Pericardial rupture

Introduction Pericardial injury is more common in penetrating cardiac trauma. Penetrating heart trauma is caused by a strong, high-speed, sharp foreign body penetrating the chest wall or entering the heart. A small number of sternal or rib fractures are severely displaced. Caused by the heart. Heart penetrating injuries have pericardial breaks, and sometimes there are many heart wounds, which are especially common in stab wounds and gunshot wounds.

Cause

1. High-speed foreign matter damage, high-speed foreign matter usually refers to bullets, shrapnel, sharp knives and other high-speed sharp foreign objects penetrate the chest wall injury and pericardium, heart. This is especially common in wartime and is common in peacetime. This type of injury is often associated with chest and abdominal trauma and is the most common cause of penetrating heart injury.

2. The rupture of the sternum or rib fracture is violently displaced inwardly and penetrates the heart to cause damage, mostly caused by traffic accidents or industrial accidents.

3. Penetrating heart injury caused by other causes, cardiac catheterization, interventional heart treatment, pericardial puncture and esophageal foreign body can cause heart penetrating injury. Occasionally, the rib fixed steel needle displacement causes heart damage. Heart penetrating injuries are difficult to estimate accurately. Many critically ill patients have died before the visit. only

About half of the knife wounds and 15% to 20% of gunshot wounds can reach medical institutions. Beijing Anzhen Hospital received 9 cases of penetrating heart injury from 1984 to 1993, accounting for 0.16% of cases of cardiac surgery in the same period.

an examination

Related inspection

Cardiovascular angiography, general radiography, Doppler echocardiography, dynamic electrocardiogram (Holter monitoring), electrocardiogram

The site of cardiac permeation was most common in the right ventricle (about 47%), followed by the left ventricle (34%), the right atrium (14%), and the left atrium (10%). The pathological changes of cardiac penetrating injury depend on the location of the lesion and the size of the breach, and the extent of pericardial injury. Pericardial hemorrhage and functional damage caused by rupture of the left ventricle is clearly more severe than that of the right ventricle. And the worse. According to the size and patency of the pericardial wound, there are three different pathophysiological changes and clinical manifestations:

1. The heart has a large wound, the pericardial wound is small or the blood clot is blocked around the wound. Acute pericardial hemorrhage 100 ~ 200ml can make the pressure in the pericardial cavity rise sharply, and affect the normal relaxation of the heart, resulting in acute pericardial tamponade. The first to be compressed is the vena cava and atrium, causing an increase in central venous pressure and end-diastolic pressure, which gradually increases the venous pressure of the body. At first, due to the reflex contraction of the surrounding blood vessels, the blood pressure is normal or slightly higher. When the diastolic heart is severely restricted, the stroke volume per stroke is significantly reduced, and the arterial pressure drops rapidly. When the pressure in the pericardial cavity rises to 17cmH2O, the heart beats without blood, unless the rapid rehydration increases the venous pressure, otherwise the patient quickly enters the shock symptoms.

On the one hand, acute cardiac tamponade reduces the amount of cardiac output, affects the blood supply to the coronary arteries, leads to myocardial hypoxia, sudden decompensation of cardiac function, and failure. On the other hand, pericardial tamponade can delay the lethal bleeding in the early stage, or temporarily stop the myocardial rupture, which provides valuable time for the rescue of the patient's life. Acute pericardial tamponade symptoms include cold body sweat, facial cyanosis, shortness of breath, superficial venous engorgement, decreased blood pressure, fine pulse rate and odd pulse. Typical Beck triads: When the heart sounds far away, the systolic blood pressure drops and the venous pressure rises, it is helpful for the diagnosis of acute pericardial tamponade. However, generally only 35% to 40% of patients have all typical symptoms. In fact, elevated venous pressure first appeared, and arterial pressure decreased in the late stage. Because the pericardial tamponade caused by heart penetrating injury is less in the pericardium, the blood collects in the posterior pericardial cavity of the heart in the supine position, so the heart sound is far less common, but the odd pulse is more common.

2. The pericardium and heart wounds are kept open, and the bleeding of the heart can be unimpeded. It flows out from the chest wall wound or flows into the chest, mediastinum or abdominal cavity, and there is no large blood accumulation in the pericardium. Clinical hemorrhagic shock is the main manifestation. It manifests as shock symptoms such as cold sweating, thirst, rapid pulse, weak breathing, decreased blood pressure, and irritability. Major bleeding usually causes the casualty to die quickly.

3. The heart is small, especially the oblique stab wound of the myocardium, which can be closed by itself, the bleeding stops, and the condition tends to be stable; but after several days or weeks, the blood clots dissolve or fall off and re-bleed, causing delay. Pericardial tamponade. A few days or weeks after the injury, the pericardial tamponade suddenly appeared, and the pericardial puncture was not a blood clotting solution.

Differential diagnosis

Differential diagnosis of pericardial injury:

For patients with penetrating cardiac trauma, it is necessary to identify pericardial tamponade and acute blood loss in time, which is extremely important for the treatment of this disease. Therefore, the central venous pressure needs to be measured repeatedly in order to make the correct diagnosis and treatment.

