definitive management of acute cardiac tamponade secondary to blunt trauma

Emergency Medicine Australasia

(2005)

17

494ndash499

Blackwell Science LtdOxford UKEMMEmergency Medicine Australasia1035-68512005 Blackwell Publishing Asia Pty Ltd 2005175494499Miscellaneous

Blunt trauma and cardiac tamponadeM Fitzgerald

et al

Correspondence Associate Professor Mark Fitzgerald Emergency and Trauma Centre The Alfred Commercial Road Melbourne Vic 3004 Australia Email mfitzgeraldalfredorgau

Mark Fitzgerald FACEM Associate Professor Director Jack Spencer FACEM Emergency Physician Fiona Johnson FANZCA AnaesthetistSilvana Marasco FRCS Cardiothoracic Surgeon Chris Atkin FRCS Senior Trauma Surgeon Thomas Kossmann FRCS Professor Director ofTrauma Surgery

T

RAUMA

Definitive management of acute cardiac tamponade secondary to blunt trauma

Mark Fitzgerald

12

Jack Spencer

2

Fiona Johnson

3

Silvana Marasco

4

Chris Atkin

5

and Thomas Kossmann

15

1

National Trauma Research Institute

2

Emergency and Trauma Centre and Departments of

3

Anaesthetics

and Pain Management

4

Cardiothoracic Surgery

5

Trauma Surgery The Alfred Melbourne Victoria Australia

Abstract

Blunt cardiac injuries are a leading cause of fatalities following motor-vehicle accidentsInjury to the heart is involved in 20 of road traffic deaths Structural cardiac injuries(ie chamber rupture or perforation) carry a high mortality rate and patients rarely survivelong enough to reach hospital Chamber rupture is present at autopsy in 36ndash65 of deathfrom blunt cardiac trauma whereas in clinical series it is present in 03ndash09 of cases andis an uncommon clinical finding Patients with large ruptures or perforations usually dieat the scene or in transit ndash the rupture of a cardiac cavity coronary artery or intrapericar-dial portion of a major vein or artery is usually instantly fatal because of acute tamponadeThe small rare remaining group of patients who survive to hospital presentation usuallyhave tears in a cavity under low pressure and prompt diagnosis and surgery can now leadto a survival rate of 70ndash80 in experienced trauma centres As regional trauma systemsevolve patients with severe but potentially survivable cardiac injury are surviving to EDTwo distinct syndromes are apparent ndash haemorrhagic shock and cardiac tamponade Anypatient with severe chest trauma hypotension disproportionate to estimated loss of bloodor with an inadequate response to fluid administration should be suspected of having acardiac cause of shock For patients with severe hypotension or in extremis the treatmentof choice is resuscitative thoracotomy with pericardotomy Closed chest cardiopulmonaryresuscitation is ineffective in these circumstances Blunt traumatic cardiac injury present-ing with shock is associated with a poor prognosis The majority of survivors of blunt orpenetrating cardiac injury present to the EDtrauma centre with vital signs The mainpathophysiologic determinant for most survivors is acute pericardial tamponade Thepresence of normal clinical signs or normal ECG studies does not exclude tamponade Inrecent years the widespread availability and use of ultrasound for the initial assessmentof severely injured patients has facilitated the early diagnosis of cardiac tamponade andassociated cardiac injuries Two cases of survival from blunt traumatic cardiac traumaare described in the present paper to demonstrate survivability in the context of rapidassessment and intervention

Key words

blunt trauma

cardiac tamponade

thoracotomy

ultrasound

Blunt trauma and cardiac tamponade

495

Case reports

Case one

A 43-year-old man arrived by ambulance helicopter atthe trauma centre Ninety minutes previously he hadbeen the driver of a truck struck by a large pine treebranch that fell onto the cabin ndash tearing the roof off andstriking the patientrsquos chest The patient had extricatedhimself and was found by the road On arrival of thefirst ambulance the patient was alert with a pulse rateof 120min a respiratory rate of 24min and an unre-cordable blood pressure Oxygen was administered acervical collar applied the patient placed on a spineboard and 2500 mL of crystalloid 175 mg of morphineand 10 mg of metaclopramide administered intrave-nously en route through 2 peripheral lines

