Broken Blade in Sternum
	Date: Sat, 20 Sep 1997 15:53:22 +0100 From: John Warwick [john.warwick@virgin.net] Last night a 34 year old male stabbed twice first in URQ, second to lower half sternum - approx 2cm blade (handle broken off and not on scene) protruding from lower half sternum. Unknown length in thorax. Pt verbally responsive, HR 82, RR 28, AE clear bilaterally, HS I+II clear, no neck vein distention, ECG Lead II NSR, SPO2 96% on Fi02 1.0. Times: activation delay 4 mins Running time 5 mins Scene time 5 mins Time to hosp 5 mins 1 x 14gauge IVI en route 250 mls NaCl by arrival at ER with vitals still the same. Question If patient had gone into cardiac arrest in the field how do you do chest compressions? Should I pull the knife blade out? Try to do compressions around it? Push it in further? (surely not) Do no compressions at all? Any thoughts would be appreciated.
	Date: Sun, 21 Sep 1997 15:34:01 -0400 (EDT) From: Ken Mattox [KMATTOX@aol.com] The clinical research data is quite clear: 1. DO NOT pull the knife out. 2. NO fluids pre-hospital 3. Do NOT stop at the closest doc in the box. Go to a trauma center 4. Be sure that the surgeons are waiting for him. 5. If arrest in the field. DO NOTHING. NO compressions. Compressions in the case described, will do more harm than good. 6. If compressions are done, and for more than 5 minutes, this patient is DEAD. Do nothing in the Emergency Center.
	Date: Mon, 22 Sep 97 03:04:45 UT From: Jean Peloquin [Peloquin@classic.msn.com] Interesting! I have been aware of a somewhat similar case but acting as a coroner... First if there is any lay person to see you massaging with the knife blade still in place I would believe that it will not be possible to go on for very long. Secondly, the blade was probably broken when the assailant and the victim came apart. Let's think of this, the blade did not came out of the sternum when it was possible to pull with the handle. Now one would have to dispose of a good pair of pliers to get it out of there unhurt. Thirdly, back to the coroner case, this one was massaged having the knife removed. It only served to completely empty the hart that was separated from the aorta at it's base. But, and this is were it is interesting, it created a very good line of defence as to determine who had ported the fatal blow.
	Date: Mon, 22 Sep 1997 08:17:41 -0500 (CDT) From: John A. Aucar, M.D. [jaucar@bcm.tmc.edu] If this guy goes into cardiac arrest it would either be because of an electrical disturbance with a small heart injury, in which case pulling out the knife to avoid further injury while instituting an ACLS protocol may (might) work. OR He arrest due to major hemorrhage from a big heart injury, in which case compressions will do nothing unless you replace a large portion of his blood volume (4-6 Liters) with something that will carry and release oxygen (Packed Red Cells is the best stuff I know of) within minutes and gain control of the hole. On a good day, in the right place, this may carry some small chance of survival. How do you feel about an emergency thoracotomy (or sternotomy) in the field? I've only known one guy crazy enough to do this, as a surgical resident riding the ambulance. The patient survived (because of or spite of?) and I think it's reported. I wouldn't recommend public mutilation of dead people as a general approach, though. JAA
	Date: Tue, 23 Sep 1997 14:31:04 +0200 (IST) From: Avi Roy Shapira [avir@bgumail.bgu.ac.il] Dear John, I would think that the number 1, 2 and 3 causes for cardiac arrest in the described patient is tamponade. An electrical disturbance must be exceedingly rare. I doubt that even at BTGH you have seen any. You would actually have to produce a survivor for this maneuvre (pulling the knife and compressing the chest). Is there one? Likewise, massive bleeding from a large hole is impossible. Large holes die before the paramedic gets there. They exanguinate immediately. So, in the field, if this guy arrests all of a sudden, the only thing to try short of field thoracotomy, is to needle his pericard . I admit these probably never work, but didn't KLM just write that one Robin DOES make a spring? I mean the guy is dead anyway isn't he? Avi
	Date: Tue, 23 Sep 1997 13:09:21 -0500 (CDT) From: John A. Aucar, M.D. [jaucar@bcm.tmc.edu] Hi Avi, Electrical disturbance is a recognized complication of both blunt and penetrating cardiac injuries. How often it progresses to arrest and whether that situation is ever recoverable is probably pure speculation. The closest thing to an anecdote I have is a second hand report (non-scientific source) of a guy hit it the chest with a softball line drive, became pulseless and responded to a pre cordial thump by a paramedic watching the game. Of course this may just have been a long sinus pause, but it makes a good story. As far as tamponade goes, it might be treatable by controlled release in the pre-arrest phase. I'm not sure that suggesting that treating an arrest due to penetrating trauma, in the field, with pericardiocentis is much more than a speculative notion. The actual most common course is the one that the patient had in this scenario. He rode the ambulance alive and was treated for either no heart wound or a very small heart wound. Sometimes survival is still related to the nature of the wound rather than our self glorifying interventions. I have not found any compelling evidence to discard the notion that patients who tolerate any specific intervention the best are the ones that didn't need it. Emergency Thoracotomy may be the paradigm.
