An aortic arch arteriogram was normal, and the patient was observed after laparotomy in the Surgical Intensive Care Unit.
On arrival to the Surgical Intensive Care Unit, the blood pressure was 120/80 mm Hg, with a pulse of 110 beats per minute. Within the following three hours, blood pressure fell to 80/50 mm Hg, and the heart rate increased to 140 beats per minute, but pulsus paradoxus was less than 8 mm Hg. A flow directed thermodilution catheter was placed, demonstrating elevated central venous pressure to 18 mm Hg and a pulmonary capillary wedge pressure of 15 mm Hg. Cardiac output was depressed at 2 L/min/m2 and a cardiac tamponade was suspected.
The patient was recuscitated with Ringers lactate and packed red blood cells, and an intravenous dobutamine infusion was started. A two-dimensional echocardiogram revealed a large mass anterior to the right ventricle with intermediate echogenicity when compared to the right ventricular wall and the intracardiac chambers (Fig 2) causing complete compression of the right ventricular chamber and preventing visible filling during diastole. Link
The patient underwent a thoracotomy with evacuation of a large anterior mediastinal hematoma. The sternum was found to have two fractures (which were not seen on the previous chest roentgenogram) and was stabilized with wire sutures. Several small actively bleeding vessels were ligated and mediastinal drains were placed. The patient was relatively stable in the postoperative period with no further episodes of hypotension or decreased cardiac output. Two days after thoracotomy, a hematoma formed in the left pleural cavity which required repeat exploration and evacuation, but the patient showed no further hemodynamic compromise or recurrence of the mediastinal hematoma and continued a course of steady recovery.
Figure 2 (Upper). Parasternal long axis view of a two-dimensional echocardiogram in diastole demonstrating an anterior mediastinal hematoma compressing the right ventricle and right ventricular outflow tract. (Lower). A schematic diagram identifying the relationship of the hematoma to the right ventricle and outflow tract. A Swan-Ganz catheter is seen in the right ventricular outflow tract. AWRV, anterior wall, right ventricle; IVS, interventricular septum; AMH, anterior mediastinal hematoma; RVOT, right ventricular outflow tract; C, catheter; Ao, aortic root; PWLV, posterior wall, left ventricle; and LA, left atrium.