1. Constrictive pericarditis

Constrictive pericarditis is a disease in which pericardial thickening, adhesions, and even calcification are caused by chronic inflammation of the pericardium, which causes diastole, limited contraction, and decreased cardiac function, causing systemic blood circulation disorders. The generally thickened pericardium binds the heart, and all organs of the body are bruised, and signs of jugular vein engorgement, hepatomegaly, ascites, and pleural effusion appear.

2, hemorrhagic shock

The rapid loss of blood due to trauma, if not treated in time, will lead to a rapid decline in blood volume leading to shock.

3, acute pericardial tamponade

Traumatic heart rupture or pericardial vascular injury causes blood accumulation in the pericardial cavity. Due to the limited elastic force of the pericardium, acute pericardial hemorrhage up to 150ml can limit blood back to heart and heart beat, causing acute circulatory failure, which leads to cardiac arrest. Therefore, once the blood pericardium appears, it must be rushed to perform rescue treatment. When a sharp-breasted wound in the chest wall is injured in the precordial area or chest, there is progressive blood pressure drop, pale complexion, increased heart rate, distant heart sound, jugular vein engorgement, and irritability, you should first consider the blood pericardium. The existence of emergency pericardial puncture, blood decompression, relief of filling, temporary improvement of hemodynamics, fight for rescue time, and the replacement of saline and blood to correct hemorrhagic shock while preparing for emergency thoracotomy exploration, strict anesthesia management, strict prevention of the heart Sudden stop, add enough blood, remove the blood in the pericardial cavity during surgery, restore the normal contraction and diastolic function of the heart, and repair the heart damage accurately and accurately. Postoperative monitoring of cardiac function and rational application of cardiovascular active drugs.

The site of cardiac permeation was most common in the right ventricle (about 47%), followed by the left ventricle (34%), the right atrium (14%), and the left atrium (10%). The pathological changes of cardiac penetrating injury depend on the location of the lesion and the size of the breach, and the extent of pericardial injury. Pericardial hemorrhage and functional damage caused by rupture of the left ventricle is clearly more severe than that of the right ventricle. And the worse. According to the size and patency of the pericardial wound, there are three different pathophysiological changes and clinical manifestations:

1. The heart has a large wound, the pericardial wound is small or the blood clot is blocked around the wound. Acute pericardial hemorrhage 100 ~ 200ml can make the pressure in the pericardial cavity rise sharply, and affect the normal relaxation of the heart, resulting in acute pericardial tamponade. The first to be compressed is the vena cava and atrium, causing an increase in central venous pressure and end-diastolic pressure, which gradually increases the venous pressure of the body. At first, due to the reflex contraction of the surrounding blood vessels, the blood pressure is normal or slightly higher. When the diastolic heart is severely restricted, the stroke volume per stroke is significantly reduced, and the arterial pressure drops rapidly. When the pressure in the pericardial cavity rises to 17cmH2O, the heart beats without blood, unless the rapid rehydration increases the venous pressure, otherwise the patient quickly enters the shock symptoms.

On the one hand, acute cardiac tamponade reduces the amount of cardiac output, affects the blood supply to the coronary arteries, leads to myocardial hypoxia, sudden decompensation of cardiac function, and failure. On the other hand, pericardial tamponade can delay the lethal bleeding in the early stage, or temporarily stop the myocardial rupture, which provides valuable time for the rescue of the patient's life. Acute pericardial tamponade symptoms include cold body sweat, facial cyanosis, shortness of breath, superficial venous engorgement, decreased blood pressure, fine pulse rate and odd pulse. Typical Beck triads: When the heart sounds far away, the systolic blood pressure drops and the venous pressure rises, it is helpful for the diagnosis of acute pericardial tamponade. However, generally only 35% to 40% of patients have all typical symptoms. In fact, elevated venous pressure first appeared, and arterial pressure decreased in the late stage. Because the pericardial tamponade caused by heart penetrating injury is less in the pericardium, the blood collects in the posterior pericardial cavity of the heart in the supine position, so the heart sound is far less common, but the odd pulse is more common.

2. The pericardium and heart wounds are kept open, and the bleeding of the heart can be unimpeded. It flows out from the chest wall wound or flows into the chest, mediastinum or abdominal cavity, and there is no large blood accumulation in the pericardium. Clinical hemorrhagic shock is the main manifestation. It manifests as shock symptoms such as cold sweating, thirst, rapid pulse, weak breathing, decreased blood pressure, and irritability. Major bleeding usually causes the casualty to die quickly.

3. The heart is small, especially the oblique stab wound of the myocardium, which can be closed by itself, the bleeding stops, and the condition tends to be stable; but after several days or weeks, the blood clots dissolve or fall off and re-bleed, causing delay. Pericardial tamponade. A few days or weeks after the injury, the pericardial tamponade suddenly appeared, and the pericardial puncture was not a blood clotting solution.

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