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Thu Sep 6 23:16:57 BST 2007

Ivan,

Well. As you know, in acute trauma, the absence of these signs means little.
Beck's triad is actually present in trauma in only about 15% of patients.
(who could appreciate muffled heart tones). Your patient may be tachycardic
or hypovolemic for a variety of reason. I would absolutely never rule out
tamponade based on the absence of those clinical signs until of course the
patient is hypotensive. And then you're definitely behind the curve if not
the eight ball. And in case you're going to advocate using a CVP line to
"monitor" the patient, I would never do that either. Same thing. Watching,
watching watching, pt. and CVP fine, and then they're not. At the critical
point the pressure goes up abruptly for a small change in volume.

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 5:46 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: 2D or 3D TEEin penetrating cardiac injury

Rob,

don't be dramatic. You would watch the patient for clinical signs of
tamponade : dilated jugular veins, tachycardia and hypotension. Don't tell
me these signs mean nothing to you.

If you're talking about needle pericardiocentesis, then perhaps.
I haven't seen it done for ages, I wonder if cardiologists still do it
anywhere (not here) ?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 17:26:31 -0400> Subject: RE: 2D or 3D TEEin penetrating cardiac injury>
> 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