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Fri Sep 7 13:37:58 BST 2007

Tim,

I'd be very interested to see that literature that defines what thickness of
effusion on FAST or ECHO that is safe to observe. The study designs would
especially interest me. I've heard that only about 15% of the young
population has physiologic fluid. If you're taking the Eric Frykberg
approach that many things we can "see" on images will heal just fine without
intervention; even if there really is an injury that is being "seen", that's
a different question. But in general I think people would be less
comfortable observing a true cardiac injury than a peripheral vascular
injury. There does seem to be a trend to observe more and more things that
used to require operative intervention. Maybe early surgical intervention
for GSW abdomens is not what should be done. It's just that the time to
catastrophic outcome for tamponade can be so short and definitive.

Rob

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Hardcastle, Tim, Dr <tch at sun.ac.za>
Sent: Friday, September 07, 2007 1:05 AM
To: Trauma &amp; Critical Care mailing list
Subject: RE: 2D or 3D TEEin penetrating cardiac injury

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
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
M.Med (Emergency Medicine) Executive Committee member
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Division of Surgery (General) Room 4064
Department of Surgical Sciences
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

-----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> > -->
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2D or 3D TEEin penetrating cardiac injury