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Wed May 2 04:51:09 BST 2007

OK, thanks to all who have responded.  There are clearly several different
opinions to this 'not uncommon' scenario.

I'll tell you what was done.  I wasn't there, but as the trauma director I
am "QAing" (quality assurance) or "PIing" (performance improvement) this
case  (choose your favorite acronym).  I present this case because I truly
value your opinions (although I secretly hope that they support my own
biases).

To re-cap:  16 year old kid, single stab-wound to precordium, clearly in
advanced state of shock on arrival, intubated rapidly, equal bilateral
breath sounds, no other signs of injury except laceration located just to
left of xyphoid, FAST clearly shows pericardial effusion.

So....after intubation, bilateral chest tubes were placed.  This did
notimprove the situation.  No blood evacuated through the tubes, no
'rush of
air' heard (but the room was loud).  The surgeon then opened the chest via
left anterolateral approach through fourth interpsace.  No blood in left
thoracic cavity, but tense pericardium noted.  This was opened in the
standard fashion releasing a large, congealed clot.  A three cm laceration
over the left ventricle was noted, bleeding freely.  The surgeon then
inserted a Foley catheter into the heart through the stab wound, inflated
the balloon, and stopped the bleeding.  The injury was then repaired around
the Foley catheter using 2-0 prolene sutures on teflon pledgets.  The Foley
balloon was deflated and and removed, with a final 2-0 prolene suture placed
where the catheter had exited.  Good cardiac hemostasis.  Patient then taken
to OR where the left chest was fully explored and peripheral hemostasis was
achieved, fresh chest tubes were placed, and the chest was closed. Patient
extubated about 18 hours later.  No obvious neurologic deficits, but he will
undergo formal cognitive testing prior to discharge.

Questions for the list members:

1.  Were the bilateral chest tubes indicated?  Remember, there was FAST
evidence of cardiac tamponade shortly after arrival, and the breath sounds
were 'equal.'  Placing chest tubes did delay the thoracotomy (not by much,
but there was a delay), since the surgeon was one of two individuals
inserting them (an ER doc placed the other tube).  Should a patient with
fading or absent pulses presenting with a suspected cardiac injury (based on
wound location and clinical or ultrasonographic signs of cardiac tamponade)
ever get chest tubes first, or is the resuscitative thoracotomy the first
step?  Seems to me you can rapidly decompress the left chest and evaluate
the heart with one swift stroke of the scalpel rather than spend time
inserting a chest tube that will do nothing for a heart injury, if present.
If the left chest and heart seem normal, the thoracotomy can rapidly be
extended into the right chest to determine if there is any problem there.

2.  Is there any role for the Foley catheter in controlling simple, linear
stab wounds to the heart?  Granted, it is a sexy and cool approach, but does
it really accomplish anything that a gently but firmly placed finger or two
over the wound doesn't accomplish?  I'm referring to good 'ole direct
digital pressure.  Foley catheters in the heart have been blamed for making
the hole in the heart larger (with every beat of the heart) and of making
the eventual repair more difficult, etc.  I've done it myself once.  There
is even one study (in pigs) that demonstrated a reduction in cardiac output
due to the inflated intra-cardiac Foley balloon. And then there is the small
but real risk of introducing air into the cardiac chamber, which is not
always a good thing.

3.  Should one strive to repair the heart laceration in the ED during the
resuscitative thoracotomy or take the patient to the OR (with the finger on
the wound to control hemorrhage) where lights and instruments and suction
are (usually) better?  Assuming, of course, that an OR is readily available.

Thank you all of your comments.

CMU

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