	Date: Mon, 22 Sep 1997 22:58:34 +0100 From: Simon Carley [s.carley@btinternet.com] If they go into Cardiac arrest you must start CPR. You can't effectively do this with the blade in situ so take it out. CPR with the blade out is better than poor CPR with the blade in is better than no CPR at all.
	Date: Wed, 24 Sep 1997 13:56:16 -0500 (CDT) From: John A. Aucar, M.D. [jaucar@bcm.tmc.edu] I think the general perspective that is emerging, is that perhaps you should go to lunch and then start looking elsewhere for someone that you could save. JAA
	Date: Fri, 26 Sep 1997 18:34:04 +0100 From: John Warwick [john.warwick@virgin.net] My original question was posed because if he had of gone into cardiac arrest before we arrived at hospital how could I, as a paramedic prove that he was dead before I removed the knife, or could some smart legal eagle suggest that it was my fault that he died because I pulled out the knife and that this is in contravention of my protocols!! It turns out that the blade was embedded nearly three inches and it had knicked the aorta. The first stab wound to the ULQ did nearly all the damage - penetrating his R ventricle with Cardiac Tamponade. This was releaved in the ER and he underwent 6 hours surgery. The next day he was sitting up in bed. Thank God I didnt have to make the DECISION.
	Date: Mon, 22 Sep 1997 04:30:53 -0400 From: [Eric Frykberg M.D.] To John Warwick-- First of all your question suggests that there is actually a place for chest compression in patients who arrest after trauma! I strongly disagree, altho EMT's the world over have yet to understand the fallacy of this! CPR in the arrested trauma patient represents the classic pitfall of extrapolating a technique shown to be effective in one setting(the patient with coronay disease and acute arrest) to an entirely differeent setting in which it not only makes no sense, but also has no data to support its use! The typically youn and healthy trauma patient who arrests does so most often from exsanguination, tension pneumothorax, or cardiac tamponade--none of which will benefit one iota from chest compression! Does this not make simple sense? The patient you described actually provided a strong hint to you, by putting a physical barrier in your way to prevent you from doing the wrong thing--the hearts of trauma patients do not need external support--in fact, they are usually already working overtime very effectively! It's not the heart that's the problem in trauma! What a trauma victim who arrests needs is to have their chest opened, aorta cross-clamped, and, if necessary, their pericardium opened to relieve the tamponade(which chest compression can not do)--this is the rationale for getting the patient to a hospital quickly--could it be that because this is something EMT's can't do, that is why they resort to something that they Can??--despite its uselessness? Eric Frykberg, M.D. Jacksonville, Fl
	Date: Tue, 23 Sep 1997 14:19:24 -0500 From: Dennis Hudson, R.N. [dhudson@ahecpb.uams.edu] Interesting discussion....regarding Dr Frykberg's comments: 1. EMTs tend to what they can with what they have, it is a natural human response. Definetly these efforts should center around rapid transport to a competent facility. Any additional procedures should be attempted within the scope of that transport. 2. The question then seems to be; What (if anything) is most likely to contribute to the patient's arrival at a trauma center in the most salvageable condition? 3. To do nothing means that for several minutes there is 0 perfusion. At least in my institution this has been associated with a less than desirable outcome. 4. To remove the blade and initiate CPR means either: A. the patient will (or already has) exanguinate. This would certainly be no worse than the outcome of #3 above. B. compression of a truly tamponaded myocardium may produce some small measure of perfusion. This would at least be of some improvement with regards to potential salvageability. I suppose even knowing the futility of resuscitating a prehospital traumatic arrest that I would still be inclined toward making the attempt.