Case vignette
18yo presents as full trauma after stab wound to L axilla. He has L chest pain.
On scene with EMS: BP 84/41, HR 50, occlusive dressing placed.
In ED: BP 135/83, HR 73, RR 16, SpO2 96%, T 37
Primary survey: decreased L breath sounds. Secondary survey: laceration to L mix-axillary 4th intercostal space
What do you see?
Tr2 US1: thin anechoic stripe outside LV suggestive of pericardial effusion
Tr2 US2: anechoic stripe at pericardial apex suggestive of effusion
Tr2 US3: dilated IVC with minimal respiratory variation
Tr2 M-mode (image): RV diastolic collapse
What do you do next?
Suspecting traumatic tamponade as well as a L traumatic PTX, the patient is deemed sufficiently stable for transport to the OR. There, 200mL of partially clotted blood is removed from the pericardium and a cardiac LV apex laceration is repaired with sutures/pledgets. A left chest tube is left in place. A mini-laparotomy is performed to look for diaphragmatic injury but none is found.
The patient eventually makes a full recovery.
Teaching points. POCUS is critical to assessment of penetrating thoracoabdominal trauma, especially in unstable patients. The following POCUS findings are concerning for tamponade:
RA systolic collapse (sensitive)
RV diastolic collapse (specific) —> seen in this case
Plethoric IVC (>2cm with <50% respiratory variation) (sensitive, except in cases of severe hypovolemia, for example if concurrent hemorrhagic shock)
Systolic "bounce" (or interventricular dependence for advanced users)
"Man jumping on trampoline" or "John Travolta Sign" (wiggling of RV due to impaired diastolic filling)
MV inflow variation > 25%, TV inflow variation > 40% (best performed using apical 4C, pulse wave doppler)
Traumatic Tamponade #2