Primary survey on arrival at the trauma centrerevealed no airway compromise a central flail of thechest (Fig 1) with poor air entry bilaterally a pulse rateof 130min an initial blood pressure of 12050 and arespiratory rate of 28 and pink feet The patientrsquos pupilswere equal and reacting he answered questions appro-priately and had no gross neurological deficits

Ultrasound (focused assessment with sonography fortrauma [FAST]) demonstrated no free intraperitonealfluid but was positive for pericardial fluid and demon-strated right ventricular collapse consistent with tam-ponade (Fig 2) Opening of the cervical collar revealeddistended neck veins

There appeared to be no other major injuries Chestpelvic and lateral cervical spine X-ray radiographswere completed and demonstrated no significant

abnormality The patient was log-rolled and a Foleycatheter was placed A 12-lead ECG demonstratedsinus tachycardia electrical alternans a right bundlebranch block and widespread ST segment depressionThe agreed management plan was to delay intubationuntil immediately prior to thoracotomy and for thetrauma surgeon to scrub and be ready in theatre ndash withan anticipated time to theatre of 20 min During thattime a 12 G large bore iv access was established in theright cubital fossa A right femoral artery line wasinserted which demonstrated an invasive pressure of8040 mmHg A cross-match of 10 units of packed redcells was requested A total of 1000 mL of crystalloidwas administered and 30 min post arrival the patientwas transferred to theatre

In the operating theatre the patient was prepped anddraped The anaesthetic aims were to promptly securethe airway with minimal haemodynamic upset allowrapid sternotomy with surgical drainage and to diag-nose or exclude associated cardiac injuries throughtrans-oesophageal echocardiography (TOE) Thepatient was preoxygenated Rapid sequence inductionwas undertaken with cervical manual in line stabiliza-tion Propofol 50 mg iv Suxamethonium 100 mg ivand incremental MetaraminolAdrenaline iv Post intu-bation intermittent positive pressure ventilation (IPPV)was undertaken with small tidal volumes A TOE wasinserted while median sternotomy was performedImmediately prior to opening the pericardium the bloodpressure was 5530 mmHg

At thoracotomy the pericardium was decompressedand a 3 mm rupture of the right ventricle at the base of

Figure 1

Case one precordial bruising with central flail

Figure 2

Case one focused assessment with sonography fortrauma with pericardial fluid

M Fitzgerald

et al

496

the pulmonary outflow tract was over sewn (Figs 34)TOE revealed an associated traumatic tricuspid regurgi-tation which was managed conservatively with opera-tive repair 3 months later The patient had an uneventfulrecovery and was discharged to home on day 20

Case two

A 62-year-old male driver had collided with a roadsidetree while travelling at an estimated speed of 60 kmhHe was wearing a seat belt and the airbag deployed Hewas trapped in the vehicle for approximately 1 h andcomplained of left hip pain There might have been atransient loss of consciousness Paramedics noted per-sistent hypotension with a systolic blood pressure of70 mmHg Prehospital 5500 mL of crystalloid and col-loid were administered as well as Morphine 5 mg andMetaclopramide 5 mg intravenously

The patient arrived at the trauma centre 105 minafter the accident Primary survey revealed plethoradyspnoea and hypotension with equal bilateral airentry a pulse rate of 80min a respiratory rate of 32min a blood pressure of 70ndash mmHg and a GCS of 14

The patient was conversant without neurological defi-cit Left-sided rib fractures were noted clinically and theleft hip appeared dislocated

Focused assessment with sonography for traumademonstrated pericardial fluid with right ventricularcollapse (Fig 5) Chest X-ray radiograph demonstratedmediastinal widening left pulmonary contusion and leftsided rib fractures Pelvic X-ray radiograph demon-strated a dislocated left hip

A 12 G large bore iv access was established in theright femoral and right jugular veins A packed cell

Figure 3

Case one blunt perforation to right ventricle

Figure 4


Figure 5

Case two focused assessment with sonography fortrauma with pericardial fluid indicated by arrows


497

transfusion was commenced and 30 min post arrival thepatient was transferred to theatre

