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Three Part Question

In [patient with cardiac tamponade in penetrating chest trauma] does [pericardiocentesis] reduce [mortality and morbidity]?

Clinical Scenario

A 43-year-old male is brought into the resuscitation room having been stabbed with a knife in his left chest. The patient is hypotensive (blood pressure 80/40mmHg) but remains conscious, and cardiac tamponade is suspected. A focussed abdominal sonography for trauma scan (FAST) shows an obvious haemopericardium with early right ventricular collapse. There is no on site cardiothoracic support and the general surgeons want to transfer the patient to another hospital for definitive surgery. The on call surgical registrar decides to perform pericardiocentesis for this patient but you wonder if this procedure is useful.

Search Strategy

Medline 1950-11/2008 using the OVID interface:
[(cardiac tamponade.mp OR exp cardiac tamponade OR pericardial tamponade.mp) AND (trauma.mp OR exp "Wounds and Injuries" OR wounds.mp OR injuries.mp) AND (pericardiocentesis.mp OR exp pericardiocentesis OR pericardial tap.mp OR pericardial aspiration.mp)] LIMIT to human AND English.

Search Outcome

Seventy-four papers found of which only two were relevant (see table).

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Symbas et al, 1976, USA	102 patients with penetrating cardiac wounds. Group 1 (1964 to 1967, N=17) all treated first with PCC followed by operation. Group 2 (1968 to 1971, N=34) treated stab wounds with PCC first, bullet wounds to OR immediately. Group 3 (1972 to 1974, N=20) all operated upon immediately, PCC used only to provide time for 'safe operation'.	Retrospective	Mortality	Group 1: 17.5%; Group 2: 14.7%; Group 3: 5.0%.	Selection bias, interventional groups divided by random time periods; number of PCC done in Group 3 not recorded; number of survivors with intact neurological function not indicated.
Breaux et al, 1979, USA	197 patients with penetrating mediastinal injuries with cardiac tamponade. In all groups, PCC at discretion of treating physician. Group 1 (N=96) had ORT. Group 2 (N=44) had EDT. Group 3 (N=34) had PCC and observation.	Retrospective	Mortality	Group 1: pre-operative PCC decreased mortality from 25% to 11%; Group 2: pre-thoracotomy PCC decreased mortality from 94% to 63%; Group 3: 15% mortality.	Unknown criteria for performing PCC in all groups; selection bias; groups divided according to treatment, not severity; number of survivors with intact neurological function not indicated.

Comment(s)

Pericardiocentesis played an important diagnostic role in both studies cited, because ultrasound was not available at that time. Emergency department ultrasound has now been widely accepted for the diagnosis of cardiac tamponade and we are more concerned about the role of pericardiocentesis for decompression. Both of the studies were observational and failed to answer the three-part question directly. Whereas more research may clarify the usefulness of pericardiocentesis, it seems unlikely that a randomised controlled trial will ever be conducted in these relatively rare and complex patients.

Clinical Bottom Line

Pericardiocentesis should not delay the definitive treatment (emergency department thoracotomy or operating room thoracotomy) for patients with penetrating chest trauma and evidence of cardiac tamponade.

References

1. Symbas PN, Harlaftis N, Waldo WJ. Penetrating cardiac wounds: A comparison of different therapeutic methods. Ann Surg 1976; 183(4):377-81.
2. Breaux EP, Dupont JB Jr, Albert HM, Bryant LR, Schechter FG. Cardiac tamponade following penetrating mediastinal injuries: improved survival with early pericardiocentesis. J Trauma 1979; 19(6):461-6.