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Wed May 2 07:51:42 BST 2007

Dr. Mattox,

Pardon the question, but I thought that blood in a Pericardial effusion will
not clot...I have seen a few in our small ER and every single time it's
done, it will not clot and the cardiologist that does it, always makes a
point of saying to the residents; " See, the blood will not clot" He leaves
the initial finder needle/syringe on a mayo stand and picks it up at the end
of the procedure and is able to squirt it into a bowl or onto a gauze....I
once saw a centesis where the cardiologist removed over 750cc of blood from
around the heart...none of which clotted... So is it that way all the time
or can it clot....?

Steven P. Rogers, RN
Olive View/UCLA Medical Center
Sylmar, CA 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of kmattox at aol.com
Sent: Tuesday, May 01, 2007 3:26 PM
To: Trauma &amp; Critical Care mailing list
Subject: Re: stabbed heart

Pericardiocentisis is NOT indoicated, nor effectiive.  The bulk of the
offending blood ois clotted and cannot be removed w a needle.  

K

Sent via BlackBerry from Cingular Wireless  

-----Original Message-----
From: "Pret Bjorn" <p.bjorn at netzero.net>
Date: Tue, 1 May 2007 18:57:15 
To:"'Trauma &amp; Critical Care mailing list'" <trauma-list at trauma.org>
Subject: RE: stabbed heart

I see the votes are favoring thoracotomy.  Me, I'd be looking for a
pericardiocentesis.  THEN intubation, chest tubes, IV access, and by then
the OR should be ready, if he still needs it.

If there's nothing hidden, draining the pericardium should do a world of
good, and it only costs you thirty seconds, with none of the inherent
high-risk melee of opening the chest of a combative patient in the ED.  

In a lean kid, it should be an easy stick.

Easy for ME to say.

Pret Bjorn, RN
Bangor, ME 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of caesar ursic
Sent: Tuesday, May 01, 2007 4:51 PM
To: Trauma &amp, Critical Care mailing list
Subject: stabbed heart

True story:

16 yo previously healthy male stabbed once in anterior chest.  Confused and
combative at scene.  Minimal external blood loss noted.  Paramedics scoop
and run - one antecubital IV, minimal fluid given en route (less than 20
mL), no attempt at intubation.  Eight minute interval from first patient
contact at scene to arrival in ED.

On arrival to ED he's even more combative; very diaphoretic, ashen-colored
lips, cool periphery; carotid pulses not palpable (but he's thrashing about
too much to really tell).  Only obvious external injury is a 3-4 cm stab
wound just to the left of the xyphoid.  Breath sounds are equal.

Patient intubated (rapid sequence orotracheal) within three minutes of
arrival.  FAST shows fluid around heart, no fluid in abdomen.  He's been in
the ED for about four-five minutes.  Now it is clear he has no palpable
pulses.  Cardiac monitor: sinus tachycardia at 150 bpm.  Nobody can feel a
pulse in this thin 16 y.o. boy.

The on-call surgeon is in the room and is trained and willing to open chest,
put in chest tubes, insert a central line, etc. The OR will be ready to take
the patient in 5-10 minutes, but not immediately.

What is the next step?

A. bilateral large bore tube thoracostomies
B. resuscitative left anterolateral thoracotomy (in the ED)
C. fluid bolus or o-positive packed RBCs (i.e. volume-expand)
D. start epinephrine, calcium
E. subxyphoind pericardiocentesis
F. none of the above

I am not trying to trick you - there are no other hidden injuries.

Many thanks, etc.

Caesar Ursic, MD
Santa Fe, USA
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stabbed heart