In the operating theatre the patient was preppedand draped The patient was preoxygenated Rapidsequence induction was undertaken with cervical man-ual in line stabilization Fentanyl 100

+

400

micro

g iv Thi-opentone 50 mg iv Suxamethonium 100 mg iv andincremental Metaraminol iv

A midline laparotomy incision was performed andthe pericardium decompressed prior to the incisionbeing extended as a median sternotomy The pericardo-tomy was extended and a left atrial appendage tearcontrolled with digital pressure and then clampingprior to being over sewn Intraoperative TOE revealedno further injuries and demonstrated a normal aorta Aperinephric haematoma was not explored The hip wasreduced A total of 25 L of crystalloid colloid blood andblood products were administered The patient made agood recovery and was discharged to rehabilitation onday 20

Discussion

Patients with cardiac tamponade secondary to blunt orpenetrating cardiac injury are rarely seen in an Aus-tralasian ED The improvements in prehospital care andtransportation might result in an increase in the num-bers of such patients Immediate use of ultrasonogra-phy will establish the diagnosis Prompt repair of theinjury might improve overall survival

Focused assessment with sonography for trauma hasbecome a widespread tool for demonstrating free intra-peritoneal and pericardial fluid during the initial man-agement of the severely injured patient It is particularlyvaluable when used for the early detection of haemo-pericardium in trauma patients without overt signs ofpericardial tamponade

1ndash5

or external signs of chestinjury

56

There are reported cases of blunt cardiac rup-ture that do present with haemodynamic stability fol-lowed by clinical deterioration

15

Therefore clear viewsof the pericardium are a key component of the FASTexam enabling early diagnoses and interventions in theabsence of clinical signs of cardiac injury

7

The early use of FAST in the assessment of thoracictrauma patients is the key to early diagnosis of hae-mopericardium in turn preventing physiologic deteri-oration and contributing to improved patient survival

8

Although studies emphasize the importance for FASTin penetrating chest trauma the utility of ultrasoundhas also been demonstrated in the early detection of

haemopericardium in blunt cardiac trauma

9

When pro-spectively studied FAST is accurate when used for theevaluation of a possible haemopericardium in patientswith blunt torso trauma who are hypotensive

23

Oncehaemopericardium has been demonstrated the subse-quent management of the patient prior to thoracotomybecomes critical The patientsrsquo appearance at presenta-tion does not predict severity of injury

1011

and the time-course of the patientsrsquo circulatory state cannot bepredicted because of the non-linear course of the pres-surendashvolume relationship

11

Patients might rapidly losecardiac output during the transition phase from the EDto the operating theatre One explanation is that tam-ponade from an atrial tear for example does notbecome haemodynamically significant until the patienthas been volume-loaded

1

Therefore aggressive ivfluid administration might precipitate a loss of cardiacoutput by increasing the rate of development of thetamponade and the associated reduction in strokevolume

Data extracted from the Alfred Trauma Registry forthe 12 months (October 2002ndashSeptember 2003) revealed5 patients with cardiac tamponade (not requiring resus-citative thoracotomy in the trauma centre) with amedian time from arrival to operating theatre of 45 minMore than 1 h elapsed before initiation of repair in 59of patients with haemopericardium in a North Americanseries published in 2000

12

Physicians performing FASTshould anticipate this delay and have a clear manage-ment plan in case the patient deteriorates unexpectedlyduring this period

13

Severe hypotension and cardiac arrest is commonfollowing induction of general anaesthesia in patientswith cardiac tamponade Induction agent dosing shouldbe very conservative Patients with pericardial tampon-ade depend on preload and heart rate to maintain theircardiac output This is confounded by the drop invenous return associated with the institution of inter-mittent positive pressure ventilation myocardialdepression from anaesthetic agents and the sympathol-ysis associated with general anaesthesia and the asso-ciated reduction in heart rate Low tidal and minutevolumes are recommended prior to pericardotomy

Adding further complexities to management are theproblems of non-fasted patients and concerns aboutpotential spinal injuries Therefore careful consider-ation should be given to when mechanical ventilation isinstituted For the non-intubated patient rapidsequence intubation should coincide with the abilityto undertake immediate thoracotomy Pericardialaspiration or subxiphoid pericardotomy can be used as

