diagnosis, but since this patient is unstable and echocardiogram may not be
readily available, the treatment is immediate thoracotomy in the operating
room.
While pericardiocentesis (c)may help relieve tamponade, it is not the
optimal procedure for traumatic tamponade. Pericardiocentesis may be dif-
ficult when clots fill the pericardium and may therefore give false-negative
results. The procedure may also injure the heart and delay definitive treat-
ment. Some clinicians perform bilateral tube thoracostomy (b)prior to
thoracotomy to rule out a hemo- and pneumothorax. However, with equal
breath sounds, midline trachea, and no evidence of pneumothorax or con-
solidation on radiograph, chest tubes are low yield in this patient. The
patient is not in respiratory distress. Intubation (a)should be performed in
the OR to prevent additional delays in definitive surgical care. IV fluids and
blood transfusion (e)increase venous return to the heart and are excellent
supportive measures prior to definitive thoracotomy.
214.The answer is d.(Tintinalli, pp 383-385, 1876-1877.)This patient
hascardiac tamponadefrom metastatic breast cancer. Bedside ultrasound
is often diagnostic. The echo-free area around the heart is a pericardial
effusion.It is important to realize that the presence or absence of pericar-
dial effusion is not diagnostic of tamponade; right atrialandventricular
collapse,on the other hand, are more specific ultrasound signs for tam-
ponade.Clinical findings should always be considered in making the diag-
nosis. Patients with tamponade usually have tachycardia, low systolic BP,
and narrow pulse pressure. Tamponade must always be considered with
trauma to the chest, as well as patients with metastatic malignancy, peri-
carditis, uremia, and those patients on anticoagulation.
(a)Pulmonary embolism should certainly be considered in this case
since the patient is at high risk for the diagnosis (ie, limited mobility, malig-
nancy). Echocardiographic findings in patients with a pulmonary embolism
include right ventricular enlargement, hypokinesis of the free wall, leftward
septal shift, and evidence of pulmonary hypertension. This patient’s bedside
cardiac ultrasound reveals fluid around the heart with right ventricular col-
lapse, which is more consistent with pericardial effusion with tamponade.
Echocardiogram in congestive heart failure (b)will show decreased con-
tractility or ejection fraction. Years of experience with ultrasound are neces-
sary to accurately and reliably interpret ejection fraction. MIs (c)will
typically show evidence of wall motion abnormalities or global hypokinesis.
Dehydration(e)will make the heart hyperdynamic with decreased size of
the right atria and ventricles from decreased preload.
Shock and Resuscitation Answers 233