From: Karl P.R.J Orlebar-Edwards
Date: Tue 26/11/2002 16:03

Afternoon....

I am slightly confused indeed FAST is the method to diagnose Cardiac Tamponade in the trauma patient, this has been drilled into my head in the last few months, but once a diagnosis of tamponade has been obtained. What is the best treatment.... Sub Xiphoid Pericardial Window or Pericardiocentesis????

Karl P.R.J Orlebar-Edwards

From: Stephanie Stafford
Date: Tue 26/11/2002 20:30

pericardiocentesis is best in ED. Ever try pericardial window?..it's hard enough in OR, dangerous to try in ED...or so is my experience with trauma CT surgery.

stephanie stafford, DO

From: Eric Frykberg
Date: Tue 26/11/2002 23:10

Uhhhhh..... Some confusion seems to be present here--neither a pericardiocentesis nor a pericardial window are therapeutic maneuvers, only diagnostic ones--blood in the pericardial sac is NOT the problem--the problem is WHERE the blood came from. And....in the pericardial sac, that is really only one place----THE HEART!

No injury of the heart can be fixed by simply draining the blood, nor thru a subxyphoid window, right?

Just think about it for a few minutes....

ERF

From: Michael Parr
Date: Wed 27/11/2002 00:23

This is from the soon to be published revised Liverpool Trauma Manual, which will be available on the Liverpool Trauma wewbsite in pdf form:


Pericardiocentesis is not a good idea in trauma patients because:

• the patient you are convinced needs it (in extremis) actually needs a thoracotomy,
• the patient you are considering it for (stable) usually needs a thoracotomy.

There are many risks:

• damage to organs (myocardium, lung, stomach, bowel, oesophagus, spleen, kidney),
• laceration of coronary artery,
• failure to aspirate blood from the pericardial sac because it is clotted (common).

By performing a pericardiocentesis you will be effectively committing a patient to a pericardial exploration, so, get an ultrasound if you can and a surgeon if you are suspicious of tamponade.

Pericardiocentesis may be performed if the following criteria are met:

• You are unable to do a thoracotomy
• A surgeon is not availabl
• The patient is in extremis (about to die)
• You have a high degree of suspicion that tamponade is present.

from:
HANDBOOK OF TRAUMA CARE
LIVERPOOL HOSPITAL TRAUMA MANUAL – 6TH EDITION

Michael Parr
Intensive Care Unit
Liverpool Hospital
Sydney Australia

From: Rene J.Rodriguez
Date: Wed 27/11/2002 21:04

Once you become skilled at pericardial window , you start forgetting pericardiocentesis. It's a very easy procedure , and it is minimally invasive . I'm agree that there is confussion in the first question about diagnostic and terapeutic concept . In a FAST positive study for blood , toracotomy is mandatory. Which thoracotomy one is better , is another and endless dicussion between trauma and cardiac surgeons. Any suggestion??

Rene J.Rodriguez
Rosario-Argentina

From: Rowley Cottingham
Date: Wed 27/11/2002 06:11

Pericardiocentesis. Aptly termed a needle with a clot at each end. I do a left lateral thoracotomy. Yes, in the Emergency Department. I get someone else to close it if the patient survives.

Best wishes,
Rowley

From: Eric Frykberg
Date: Thu 28/11/2002 14:31

Good for you, Rowley--this is the real answer to save a life

ERF

From: John Wood
Date: Wed 27/11/2002 11:07

I would say "perform the technique you're most famililar with" P'centesis in ER will save pts life until cardiac surgeons arrive to open the chest. I've never heard of a window being performed in ER but that may reflect trauma patterns in the UK

John Wood
London

From: Eric Frykberg
Date: Thu 28/11/2002 14:30

This is just not true, as anyone with experience at cardiac injuries will attest--I have yet to see it work at all for this purpose, and many iatrogenic--a couple at least fatal--injuries the patient just does not need. Whenever you open the pericardium of someone with traumatic tamponade, it is full of CLOT--the best explanation of why a needle decompression does not work.

And no--it is not worth the try, either--much too risky--what these patients need is an immmediate thoracotomy with opening of the sac, evacuation of the clot and a finger on the hole--THEN you can wait for someone who can close the chest to arrive. Actually, this is a system problem, if you must wait at all for someone to arrive with no one to immediately help.

