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Acute cardiac tamponade is a life-threatening emergency that requires prompt treatment by either percutaneous or surgical pericardiocentesis. It may occur after penetrating or blunt chest trauma. We report a case of pericardial tamponade in the absence of penetrating trauma, due to blast overpressure injury after a dynamite explosion—which has not, to our knowledge, been reported before. Physicians should be aware of the possibility of pericardial tamponade in victims of barotraumatic events such as dynamite or bomb explosions, even in the absence of penetrating trauma. Cardiac tamponade, although life-threatening, is easy to treat when recognized.
Acute cardiac tamponade is a life-threatening emergency that requires prompt treatment by means of percutaneous or surgical pericardiocentesis. The diagnosis is confirmed by transthoracic echocardiography, usually after clinical suspicion has been aroused. Cardiac tamponade can occur after penetrating or blunt chest trauma,1,2 due to injury of cardiac chambers or vascular structures.3–7 We report a case of pericardial tamponade due to a nonpenetrating blast overpressure injury after a dynamite explosion—which has not, to our knowledge, been reported before.
In March 2007, a 41-year-old male miner was admitted to our emergency department 1 hour after a dynamite explosion. Upon his admission, his blood pressure was 105/50 mmHg, his heart rate was 129 beats/min, and his respiration rate was 26 breaths/min. Results of the physical examination were within normal limits, except for multiple fractures of the right tibia (confirmed on radiography) and jugular venous distension. There was no sign of penetrating trauma over the chest and abdomen. In the emergency department, his blood pressure dropped to 85/50 mmHg, and this was accompanied by deterioration of consciousness. The patient's arterial saturation (on room oxygen) was 80%. His blood pressure remained low, despite inotropic treatment and volume infusion. After pulsus paradoxus developed, a bedside transthoracic echocardiographic examination revealed normal cardiac chambers, valvular structures, and systolic function; however, we detected a circumferential pericardial effusion with a diameter of 2.5 cm (Fig. 1). A “swinging heart” appearance was associated with diastolic collapse of the right atrium and right ventricle. A diagnosis of pericardial tamponade mandated prompt subxiphoid pericardiocentesis. After approximately 450 mL of serohemorrhagic fluid was extracted, the patient's blood pressure rose to 125/75 mmHg. His arterial room-oxygen saturation level returned to normal. Analysis of the pericardial fluid (cell count, culture, cytology, etc.) showed no sign of infection or malignancy. During follow-up, pericardial effusion did not recur, and the patient, wearing a short leg-cast, was discharged from the hospital on the 15th day after admission. His follow-up transthoracic echocardiographic examinations, at 3 months and 1 year, showed him to be free of pericardial effusion.
Pericardial tamponade is a clinical phenomenon that is not uncommon after penetrating or blunt chest trauma.1,2 Causes of pericardial tamponade in association with blunt chest trauma include motor vehicle accidents, falls from a height, and animal kick.8–13 The present paper presents a novel case of pericardial tamponade due to a nonpenetrating blast overpressure injury after a dynamite explosion.
A dynamite or bomb explosion causes a blast wave or “blast overpressure,” which is an abrupt increase in air pressure over normal atmospheric pressure. Consequent injury is called blast overpressure injury.8,9,14 Blast overpressure can injure the heart through a variety of mechanisms, causing myocardial contusions, the initiation and propagation of cell-mediated pathways of injury, valvular rupture or damage, cardiac-chamber rupture, pericardial injury, arrhythmias, and conduction abnormalities.13,15 In the absence of penetrating trauma, common manifestations of cardiac blast overpressure injuries are asystole, bradycardia, tachycardia, and ventricular fibrillation.9 Major determinants of the severity of blast overpressure injury are the velocity of the blast wave and the distance of the subject from the origin of the blast.14
In conclusion, physicians should be aware of the possibility of pericardial tamponade in victims of such barotraumatic events as dynamite or bomb explosions, even in the absence of penetrating trauma. Tamponade is life-threatening but easy to treat when recognized.
Address for reprints: Orhan Ozer, MD, Department of Cardiology, School of Medicine, Gaziantep University, 27310 Gaziantep, Turkey. E-mail: rt.ude.petnag@rezoo