M Fitzgerald

et al

498

temporizing procedures if there is significant hypoten-sion associated with any delay to thoracotomy

71415

butthoracotomy remains the definitive procedure Thereceiving trauma team should accompany the patient tothe operating theatre ndash because of the real risk of sud-den decompensation prior to and at the time of anaes-thetic induction For similar reasons the surgeon shouldbe scrubbed and the patient prepped and draped priorto induction of anaesthesia

If the patient is haemodynamically unstable andalready ventilated immediate resuscitative thoracot-omy should be undertaken

22

Unresponsive hypotensionwith a systolic blood pressure of less than 70 mmHgand a FAST positive for pericardial tamponade is aconsensus-based indication for immediate resuscitativethoracotomy

1629

However it should be stressed thatresuscitative thoracotomy in Australasia is a significantndash yet infrequent ndash procedure The capacity to expedi-tiously perform it in the EDtrauma centre appears tobe limited to those departments with the appropriateequipment lighting clinical experience and anaestheticand surgical support

Conclusion

Most fatalities from blunt or penetrating cardiac inju-ries occur prior to hospital arrival

17

Of those patientswith vital signs on EDtrauma centre arrival

122023ndash26

themain physiological determinant for survival is acutetamponade

2021

ndash which might be present despite noexternal signs of injury normal clinical signs and anormal ECG

127

In recent years the widespread avail-ability and use of ultrasound for the initial assessmentof severely injured patients has facilitated the earlydiagnosis of cardiac tamponade and associated cardiacinjuries

123491928

Receiving trauma teams should be vigilant andattempt to clearly document the absence of pericardialfluid during the FAST exam to reduce the likelihood ofmissed or delayed diagnoses

Once haemopericardium has been demonstrated thesubsequent management of the patient prior to defini-tive thoracotomy becomes critical Aggressive iv fluidanalgesic and induction agent administration mightprecipitate a loss of cardiac output If the systolic bloodpressure remains less than 70 mmHg despite volumeloading (and pleural decompression if indicated) imme-diate thoracotomy with pericardial decompressionand direct control of the cardiac injury should beundertaken

19

Author contributions

Mark Fitzgerald contributed to the concept case infor-mation and case photographs discussion and literaturereview Jack Spencer and Chris Atkin contributed to thecase information and discussion Fiona Johnson con-tributed to the case information discussion and anaes-thetic literature review Silvana Marasco contributedto the discussion and operative approach ThomasKossmann contributed to the format and operativeapproach

Competing interests

The authors have no conflicting interests associatedwith this publication

Accepted 8 July 2005

References

1 Mangram A Kozar RA Gregoric I

et al

Blunt cardiac injuriesthat require operative intervention an unsuspected injury

JTrauma

2003

54

286ndash8

2 Rozycki GS Ballard RB Feliciano DV

et al

Surgeon performedultrasound for the assessment of truncal injuries lessons learnedfrom 1540 patients

Ann Surg

1998

228

557ndash67

3 Rozycki GS Feliciano DV Schmidt JA

et al

The role of surgeon-performed ultrasound in patients with possible cardiac wounds

Ann Surg

1996

223

737ndash46

4 Chelley MR Margulies DR Mandavia D

et al

The evolving roleof FAST scan for the diagnosis of pericardial fluid

J Trauma

2004

56

915ndash17

5 Ball C Peddle S Way J Mulloy R Nixon J Hameed M Bluntcardiac rupture isolated and asymptomatic

J Trauma

2005

58

1075ndash7

6 Chapman T Cardiac injury in blunt trauma without externalsigns of chest injury

West J Med

1989

151

662ndash3

7 Duke JC Anesthesia In Moore EE Feliciano DV Mattox KL(eds)

Trauma

New York McGraw-Hill 2004 347

8 Pretre R Chilcott M Blunt trauma to the heart and great vessels

N Eng J Med

1997

336

626ndash32

9 Kato K Kushimoto S Mashiko K

et al

Blunt traumatic ruptureof the heart an experience in Tokyo

J Trauma

1994

36

859ndash63

10 Buchman TG Phillips J Menker JB Recognition resuscitationand management of patients with penetrating cardiac injuries

Surg Gynecol Obstet

1992

174

205ndash10

11 Zerkowski HR Schmit-Neuerburg KP Reidemeister JC [Interdis-ciplinary management of perforating heart injuries]

Langen-becks Arch Chir Suppl Kongressbd

1991 550ndash6

12 Tyburski JG Astra L Wilson RF

et al

Factors affecting prog-nosis with penetrating wounds of the heart (annual meetingarticles)

