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Evaluation of pericardial effusion by contrast echocardiography after gunshot injury

A 25-year-old morbidly obese man (body mass index of 41.7 kg/m) was transferred to our institution with multiple gunshot wounds to the back and left leg. The patient also suffered from a popliteal vessel injury that was evaluated by computed tomography angiography (CTA). He had multiple soft tissue injuries in the chest and a penetrating gunshot wound to his back that transected the spinal column between the L2 and L3 spinal cord level. The patient sustained serious neurological deficits with no sensation and significantly decreased motor function below the knees bilaterally. Despite multiple red blood cell transfusions, he remained hypotensive, tachycardic and anaemic. Therefore, he was transferred to a cardiac telemetry unit. A subsequent chest X-ray did not reveal any acute cardiopulmonary disease including a pneumothorax. CT imaging revealed fluid within the pericardial space, however, its aetiology remained unclear (Fig. 1). It became difficult to ascertain whether there was active bleeding into the pericardial space from the initial clinical assessment and the use of a standard transthoracic echocardiogram (TTE) cannot differentiate between different types of fluid. Physiological pericardial fluid resembles blood on TTE and increased heart rate made it difficult to demonstrate the characteristics of the tamponade by two-dimensional echocardiogram. Thus, a contrast-enhanced TTE (CETTE) was performed by a certified echocardiography technologist under the supervision of a level 3 cardiologist trained echocardiography with long and extensive use of contrast agent experience to help with the differential diagnosis. After activation, 0.5 mL Definity (Lantheus Medical Imaging, North Billerica, MA, USA) was used as the contrast agent, a second generation product made of octafluoropropane surrounded by a phospholipid outer shell, commonly used in CETTE. It was administered with bolus injection via peripheral intravenous line. The equipment was Philips iE33 (Philips, Bothell, WA, USA) and used with the original manufacturing left ventricular (LV) opacification programme with second harmonics. CETTE demonstrated a small pericardial effusion. There was no evidence of a significant bleeding into the pericardium at the time of the study without any extravasation of the contrast material into the pericardial space in several views. This suggested evidence of a very small cardiac rupture initially with very limited amount of bleeding into the pericardial space that was spontaneously tamponaded leaving only a small pericardial effusion (Figs 2,3). Absence of microsphere contrast agent in the pericardial space was sufficient to rule out a small cardiac rupture with communication to the pericardium. The patient was then transferred to the intensive care unit but had no further cardiac complications. He remained stable during the rest of his hospital course, discharged 40 days after the initial day of admission and expected to recover fully. To evaluate a thoracic trauma with cardiac injury, the use of a chest X-ray and CTA is the obvious first step. Echocardiography has recently emerged in the rapid evaluation of patients that have sustained thoracic trauma and that are haemodynamically stable. For the initial echocardiographic evaluation of patients arriving at a trauma centre, a focused cardiac ultrasound study is the accepted approach at most centres as part of the focused assessment with sonography for trauma evaluation. If a patient is haemodynamically unstable, an emergency thoracotomy is mandatory.