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Fri Sep 7 06:05:26 BST 2007

Ben

You have obviously never had to re-open a sternum on a previous sternotomy patient. I know of too many cases of sternal saw to hear in redo's to not want to open a chest unnecessarily.

Echo / Sonar has been shown to be overly sensitive. Only react to an effusion of over 5mm (some people even use 8mm) in the stable patient. If unstable - operate, no question. There is extensive evidence from South Africa and the USA that this is safe and indeed prudent. Echo is often confounded by associated pleural fluid too.

Regards
Tim
Dr T C Hardcastle
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-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Ben Reynolds
Sent: Thursday, September 06, 2007 10:17 PM
To: ih7 at msn.com
Cc: trauma-list at trauma.org
Subject: RE: 2D or 3D TEEin penetrating cardiac injury

I am one of those people who don&#39;t believe in &quot;observation&quot; or &quot;conservative management&quot;  of penetrating wounds to the heart. Seeing blood on echo (whether 2D or whatever) in my mind is the same as a positive pericardial window:  Exploration becomes mandatory.   

Rare is the instance that one loses sleep over a nontherapeutic exploration.

Ben Reynolds, PA-C

IVAN HRONEK wrote: 
> 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> To change your settings or unsubscribe visit:> http://www.trauma.org/index.php?/community/--
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2D or 3D TEEin penetrating cardiac injury