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Wed May 2 23:08:07 BST 2007

Absolutely correct. If you look at published series stab wounds to the
heart, the hemopericardium is clotted in up to 60%!

Pat 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Ronald Gross
Sent: Wednesday, May 02, 2007 4:55 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: stabbed heart

There is a big difference between a chronic (bloody) pericardial
effusion and blood in the pericardium due to trauma.

>>> "Steven P. Rogers, RN" <rogers3 at socal.rr.com> 5/2/2007 2:51 AM >>>
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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