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Wed May 2 05:22:36 BST 2007

1 - In my opinion there wasn't an absolute indication for the chest tubes, 
because the patient was showing clearly signs of cardiac tamponade (and the 
FAST "confirms" that), so we need to go directly to the point: decompress 
the pericardium. Besides that, the breath sounds were 'equal', so why put 
chest tubes in first moment?

2 - It depends only on the surgeon. We have being experiencing good results 
acomplishing fingers in heart wounds.
3 - The repair of the heart laceration must happen as soon as possible; if 
the surgeon is able to do it works out in the ED, so do it there. If the 
surgeon consider a better proeficience on the repair if it's done in the OR 
(and it is readly prepared), so take the patient to the OR.

Gustav Reinehr

----- Original Message ----- 
From: "caesar ursic" <cmursic at gmail.com>
To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>
Sent: Wednesday, May 02, 2007 12:51 AM
Subject: Re: stabbed heart

> 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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