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Fri Mar 23 05:05:17 GMT 2007

No pictures attached.

AJB

On 3/22/07, Teperman, Sheldon <Sheldon.Teperman at nbhn.net> wrote:
>
> Gentleman and ladies
>
>            We received the following patient in transfer from a nearby
> non trauma center.  Jacobi is a level one in the North East Bronx.  Ron
> Simon (frequently depicted in these pages) has gone off to make Bellevue
> hospital a better place and has handed the Baton off to me (lucky me).
> We all wish Ron well and know he will do great things there as he did
> for us here.
>
>
>
>            To the Case: A 22 year male stabbed in the left chest not
> far from the PMI ( on Tuesday-midday). Mild hypotension responded to a
> fluid bolus and a unit of blood, a left chest tube puts out 500 cc's
> initially with a negative FAST.  He is admitted to that hospital's ICU
> with an official echo cardiogram showing a small pericardial effusion.
> In the morning a routine ECG shows 1 to 2 millimeter ST segment
> elevation across the precordium.  And soon thereafter a repeat Echo
> show's that the effusion was now moderate in size. At the same time the
> patient begins to drop his pressure and they placed an urgent call to us
> as they did not have a chest Surgeon on staff. We encouraged an
> expedited transfer, which occurs in a non expeditious fashion.
>
>            Pt arrives to us with a BP of 129 over 85, a pulse of 110
> and room air Sats of 89%. Our Fast shows a significant pericardial
> effusion, esp. when looking transthoracially.  I have attached a cell
> phone pic of the Fast and the ECG. The patient is then taken to the OR
> in the company of both our trauma service and our Chest Surgeon (full
> CTS training). There is a healthy back and forth about a Sternal split
> vs. a pericardial window. I make a $1,00,000 bet with my colleague that
> she will find blood on the Window, she agrees its likely but wishes to
> avoid the embarrassment (and morbidity) of finding a serous effusion and
> making an unnecessary Sternotomy .
>
>            In the OR( about 28 hours post injury) the vitals continue
> as same, but the Sats are alarming low even with Supplemental O2.
> The patient gets a modified induction, after full prep. And the Window
> shows 200cc's straw colored (just a bit turbid) fluid.  An organized
> linear piece of fibrin with some hemorrhage in it is also removed from
> the pericardial sac (a pericardial biopsy is cooking and a drain was
> left in place.)
>
>            The patient is now making a normal recovery with the Sat
> issue having gone away.
>
>
>
>            So to the question.  What is this?
>
> Our first theory is that the knife wound approached, irritated or
> injured the pericardium-causing a rip roaring and rapidly progressive
> Pericardiditis ( the first ECG showing it was 18 hours post
> injury)-without an actual injury to the heart. One of my younger
> colleagues likes this theory saying,..."If it walks like a duck...."
>
>            Less likely is the possibility that the patient was already
> sick and that he was walking around with this when he was stabbed. But
> he has no antecedent medical history. Another possibility is that this
> was some how related to the chest tube. (Always nice to blame someone
> else).
>
>            A quick medline search does not yield much in the way of
> similar case/or case studies.
>
>
>
>            See some of You all, next week at the Dr. Mattox show in
> Vegas. I will be the guy haplessly sitting by the slots-hoping to hit
> the big one and pay back the Cool Mill I now owe my Chest Surgeon
> friend:)
>
>
>
>
>
>
>
> Sheldon Teperman, M.D.
> Director of Trauma and Critical Care Surgery
> Jacobi Medical Center
> 1400 Pelham Pkwy.
> Rm. 1213
> Bronx NY 10461
>
> Tel 718-918-5592
> Fax 718-918-5593
> Email  Sheldon.Teperman at NBHN.net
>
>
>
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A strange case of Pericardial Tamponade