CASE REPORT cardiac tamponade; hernia, traumatic diaphragmatic

Delayed Traumatic Intrapericardial Diaphragmatic Hernia Associated With Cardiac Tamponade

We describe a case of delayed presentation of traumatic intrapericardial diaphragmatic hernia associated with cardiac tamponade. A 71-year-old woman presented to our emergency department complaining of epigastric and midabdominal pain one month after hospitalization for multiple inju- ries suffered in an automobile accident. Chest radiograph showed a dia- phragmatic hernia. In the ED, the patient became hypotensive and tachy- cardic with elevated central venous pressure. A t surgery, she was found to have omentum and transverse colon herniated into the pericardial sac causing cardiac tamponade. The defect was repaired, and her postopera- tive course was uncomplicated. Cardiac tamponade should be included in the differential diagnosis of hypotension in patients with radiographic evi- dence of diaphragmatic hernia. [Girzadas DV Jr, Fligner DJ: Delayed trau- matic intrapericardial diaphragmatic hernia associated with cardiac tam- ponade. Ann Emerg Med November 1991;20:1246-I247.]

INTRODUCTION Patients with delayed diaphragmatic hernias often present with pain,

respiratory complaints, or gastrointestinal symptoms. 1 Rarely does the clinical picture include hypotension.2, 3 Reported causes of hemodynamic instability resulting from delayed diaphragmatic hernia include tension pneumothorax, tension viscerothorax, bowel strangulation, or perforation with secondary sepsis and hypovolemiaA,4, s With our case report, we add cardiac tamponade secondary to intrapericardial diaphragmatic hernia (IDH) to the differential diagnosis.

CASE REPORT A 71-year-old woman presented to our ED with a complaint of severe

midabdominal and epigastric pain that began suddenly 30 minutes after she had eaten dinner. She characterized the, pain as a constant ache radiat- ing to the back that improved with sitting. The pain was accompanied by nausea but not emesis. She had experienced mild diarrhea for the previous four days but otherwise had felt well. She denied chest pain, diaphoresis, and shortness of breath.

The patient had been hospitalized at our institution four weeks earlier for acute injuries sustained in an automobile accident. At that time, she had been treated for a pubic ramus fracture, multiple rib fractures, and pulmonary contusion; her therapy included endotracheal intubation and assisted ventilation. She had been asymptomatic at the time of discharge. She had no other significant medical history, was receiving no medica- tions, and had no drug allergies.

Physical examination revealed an obese woman who was pale and mild- ly dyspneic. The patient was alert but appeared uncomfortable and fre- quently moved about on the cart. Vital signs were blood pressure of 150/68 mm Hg; pulse, 132; respirations, 24; and temperature, 36.8 C. There were no significant orthostatic changes in pulse or blood pressure. Cardiopulmo- nary examination was normal, although the neck veins could not be as- sessed secondary to adiposity. The abdomen was obese, without scars, soft, and nontender; bowel sounds were high pitched. There was no palpable organomegaly and no masses. The aorta was not palpable. Rectal examina- tion was normal except for trace occult blood in the stool.

Daniel V Girzadas, Jr, MD Denise J Fligner, MD, FACEP Oak Lawn, Illinois

From the Emergency Medicine Residency Program and the Department of Emergency Medicine, Christ Hospital and Medical Center, Oak Lawn, Illinois.

Received for publication November 26, 1990. Revision received May 13, 1991. Accepted for publication June 20, 1991.

Address for reprints: Patricia Deacetis, Department of Emergency Medicine, Christ Hospital and Medical Center, 4440 West 95th Street, ©ak Lawn, Illinois 6O465.

106/1246 Annals of Emergency Medicine 20:11 November 1991

HERNIA Girzada & Fligner

An arterial blood gas drawn during the initial examination showed pH 7.49; Pco2, 27 mm Hg; Po2, 79 mm Hg; HCO3, 21 mmol/L; base excess, - 1 mmol/L; and oxygen saturation, 96% on room air. An ECG was inter- preted as sinus tachycardia at 117 beats per minute with lateral non- diagnostic ST depression. A periph- eral IV line was started, and the pa- tient was sent for chest and abdomi- nal radiographs.

On returning from the radiology suite, she was profusely diaphoretic. She appeared to be in more distress and complained of increased epi- gastric pain. Systolic blood pressure was 112 mm Hg by Doppler, and pulse was 128. A second peripheral IV line was started, and a 300-mL bo- lus of normal saline was infused. Oxygen was given by nasal cannula, and a nasogastric tube was placed. Gastroccult testing of nasogastric as- pirate was negative. After the initial f lu id cha l l enge , b lood p res su re dropped to 80 mm Hg systolic. Both IV line sites were increased to the maximal flow rate. The chest and abdominal examinations remained unchanged despite worsening symp- toms.

