Cardiac tamponade secondary to iatrogenic needle decompression in blunt force trauma

Abstract

The proper treatment for tension pneumothorax is rapid needle decompression. This procedure is frequently performed in the field for trauma patients who have clinical symptoms of pneumothorax. The procedure itself has a high rate of failure due to improper placement, operator inexperience, or chest wall thickness. A 22-year-old unrestrained driver in a high-speed motor vehicle collision was found unconscious and subsequently had needle decompression for decreased breath sounds in the field. The patient was initially stable upon arrival but progressed to cardiac arrest. She had a thoracotomy in the emergency department that showed cardiac tamponade followed by return of spontaneous circulation. On formal thoracotomy, it was discovered that the patient had an iatrogenic cardiac injury from the angiocatheter placed during needle decompression. Needle decompression is a lifesaving procedure, but it is associated with high failure rates and possibility for iatrogenic injury.

Needle decompression (ND) for suspected tension pneumothorax in trauma patients in the prehospital setting has been proven to save lives when performed correctly by trained providers. ND should take place in the midclavicular line in the second intercostal space just above the third rib, or in the anterior axillary line in the fourth or fifth intercostal space.¹ An observational study of emergency medicine physicians showed that only 60% correctly identified the second intercostal space in a human volunteer.² A rare but life-threatening consequence of an improperly placed ND is cardiac tamponade. We present a case of ND causing pericardial tamponade and cardiac arrest.

CASE PRESENTATION

A 22-year-old woman who was an unrestrained driver in a high-speed motor vehicle collision was found unconscious in the passenger seat. Emergency medical services was not able to auscultate breath sounds over the right chest in the field, and a ND was performed at the right parasternal border in the fourth intercostal space. In the emergency department (ED), she was intubated for a Glasgow Coma Scale of 7, and a right-sided chest tube was placed with a notable rush of air. She was intermittently hypotensive with systolic blood pressures in the 70s and a heart rate in the 140s, for which she was transfused 8 units of blood product. After transfusion, her systolic blood pressure improved to >120 mm Hg and her tachycardia resolved. Initial focused ultrasound assessment for the trauma exam was negative. Radiography of the chest demonstrated a prominent leftward shift of the heart and mediastinum (Figure 1a).

Figure 1.

(a) Initial chest x-ray showing a prominent leftward shift of the heart and mediastinum. (b) CT demonstrating gross hemopericardium with signs of left ventricular compromise. Within 1 minute of this CT scan, our patient went into cardiac arrest and was resuscitated with a thoracotomy.

Subsequently, during computed tomography (CT) scans of the head, neck, chest, abdomen, and pelvis, the patient underwent cardiac arrest with initiation of cardiopulmonary resuscitation. CT of the chest demonstrated a hemopericardium (Figure 1b). A left anterolateral resuscitative ED thoracotomy was performed. The pericardium appeared very tense. A pericardiotomy was performed with evacuation of blood clot. With intracardiac epinephrine and cardiac massage, return of spontaneous circulation was achieved after 12 minutes of resuscitation. The patient was then transferred to the operating room for further evaluation.

In the operating room, 400 cc of blood clot was evacuated from around the heart. The inappropriately placed ND had resulted in a puncture of the right ventricle resulting in cardiac tamponade, which was repaired. The patient was subsequently transferred to the intensive care unit. She had a prolonged course that included a 28-day intensive care unit stay, tracheostomy, gastrostomy placement, ventilator-associated pneumonia, and bilateral loss of vision due to ischemic optic neuropathy before being discharged to an acute rehabilitation facility.

DISCUSSION

ND is a valuable tool for prehospital management of tension pneumothorax; however, it carries significant risk of failure and iatrogenic injury. Failure of ND occurs in up to 65% of patients verified by persistent pneumothorax on imaging.³ Potential reasons include incorrect location, incorrect depth or catheter length, operator inexperience, occlusion or obstruction of the catheter, and inability to relieve the pneumothorax. Misplacement can easily occur secondary to the urgency and inexperience of the operator performing the procedure.³ To perform an ND, the second intercostal space in the midclavicular line or the fourth/fifth intercostal space in the midaxillary or anterior axillary line can be used. A large-bore, 5 cm angiocatheter is advanced through the skin and over the target rib, taking care not to injure the neurovascular bundle of the superior rib. Lesperance et al demonstrated that when performed at the second intercostal space, failure to reach the pleural space ranged from 39% to 76%. Sanchez et al reported a failure rate of 33.6% with the anterior approach and 73.6% and 55.3% at the midaxillary line in the fourth and fifth intercostal space, respectively.⁴ In a separate study comparing chest wall thickness, the distance was >5 cm in 42.5% of patients with the anterior approach and 16.7% of patients with the anterior axillary line approach.⁵ Although actual performance was not evaluated, the chest wall thickness indicates that ND would be more successful in the fifth intercostal space at the anterior axillary line.

In this case, an iatrogenic injury to the heart and pericardium resulted in cardiac tamponade and subsequent cardiac arrest. The witnessed cardiac arrest prompted an ED thoracotomy. After a prolonged intensive care unit stay and subsequent ventilator dependence, the patient also incurred vision loss secondary to the hypoxic episode during cardiac arrest. She further incurred the morbidity of an ED thoracotomy. The survival for patients undergoing resuscitative ED thoracotomy is 1.4% for blunt trauma and 8.8% for penetrating trauma, although survival rates increase for patients who showed signs of life on arrival to the ED with a single penetrating cardiac injury.⁶

The volume of blood required to produce cardiac tamponade acutely is as low as 200 mL.⁷ The acute accumulation of blood causes a decrease in stroke volume and development of obstructive shock. Untreated, this will invariably result in cardiac arrest.⁸ The focused assessment of ultrasound in trauma exam has proven to be accurate in the detection of hemopericardium, with a sensitivity of 86.7% and specificity ranging from 95% to 100%.^9–11 However, it has the potential to miss small pericardial effusions, particularly in patients with concurrent left hemothorax, and is heavily operator dependent.

ND, if not performed with the correct technique, could yield significant complications, as presented in this case. Quick recognition and evaluation of a trauma patient requiring ND with subsequent interventions is lifesaving.