J Trauma

2000

48

587ndash91


499

13 Ordog GJ Emergency department thoracotomy for traumaticcardiac arrest

J Emerg Med

1987

5

217ndash23

14 Hanowell LH Perioperative management of thoracoabdominaltrauma In Grande CM (ed)

Textbook of Trauma Anesthesiaand Critical Care

Baltimore Mosby 1993 575

15 Pimentel MC Frost EAM Trauma anesthesia In IvaturyRR Cayten CG (eds)

The Textbook of Penetrating Trauma

Baltimore Williams amp Wilkins 1996 224

16 Brohi K

Emergency Department Thoracotomy

[traumaorgweb site] 66 June 2001 Available from URL httpwwwtraumaorgthoracicEDTindicationshtml [Accessed 22December 2004]

17 Krasna MJ Flancbaum L Blunt cardiac trauma clinical mani-festations and management

Semin Thorac Cardiovasc Surg

1992

4

195ndash202

18 Feliciano DV Rozycki GS Advances in the diagnosis and treat-ment of thoracic trauma

Surg Clin North Am

1999

79

1417ndash29

19 Martin TD Flynn TC Rowlands BJ

et al

Blunt cardiac rupture

J Trauma

1984

24

287ndash90

20 Powell M Lucente F Diagnosis and treatment of blunt cardiacrupture

W V Med J

1997

93

64ndash7

21 Luna GK Pavlin EG Kirkman T

et al

Hemodynamic effects ofexternal cardiac massage in trauma shock

J Trauma

1989

24

287ndash90

22 Braithwaite CE Rodriguez A Turney SZ

et al

Blunt cardiacrupture A 5-year experience

Ann Surg

1990

212

701ndash4

23 Rhee PM Foy H Kaufmann C

et al

Penetrating cardiac injuriesa population based study

J Trauma

1998

45

336ndash70

24 Fulda G Brathwaite CE Rodriguez A

et al

Blunt traumaticrupture of the heart and pericardium a ten-year experience(1979ndash1989)

J Trauma

1991

31

167ndash72

25 Williams J Silver D Laws H Successful management of heartrupture from blunt trauma

J Trauma

1981

21

534ndash7

26 Lancey RA Monahan TS Correlation of clinical characteristicsand outcomes with injury scoring in blunt cardiac trauma

JTrauma

2003

54

509ndash15

27 Mandavia DP Joseph A Bedside echocardiography in chesttrauma

Emerg Med Clin North Am

2004

22

610ndash19

28 Fialka C Seboumlk C Kemetzhofer P Kwasny O Stertz F VeacutecseiV Open-chest cardiopulmonary resuscitation after cardiac arrestin cases of blunt chest or abdominal trauma a consecutive seriesof 38 cases

J Trauma

2004

57

809ndash14


495

Case reports

Case one

A 43-year-old man arrived by ambulance helicopter atthe trauma centre Ninety minutes previously he hadbeen the driver of a truck struck by a large pine treebranch that fell onto the cabin ndash tearing the roof off andstriking the patientrsquos chest The patient had extricatedhimself and was found by the road On arrival of thefirst ambulance the patient was alert with a pulse rateof 120min a respiratory rate of 24min and an unre-cordable blood pressure Oxygen was administered acervical collar applied the patient placed on a spineboard and 2500 mL of crystalloid 175 mg of morphineand 10 mg of metaclopramide administered intrave-nously en route through 2 peripheral lines

Primary survey on arrival at the trauma centrerevealed no airway compromise a central flail of thechest (Fig 1) with poor air entry bilaterally a pulse rateof 130min an initial blood pressure of 12050 and arespiratory rate of 28 and pink feet The patientrsquos pupilswere equal and reacting he answered questions appro-priately and had no gross neurological deficits

