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Thu Sep 6 22:26:31 BST 2007

No, I do want a window to assess the nature of the fluid. No blood, or
persistently lavages perfectly clear. Fine, I'm good to go. Blood that
doesn't clear, I want my injury repaired. We take penetrating injuries to
the box fairly seriously because what are you going to watch for? Arrest? As
you point out, the curve on the pressure volume relationship beneath a young
taut pericardium is pretty steep.

Rob 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of IVAN HRONEK
Sent: Thursday, September 06, 2007 5:15 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: 2D or 3D TEEin penetrating cardiac injury

Rob,

don't tell me you want a thoracotomy with a pericardial window for a
physiological pericardial effusion,
I just don't believe that.

I think this is the hard part where the surgeon has to be gentle..and do a
little of medical management..

And also: the presence of a small amount of pericardial effusion without any
other clinical signs of 
tamponade I do not think is an indication for a thoracotomy.Ivan Hronek
MDChief, Critical Care & Trauma AnesthesiaSFMC Gas, Inc.St. Francis Medical
Center3630 E. Imperial HighwayLynwood, CA 90262 Cell: 310 487-3288Pager: 310
636-6020

> From: rfsmithmd at comcast.net> To: trauma-list at trauma.org> Date: Thu, 6 Sep
2007 17:04:02 -0400> Subject: RE: 2D or 3D TEEin penetrating cardiac injury>
> Well if a big shard of glass or piece of metal somehow managed to pierce
my> chest in the area of the box, I'd feel great about being worked up and>
getting a window at least. We wouldn't echo unless penetrating injury. And>
I'm not tough (total wimp), weathered (just aging), or a surgeon (you don't>
even want to know), lol.> > Rob Smith> > -----Original Message-----> From:
trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]> On
Behalf Of IVAN HRONEK> Sent: Thursday, September 06, 2007 4:54 PM> To:
Trauma &amp; Critical Care mailing list> Subject: RE: 2D or 3D TEEin
penetrating cardiac injury> > ok, you guys are tough weathered surgeons I
understand...> However...a small amount of pericardial effusin is present in
a ceertain> percentage of normal people, perhaps you have some.> How are you
going to feel if you have a small (or medium-sized)> fender-bender and your
trauma surgeons opens your chest and pericardium for> your physiological
pericardial effusion ?Ivan Hronek MD Chief, Critical Care> & Trauma
AnesthesiaSFMC Gas, Inc.St. Francis Medical Center3630 E. Imperial>
HighwayLynwood, CA 90262 Cell: 310 487-3288Pager: 310 636-6020> > > > >
From: rfsmithmd at comcast.net> To: trauma-list at trauma.org> Date: Thu, 6 Sep>
2007 16:44:36 -0400> Subject: RE: 2D or 3D TEEin penetrating cardiac
injury>> > Ivan,> > I was just skimming your post and noticed the "even
small amounts> of> fluid... etc." so I figured you would intervene for same.
A long long> time> ago in a hospital far away, the cardiologist would
sometimes say> "Echo> positive only for small amount of physiologic fluid."
Then one of> those> patients fell over while having a bowel movement because
he had> tamponade.> Since then all penetrating injuries to the "box" gets an
echo> ANY fluid> requires surgical intervention. This approach has proven>
beneficial many> times.> > Rob Smith> > -----Original Message-----> From:>
trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]> On>
Behalf Of IVAN HRONEK> Sent: Thursday, September 06, 2007 2:49 PM> To:>
Trauma &amp; Critical Care mailing list> Subject: 2D or 3D TEEin
penetrating> cardiac injury> > Matt,> > obviously, you know 2D TEE is best,
and now 3D> TEE is becoming available.> We recently found a small
pericardial effusion> in a GSW to L chest - > I advised to watch the patient
as the etiology of> the effusion obviously at> that one instance of
examination wasn't clear.>> As you know acute pericardial tamponade can
happen even with small volumes>> of effusion as the peridcardium hasn't been
"stretched" by a slowly>> accumulating effusion.> > What are people's
experiences with tamponade - I> am sure there are millions> of horrendous
stories....> > Anybody has a> better way than just watching the patient ?>
Ivan Hronek MDChief, Critical> Care & Trauma AnesthesiaSFMC Gas, Inc.> > > >
> Date: Thu, 6 Sep 2007> 19:35:45 +0100> From: mgreeds at reeds.uk.com> To:>
trauma-list at trauma.org>> Subject: ECG in penetrating cardiac injury> >>
Sa'ad,> > I once questioned> the role of ECGs in demonstrating penentrating>
cardiac > injury.> Unfortunately, I never got round to conducting a full>
review of > the> literature but I have cited a few articles below which I >>
provisionally> found some time ago.> > I am not aware of any significantly>
powered and> properly conducted > studies to demonstrate the effectiveness
of> ECGs (I> would nevertheless be > keen to hear from others on the list
who> have any> enlightening data > either way.) My belief is that it does
not have> any> real role as there > have been a number of penetrating
cardiac injuries>> documented which do > not demonstrate any ECG changes and
would have been>> missed if relied upon > as a single diagnostic test.> > >
Absence of>> hemodynamic and ECG changes in a patient with traumatic left >
ventricular>> injury and puncture of the left anterior descending branch. >
Südkamp M,>> Geissler HJ, de Vivie ER. Thorac Cardiovasc Surg. 2000 Dec;48>
(6):373-5.>> >> Penetrating cardiac trauma: follow-up study including >>
electrocardiography,> echocardiography, and functional test. Duque HA, >>
Florez LE, Moreno A,> Jurado H, Jaramillo CJ, Restrepo MC. World J Surg. >>
1999 Dec;23(12):1254-7.> (About post-operative monitoring NOT diagnostics)>>
> Dysrhythymia from an> intrapericardial air gun pellet: a case report. >>
Willemsen P, Kuo J, Azzu> A. Eur J Cardiothorac Surg. 1996;10(6):461-2. >>
(Anecdotal case.)> > > The> literature mostly refers to echocardiography>
being a much more useful > test> (greater sensitivity and specificity.)>
Although the last publication > above> refers to ECG changes being better
at> diagnosing penetrating > cardiac> injury in that particular case than>
echocardiography.> > I feel that nothing> can compare to appropriate>
histroy, examination of > the patient, mechanism> of injury (e.g. knife
stab> wound to anterior chest > = high probability of> cardiac injury until
proved> otherwised etc.) and > echo/FAST etc. are more> appropriate in
making a> proper diagnosis.> > > Matthew> > --> trauma-list :> TRAUMA.ORG>
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2D or 3D TEEin penetrating cardiac injury