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HAEMOPERICARDIUM

Studies of eFAST for pericardial effusion all show high levels of accuracy (1,2). The presence of haemoperitoneum in the hypotensive patient is one of the main indications for ED thoracotomy. Survival from ED thoracotomy is higher when patients with haemopericardium are selected (3). 

Typically, the subxyphoid view is used to assess for haemopericardium. However, abdominal injuries may make the view difficult. If this is the case, examine the heart from a parasternal window. You can use the phased array (echo) transducer for this. Alternatively, to avoid wasting time, you can use the abdominal transducer in the L parasternal space with the probe marker pointed to the patient's left hip.  

parasternal imaging with the probe marker to the patient's right shoulder, but the setting is abdominal so the probe marker is on the left hand side of the screen (right side in cardiac imaging). 

Same abdominal setting, but the probe marker is now to the patient's left hip giving the traditional PLAx view

BLUNT TRAUMA

Cardiac rupture from blunt trauma has a high mortality and is only rarely seen in hospital (4). The most commonly seen cardiac injuries in hospital are right sided tears: as these are the low pressure chambers leading to a slower rate of bleeding (5). In an acute trauma, a haemopericardium in the subxyphoid view is seen as anechoic fluid anterior and posterior to the heart. But sometimes fluid may only be seen anteriorly.

echogenic material in the pericardial space of a pedestrian vs car delayed presentation

Be aware that pericardial laceration can lead to massive haemothorax (6). This is more likely with penetrating trauma. 

PENETRATING TRAUMA

 Cardiac injuries due to penetrating trauma can be more difficult to discern due to pain at the site of imaging, loss of containment of the haemopericardium due to pericardial tears, presence of air and foreign bodies (7). In this case, have a look from a parasternal window. 

Stabbing victim: subxyphoid view with a hint of a pericardial effusion anterior to the beating heart, difficult to get a perfect view due to pain and subcutaneous emphysema

same patient as above, PLAx view with the phased array (echo) transducer showing a herogenous haemopericardium

PITFALLS

HAEMOPERITONEUM

Haemoperitoneum or ascites can look like a pericardial effusion because the liver which normally sits anterior to the heart in the subxyphoid view may be pushed aside by the fluid. If in doubt, check from a chest window eg PLAx of A4C.

Ascites appearing like an anterior haemopericardium in the subxyphoid view

Haemoperitoneum or ascites can look like a pericardial effusion because the liver which normally sits anterior to the heart in the subxyphoid view may be pushed aside by the fluid. If in doubt, check from a chest window eg PLAx of A4C. Just be aware that this could be a decompressed pericardial effusion in the presence of a pericardial tear. 

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REFERENCES

1. Rozycki GS, Ochsner MG, Jaffin JH, Champion HR. Prospective evaluation of surgeons' use of ultrasound in the evaluation of trauma patients. J Trauma. 1993 Apr;34(4):516-26

2. Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM. 2019 Nov;21(6):727-738

3. Fitzgerald MC, Yong MS, Martin K, Zimmet A, Marasco SF, Mathew J, Smit V, Yeung M, Tan GA, Marquez M, Cheung Z, Boo E, Mitra B. Emergency department resuscitative thoracotomy at an adult major trauma centre: Outcomes following a training programme with standardised indications. Emerg Med Australas. 2020 Aug;32(4):657-662.

4. Martin TD, Flynn TC, Rowlands BJ, et al. Blunt cardiac rupture. The Journal of trauma 1984;24:287–90.

5. Nan YY, Lu MS, Liu KS, Huang YK, Tsai FC, Chu JJ, Lin PJ. Blunt traumatic cardiac rupture: therapeutic options and outcomes. Injury. 2009 Sep;40(9):938-45

6. Baldwin D, Chow KL, Mashbari H, Omi E, Lee JK. Case reports of atrial and pericardial rupture from blunt cardiac trauma. J Cardiothorac Surg. 2018 Jun 19;13(1):71

7. Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg. 1998 Oct;228(4):557-67