Hemopericardium

HEMOPERICARDIUM, the presence of blood in the pericardial cavity. H. is most often a consequence of injuries to the heart cavities or its coronary vessels. Other sources of bleeding, such as vessels of the pericardium itself, pleura, and lungs with their simultaneous injury to the heart, usually do not result in large accumulations of blood in the pericardial cavity. In addition to external injuries, accumulation of blood in the pericardial cavity can develop with general hemorrhagic diathesis (scurvy, etc.), with destruction of the heart wall (for example, in myomalacia or rupture of a heart aneurysm), as well as with lesions of the coronary vessels of the heart by various pathological processes leading to destruction of their walls. The latter (though not often) was observed with tuberculous, syphilitic (resp. gummatous) lesions of the pericardium, with malignant tumors of it. Only cases in which the ulceration of a blood vessel is small in size should be subject to clinical observation, due to which the hemorrhage into the pericardial cavity occurs gradually and not too profusely. In cases of rapidly developing extensive perforations, profuse bleeding in a short time leads to death. The blood poured into the pericardial cavity creates a mechanical obstacle to the activity of the heart ("Herzbeuteltamponade"). If the accumulation of blood in the pericardial cavity occurs so quickly and abundantly that the pericardium does not stretch with the necessary speed, then cardiac arrest occurs. Observations in heart injuries make it possible to establish that for the appearance of the formidable symptoms of pericardial tamponade, the presence of about 250 cubic cm of blood in the pericardium is sufficient. Usually, with heart injuries, more blood is poured out than the specified amount, but tamponade phenomena do not occur in all such cases because the poured-out blood is partly thrown outward, and partly poured into the pleural cavity, with the often accompanying injury to the pleura in heart injuries. In those cases where hemorrhage into the pericardial cavity occurs not too quickly, the elastic pericardium gradually stretches, and in such cases, a significantly larger amount of blood than the above-mentioned, which is considered the limit for fatal pericardial tamponade, can be found in its cavity. Individual surgeons (Noland, Sacken) observed accumulation of blood up to one liter. The poured-out blood can cause a reaction from the inner layer of the pericardium. This reaction will manifest in the formation of a serous effusion. The effusion gradually mixing with the poured-out blood can bring the amount of bloody contents to significant dimensions. In most cases, the blood in the pericardium does not remain liquid, and clots begin to form soon. This circumstance is important in choosing the method for emptying the pericardium of blood (puncture or incision). In most cases, the poured-out blood is distributed in the same way as inflammatory effusions, i.e., the main mass of blood accumulates behind the heart and on its sides, while the anterior surface of the heart is separated from the pericardium only by a thin layer of fluid. This circumstance dictates caution when making an incision in the pericardium in cases of hemorrhage into its cavity, as with an careless incision of the tense pericardium, the closely lying heart may be injured. For the treatment of H., an incision should be preferred over a puncture, since with a puncture it is impossible to remove blood clots, which usually occur. For exposing the pericardium and its opening, the paths recommended for exposing the heart can be indicated. After freeing the pericardial cavity from blood, sutures should be applied tightly to avoid the danger of adhesions between the heart wall and the pericardium. In the postoperative period, a complication is often observed, expressed in the accumulation of fluid in the pericardial cavity, sometimes in large quantities. The formation of a liquid effusion should be considered a consequence of mechanical irritations during the operation and, possibly, not very virulent infection introduced with the injury that caused hemopericardium. Abundant accumulation of serous fluid in the postoperative period can be eliminated by puncturing to the right of the sternum. In those cases where H. is caused not by injury, but by pathological changes in the vessels of the pericardium, in addition to surgical intervention, specific treatment for the disease is applied.