computed tomography (CT) was shown to be consistent with pericardial haematoma (Fig. 2). Also revealed on CT was a grossly (13 mm) displaced sternal fracture, retrosternal haematoma, left haemothorax and 4th rib fracture. He had a normal electrocardiogram but elevated troponin (2205 ng/L), suggestive of blunt cardiac injury.1, 2 Given the pericardial haematoma, he was acutely evaluated with transthoracic echocardiogram (TTE), which showed normal ventricular function and no evidence of tamponade effect. A left chest tube was acutely inserted for his haemothorax, and he underwent surgical evacuation of the retrosternal hematoma with placement of two size 18F drains, and open reduction and internal fixation of the abnormally moving and gaping sternum. In consultation with Cardiothoracic Surgery, a decision was made to not undertake a pericardial window or sternotomy for the pericardial effusion as part of this procedure, given the patient had normal haemodynamic status, a TTE demonstrating no tamponade effect from the pericardial fluid, and there were no signs of active or ongoing pericardial bleeding. The pericardial haematoma was thus managed initially with close monitoring and serial TTEs. Management of pericardial haematoma in this clinical setting is controversial, has limited available evidence, and thus there is significant variability in clinical practice.3 On day 10, a repeat TTE was performed to assess progress of the pericardial haematoma. It showed an increase in size, such that the pericardial haematoma was compressing the right ventricle and atrium to exert a mild tamponade effect. The pericardial haematoma was uneventfully drained with percutaneous CT-guided technique under local anaesthesia. General anaesthesia was avoided as induction agents may cause vasodilation, diminished preload and myocardial depression, each of which may cause acute decompensation and haemodynamic collapse in patients with cardiac tamponade.4 At 6-week follow-up the patient was pain free with normal cardio-respiratory function. His plain chest radiograph at this time (Fig. 3) demonstrated resolution of the abnormal cardiac silhouette. There was remaining atelectasis in the left lower lobe and small right basal pleural effusion. When encountered in the trauma bay, a plain chest radiograph with abnormal cardiac silhouette such as Figure 1 should raise the surgeon's suspicion for pericardial haematoma. In the context of haemodynamic instability, expeditious drainage may be required to treat cardiac tamponade.5 In the haemodynamically normal patient, close monitoring is required to ensure the pericardial haematoma does not expand, necessitating subsequent drainage. Open access publishing facilitated by The University of Newcastle, as part of the Wiley - The University of Newcastle agreement via the Council of Australian University Librarians. Nicholas J. Murphy: Investigation; writing – original draft. Zsolt J. Balogh: Conceptualization; writing – review and editing.