Ultrasound (focused assessment with sonography fortrauma [FAST]) demonstrated no free intraperitonealfluid but was positive for pericardial fluid and demon-strated right ventricular collapse consistent with tam-ponade (Fig 2) Opening of the cervical collar revealeddistended neck veins

There appeared to be no other major injuries Chestpelvic and lateral cervical spine X-ray radiographswere completed and demonstrated no significant

abnormality The patient was log-rolled and a Foleycatheter was placed A 12-lead ECG demonstratedsinus tachycardia electrical alternans a right bundlebranch block and widespread ST segment depressionThe agreed management plan was to delay intubationuntil immediately prior to thoracotomy and for thetrauma surgeon to scrub and be ready in theatre ndash withan anticipated time to theatre of 20 min During thattime a 12 G large bore iv access was established in theright cubital fossa A right femoral artery line wasinserted which demonstrated an invasive pressure of8040 mmHg A cross-match of 10 units of packed redcells was requested A total of 1000 mL of crystalloidwas administered and 30 min post arrival the patientwas transferred to theatre

In the operating theatre the patient was prepped anddraped The anaesthetic aims were to promptly securethe airway with minimal haemodynamic upset allowrapid sternotomy with surgical drainage and to diag-nose or exclude associated cardiac injuries throughtrans-oesophageal echocardiography (TOE) Thepatient was preoxygenated Rapid sequence inductionwas undertaken with cervical manual in line stabiliza-tion Propofol 50 mg iv Suxamethonium 100 mg ivand incremental MetaraminolAdrenaline iv Post intu-bation intermittent positive pressure ventilation (IPPV)was undertaken with small tidal volumes A TOE wasinserted while median sternotomy was performedImmediately prior to opening the pericardium the bloodpressure was 5530 mmHg

At thoracotomy the pericardium was decompressedand a 3 mm rupture of the right ventricle at the base of