Don't fool yourself into thinking this kind of mucking around does anything real for the patient

ERF

From: Honorio Ma. Jr. Pangilinan
Date: Thu 28/11/2002 06:55

Hi all,

In my opinion, pericardiocentesis and subxiphoid window will only relieve the tamponade, but will not address the source of the bleeding. Pericardiocentesis for DIAGNOSIS of cardiac tamponade is not recommended anymore because of its risk of iatrogenic cardiac injury. In our facility a patient with cardiac tamponade due to a penetrating chest injury gets needled, just to give him enough time to reach the operating room where a thoracotomy is performed. Creation of a subxiphoid window is done for non-trauma pericardial effusions.

H. Pangilinan, Jr. M.D.
Philippines

From: Ben Reynolds
Date: Thu 28/11/2002 16:41

I'm not sure that this is very responsible advice. I won't disagree with you about the extreme lack of utility with pericardiocentesis, but suggesting that an ED physician open the chest and put a "finger in the hole", perhaps in the hopes that it is JUST one hole, OR that it's even a hole that can be controlled digitally, isn't a very sage option either in the non-trauma setting.

That fact that pericardiocentesis doesn't work ALL the time (note that I am not using absolutes here because I HAVE seen it work more than several times) is no reason that the non-surgeon provider shouldn't attempt it as a stop-gap measure BEFORE attempting thoracotomy.

Ben

From: Ken Mattox
Date: Thu 28/11/2002 22:20

Ben,

in case there is any misunderstanding about absolutes, there is NO INDICATION for pericardiocentesis and subxyphoid pericardial window in suspected hemopericardium, ESPECIALLY in the emergency department. PERIOD. I would be happy to debate this subject anytime, anywhere, for any forum, including the Supreme Court of the United States or the World Court.

k

From: Eric Frykberg
Date: Fri 29/11/2002 04:19

Ben...

...and a very dangerous mindset this is--you just do not seem to get it....

ERF

From: Ben Reynolds
Date: Fri 29/11/2002 05:21

Eric.

We're talking about NON-surgeons in a NON-trauma setting, or at least I am.

Have you seen a NON-surgeon open a chest before? Judging from your answer, NO. Done properly (under echo guidance not BLINDLY)pericardiocentesis carries a morbidity of around 5% *.

What is the morbidity of a non-surgeon repairing a wound to the heart? Well, assuming that only about 8% of all ED thoracotomies for penetrating injuries to the heart done in a TRAUMA CENTER survive and that the PRESENCE of tamponade may be associated with higher survival*...

Ben

*Tsang TS, Enriquez-Sarano M, Freeman WK, Barnes ME, Sinak LJ, Gersh BJ, Bailey KR, Seward JB. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc. 2002 May;77(5):429-36

*Tyburski JG, Astra L, Wilson RF, Dente C, Steffes C. Factors affecting prognosis with penetrating wounds of the heart. J Trauma. 2000 Apr;48(4):587-90; discussion 590-1.

From: Rowley Cottingham
Date: Thu 28/11/2002 22:16

This is trauma we are talking about. [...]

I view pericardiocentesis only as a medical procedure for effusions such as lupus, renal failure and so on. The other advantage of the thoracotomy is that you can rapidly expand it to a clamshell with a pair of scissors or a Gigli saw, can get a clamp on the descending aorta to perfuse brain preferentially and can also do open massage on a heart whose filling you can simply see. It is not exactly a difficult procedure either. Pair of gloves, scalpel handle and a 15 blade is all you require. Spreaders and clamps are nice, but not essential.

Best wishes,
Rowley Cottingham

From: Pradeep Navsaria
Date: Fri 29/11/2002 07:51

Dear Colleagues

We in the Trauma Unit at GSH, Cape Town have a very simple approach to cardiac injuries:

1. Tamponade - ERT or sternotomy in theatre - depending on presentation

2. Diagnoastic pericardial window - in unstable patients or patients going to theatre for thoracoabdominal injuries - if positive - sternotomy

3. Stable patients with haemopericardium - u/s confirmed pericardial collection - usually > 10mm - we previously performed subxiphoid window - drained blood - wait 5 minutes - no active bleeding - pericardial drain - observe in high care.

4. We performed a prospective pilot study - all stable patients with u/s confirmed pericardial fluid - subxiphoid - if positive - sternotomy - and GRADE the injury - 16/20 patients had simple pericardial, myocardial or non-penetrating injuries - therefore 16 unnecessary sternotomies

5. We are presently (ethics approved) performing a randomised, prospective study on all stable patients with u/s confrimed pericardial collections: group 1 - subxiphoid window only, group 2 - sub window, if positive, sternotomy and grading of injury

We hope to have 50 patients in both groups by end of 2003.

Thank you

Pradeep Navsaria
General Trauma Surgeon
Groote Schuur Hospital Cape Town

ps - we donot use pericardiocentesis at all