The chest radiograph showed an air-filled mass over the heart shadow that had not been present on chest radiographs from the previous hospi- talization. A portable ultrasound of the abdomen at this time showed no evidence of abdominal aortic aneu- rysm. Laboratory results revealed he- moglobin of 14.8 g/dL; WBC count of 12.9/mm 3 with 81% neutrophils; and creatine kinase of 21 units/L. Electro- lytes, blood urea nitrogen, creatinine, amylase, and coagulat ion studies were otherwise within normal limits. Urinalysis was remarkable for 20 RBCs per high-power field. A repeat arterial blood gas showed an increas- ing metabolic acidosis: pH 7.4; Pco2, 26 mm Hg; Po2, 161 mm Hg; HCO3, 16 mmol/L; and base excess, - 7 mmol/L.

Surgical consultation was obtained for a presumptive diagnosis of dia- phragmat ic hernia wi th probable bowel strangulation. Myocardial is-

chemia was again considered, and the patient was given sublingual nitro- glycerin with no relief of her pain; a repeat ECG was unchanged. After re- ceiving 2,000 mL of normal saline over 20 minutes, the patient's dia- phoresis, dyspnea, and pain contin- ued to worsen even as her blood pres- sure increased to 90/70 mm Hg and her pulse decreased to 110. A central venous catheter was introduced; cen- tral venous pressure measured 27 mm H20.

Despite physician uncertainty re- garding the patient's hemodynamic instability, she was taken to the op- erating room for emergency reduc- t ion of the hernia ted bowel and repair of the diaphragmatic rupture. Intraoperatively, not only was the di- aphragm torn but the pericardium had a defect as well. Omentum and transverse colon had herniated into the pericardial space and were caus- ing cardiac tamponade. Only minor necrosis of the omentum was pres- ent; the transverse colon remained viable. After reduction of the bowel, the pat ient 's hemodynamic status improved. The pericardium and dia- phragm were repaired, and the pa- tient recovered without complica- tions.

DISCUSSION There is an approximately 5% to

8% incidence rate of diaphragmatic tears in patients undergoing emer- gency surgery for blunt and penetrat- ing trauma J, 6 The majority of tears are loca ted in the left hemidia- phragm, whereas the pericardial por- tion of the diaphragm, which is often referred to as the central tendon of the diaphragm, is only rarely injured. In a review of 324 diaphragmatic in- juries from six series between 1976 and 1987, seven injuries were noted to extend into the central tendon from another d iaphragmat ic site, whereas only two ruptures were lo- cated exclusively in the pericardial portion of the diaphragm.I, 7 Pericar- dial diaphragmatic injuries may re- sult acutely in herniation of the heart into the abdominal cavity or more of- ten later herniation of abdominal vis-

cera into the pericardial sac. 8 Pericardial diaphragmatic injuries

may be classified according to the time elapsed between injury and rec- ognition. Acute injuries are most of- ten recognized as incidental findings at surgery for other injuries. If un- diagnosed during this period, a latent period ensues during which the pa- tient may be only mildly symptom- atic. An acute complication, usually visceral strangulation or obstruction, ends the latent period and brings the patient to medical attention. 9

Our case is unique because of the delay between injury and presenta- tion. In our review of the literature, we found no previous reports of de- layed IDH associated with hemo- dynamically significant cardiac tam- ponade.

SUM M ARY The case of a patient with delayed

presentation of traumatic IDH asso- ciated with hemodynamically signifi- cant cardiac tamponade is described. Chest radiography was crucial to making the diagnosis and differen- tiating this condi t ion from other complications of delayed diaphrag- matic hernias. The clinical presen- tation of IDH with hemodynamic instabil i ty should suggest cardiac tamponade and requires emergency operative intervention for reduction of the hernia and repair of the injury.

REFERENCES 1. Laws HL, Hawkins ML: Diaphragmatic injury. Adv Trauma 1987;2:207-228.

2. Saber WL, Moore EE, Hopeman AR, et aI: Delayed presentation of traumatic diaphragmatic hernia. J Emerg Med 1986;4:i-7.

3. Bematz PE, Burnside AF Jr, Clagett OT: Problem of the ruptured diaphragm. JAMA 1958;168:8774881.

4. Skinner EF, Cart D, Duncan JT, et al: Strangulated diaphragmatic hernia. J Thorac Surg 1958;36:102q11.

5. Kanowitz A, Marx JA: Delayed traumatic diaphrag- matic hernia simulating acute tension pneumothorax. J Emerg Med 1989;7:619-622.

6. Waldschmidt ML, Laws HL: Injuries of the dia- phragm. J Trauma 1980~20:587-592.

7. Rodriguez-Morales G, Rodriguez A, Shatney CH: Acute rupture of the diaphragm in blunt trauma: Analy- sis of 60 patients. J Trauma 1986~26:438-444.

8. Clark DE, Wiles CS, Lira MK, et al: Traumatic rup ~ ture of the pericardium. Surgery 1983;93:495-503.

9. Grimes OF: Traumatic injuries of the diaphragm: Diaphragmatic hernia. Am J Surg 1974;128:175-181.

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