Figure 1

Case one precordial bruising with central flail

Figure 2

Case one focused assessment with sonography fortrauma with pericardial fluid

M Fitzgerald

et al

496


Case two






Figure 3


Figure 4


Figure 5



497



+

400

micro



Discussion



1ndash5


56


15


7


8



9


23


1011


11


1



12


13



M Fitzgerald

et al

498


71415



22


1629


Conclusion


17


122023ndash26


2021


127


123491928



19



Competing interests



References


et al


JTrauma

2003

54

286ndash8


et al


Ann Surg

1998

228

557ndash67


et al


Ann Surg

1996

223

737ndash46


et al


J Trauma

2004

56

915ndash17


J Trauma

2005

58

1075ndash7


West J Med

1989

151

662ndash3


Trauma



N Eng J Med

1997

336

626ndash32


et al


J Trauma

1994

36

859ndash63


Surg Gynecol Obstet

1992

174

205ndash10



1991 550ndash6


et al


J Trauma

2000

48

587ndash91


499


J Emerg Med

1987

5

217ndash23







16 Brohi K





1992

4

195ndash202


Surg Clin North Am

1999

79

1417ndash29


et al


J Trauma

1984

24

287ndash90


W V Med J

1997

93

64ndash7


et al


J Trauma

1989

24

287ndash90


et al


Ann Surg

1990

212

701ndash4


et al


J Trauma

1998

45

336ndash70


et al


J Trauma

1991

31

167ndash72


J Trauma

1981

21

534ndash7


JTrauma

2003

54

509ndash15



2004

22

610ndash19


J Trauma

2004

57

809ndash14

M Fitzgerald

et al

496


Case two






Figure 3


Figure 4


Figure 5



497



+

400

micro



Discussion



1ndash5


56


15


7


8



9


23


1011


11


1



12


13



M Fitzgerald

et al

498


71415



22


1629


Conclusion


17


122023ndash26


2021


127


123491928



19



Competing interests



References


et al


JTrauma

2003

54

286ndash8


et al


Ann Surg

1998

228

557ndash67


et al


Ann Surg

1996

223

737ndash46


et al


J Trauma

2004

56

915ndash17


J Trauma

2005

58

1075ndash7


West J Med

1989

151

662ndash3


Trauma



N Eng J Med

1997

336

626ndash32


et al


J Trauma

1994

36

859ndash63


Surg Gynecol Obstet

1992

174

205ndash10



1991 550ndash6


et al


J Trauma

2000

48

587ndash91


499


J Emerg Med

1987

5

217ndash23







16 Brohi K





1992

4

195ndash202


Surg Clin North Am

1999

79

1417ndash29


et al


J Trauma

1984

24

287ndash90


W V Med J

1997

93

64ndash7


et al


J Trauma

1989

24

287ndash90


et al


Ann Surg

1990

212

701ndash4


et al


J Trauma

1998

45

336ndash70


et al


J Trauma

1991

31

167ndash72


J Trauma

1981

21

534ndash7


JTrauma

2003

54

509ndash15



2004

22

610ndash19


J Trauma

2004

57

809ndash14


497



+

400

micro



Discussion



1ndash5


56


15


7


8



9


23


1011


11


1



12


13



M Fitzgerald

et al

498


71415



22


1629


Conclusion


17


122023ndash26


2021


127


123491928



19



Competing interests



References


et al


JTrauma

2003

54

286ndash8


et al


Ann Surg

1998

228

557ndash67


et al


Ann Surg

1996

223

737ndash46


et al


J Trauma

2004

56

915ndash17


J Trauma

2005

58

1075ndash7


West J Med

1989

151

662ndash3


Trauma



N Eng J Med

1997

336

626ndash32


et al


J Trauma

1994

36

859ndash63


Surg Gynecol Obstet

1992

174

205ndash10



1991 550ndash6


et al


J Trauma

2000

48

587ndash91


499


J Emerg Med

1987

5

217ndash23







16 Brohi K





1992

4

195ndash202


Surg Clin North Am

1999

79

1417ndash29


et al


J Trauma

1984

24

287ndash90


W V Med J

1997

93

64ndash7


et al


J Trauma

1989

24

287ndash90


et al


Ann Surg

1990

212

701ndash4


et al


J Trauma

1998

45

336ndash70


et al


J Trauma

1991

31

167ndash72


J Trauma

1981

21

534ndash7


JTrauma

2003

54

509ndash15



2004

22

610ndash19


J Trauma

2004

57

809ndash14

M Fitzgerald

et al

498


71415



22


1629


Conclusion


17


122023ndash26


2021


127


123491928



19



Competing interests



References


et al


JTrauma

2003

54

286ndash8


et al


Ann Surg

1998

228

557ndash67


et al


Ann Surg

1996

223

737ndash46


et al


J Trauma

2004

56

915ndash17


J Trauma

2005

58

1075ndash7


West J Med

1989

151

662ndash3


Trauma



N Eng J Med

1997

336

626ndash32


et al


J Trauma

1994

36

859ndash63


Surg Gynecol Obstet

1992

174

205ndash10



1991 550ndash6


et al


J Trauma

2000

48

587ndash91


499


J Emerg Med

1987

5

217ndash23







16 Brohi K





1992

4

195ndash202


Surg Clin North Am

1999

79

1417ndash29


et al


J Trauma

1984

24

287ndash90


W V Med J

1997

93

64ndash7


et al


J Trauma

1989

24

287ndash90


et al


Ann Surg

1990

212

701ndash4


et al


J Trauma

1998

45

336ndash70


et al


J Trauma

1991

31

167ndash72


J Trauma

1981

21

534ndash7


JTrauma

2003

54

509ndash15



2004

22

610ndash19


J Trauma

2004

57

809ndash14


499


J Emerg Med

1987

5

217ndash23







16 Brohi K





1992

4

195ndash202


Surg Clin North Am

1999

79

1417ndash29


et al


J Trauma

1984

24

287ndash90


W V Med J

1997

93

64ndash7


et al


J Trauma

1989

24

287ndash90


et al


Ann Surg

1990

212

701ndash4


et al


J Trauma

1998

45

336ndash70


et al


J Trauma

1991

31

167ndash72


J Trauma

1981

21

534ndash7


JTrauma

2003

54

509ndash15



2004

22

610ndash19


J Trauma

2004

57

809ndash14

definitive management of acute cardiac tamponade secondary to blunt trauma

Documents