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Hemopericardium

An Emergent Finding in a Case of Blunt Cardiac Injury

¹ Department of Radiology, Harborview Medical Center, University of Washington School of Medicine, 325 Ninth Ave., Box 359728, Seattle, WA 98104-2499.
² Department of Surgery, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA 98104.

Received January 31, 2000; accepted after revision March 20, 2000.

 
This is another in the continuing series on radiology in trauma cases from the Harborview Medical Center. Editors: Fred A. Mann, Eric J. Stern, and Alexander B. Baxter.

Address correspondence to F.A. Mann.

Introduction

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A 56-year-old woman sustained severe blunt precordial injury as the result of a high-speed, head-on motor vehicle collision. In the field she was hypotensive and responded to vigorous fluid resuscitation. At the trauma center, initial chest radiography (Fig. 1A) showed enlargement of the superior mediastinum. Chest CT without IV contrast enhancement (Fig. 1B) showed a large pericardial effusion (35 H), distended superior and inferior vena cavae, obscured aortic outline, and fracture through the first costochondral junction. Unresponsive hypotension led to emergent thoracotomy, which relieved a tense hemopericardium. Continued resuscitative efforts were unsuccessful. Postmortem evaluation revealed a 2-cm right ventricular rupture.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —Hemopericardium after blunt precordial injury in 56-year-old woman. Anteroposterior chest radiograph shows widened superior mediastinal borders and indistinct cardiac silhouette.

View larger version (167K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —Hemopericardium after blunt precordial injury in 56-year-old woman. Unenhanced helical CT scan of chest shows large pericardial fluid collection (arrows) with CT density measurements consistent with hemopericardium.

Cardiac chamber rupture is an uncommon but usually fatal sequela of blunt thoracic trauma. Although cardiac injuries are reported in 20% of motor vehicle-related fatalities, the prevalence of such injuries in patients who survive until hospitalization is low overall (0.25-0.6%) [1,2]. Atria and ventricles are injured in near equal numbers, with the right atrium and right ventricle most commonly involved (1.5:1) [2]. Mortality of patients who require in-field resuscitation for cardiac injuries approaches 100%. However, if the patient survives to the trauma center and the diagnosis is made quickly, then the survival rates may be as high as 50% [2]. Accordingly, rapid diagnosis is essential.

A large hemopericardium may be the only early manifestation of significant injury. In the acute setting, a circumferential hemopericardium may be deemed large. CT is accurate in the identification and quantification of hemopericardium, and a CT density measurement exceeding 35 H differentiates hemopericardium from pericardial transudates [3]. Other important causes of blunt traumatic hemoperi-cardium include aortic root rupture, myocardial or pericardial contusion, and coronary artery laceration [4].

In individuals who have sustained blunt cardiac ruptures, cardiac tamponade is a major cause of death. Although a physiologic diagnosis, cardiac tamponade can be suggested from CT. CT findings of tamponade include enlargement of the superior vena cava (diameter greater than that of the adjacent descending aorta), enlargement of the infrahepatic inferior vena cava (diameter greater than twice that of the adjacent abdominal aorta), enlargement of the renal veins, and periportal edema (periportal radiolucency) [3].

Concomitant, surgically important injuries are common in the abdomen (approximately 40% of cases), thoracic aorta and arch vessels (approximately 20%), and head (approximately 50%) [2]. Identification of blunt hemopericardium should guide surgical decisions regarding triage (emergent or urgent exploration), surgical incision (median sternotomy versus left thoracotomy), and the need to exclude associated aortic and great vessel injuries.

References

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1. Pretre R, Chilcott M. Blunt trauma to the heart and great vessels. N Engl J Med 1997;336:9:626 -632[Free Full Text]
2. Fulda G, Brathwaite CE, Rodriguez A. Blunt traumatic rupture of the heart and pericardium: a ten-year experience (1979-1989). J Trauma 1991;31:2:167 -172[Medline]
3. Goldstein L, Mirvis SE, Kostrubiak IS, Turney SZ. CT diagnosis of acute pericardial tamponade after blunt chest trauma. AJR 1989;152:739 -741[Free Full Text]
4. May AK, Patterson MA, Rue LR. Combined blunt cardiac and pericardial rupture: review of the literature and report of a new diagnostic algorithm. Am Surg 1999;65:568 -574[Medline]

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