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Fri Sep 7 14:45:51 BST 2007

Au contraire.  Any reoperation sucks and I, like
everyone else have "been there", perhaps more than
most.  

But if what you are suggesting is that we choose
between potentially preventing sudden death in a 19
year old patient with HARD proof of a penetrating
cardiac injury or saving a cardiac surgeon a little
extra work when that same patient is forty years older
and needs a four vessel CABG, I'm afraid my answer may
seem a little callous.

My point in this whole string, if I need to be
repetitive is that whoever this person was that was
shot in the left chest and then got a TEE is no better
off and no less sicker than he was before he received
the TEE.  The TEE added nothing to the diagnosis,
added nothing to the treatment, and added nothing to
the outcome.  Because of the morbid nature of the
actually performance of the test, it had the potential
to WORSEN his outcome.

If TEE wasn't available this gentleman, presuming he
didn't have tamponade physiology, a positive
pericardial FAST, or was exanguinating in a way not
easily explained by his mechanism would have been
managed the same way every other GSW to the chest is
managed.  

So I ask again, what was gained with the use of the
TEE?  A "small effusion" was seen.  Is this an ESRD
patient with a uremic effusion?  Is this a cancer
patient with a paraneoplastic effusion?  Do we have
reason to believe that this patient has viral
pericarditis?  The only history I've heard is that
this gentleman was shot in the left chest.  

For me, a "physiologic" amount of fluid is a thin
meniscus between the myocardium and the pericardium. 
More than that, with appropriate mechanism and
suspicion is PATHOLOGIC.  Using TEE in this instance
as I stated earlier is a YES or NO algorithm:  Is
fluid around the heart?  If yes then your test leads
you to operate, PERIOD.  

If your test doesn't have the potential to change the
patient's management, then don't order it.

Ben Reynolds, PA-C
Pittsburgh, PA

--- "Hardcastle, Tim, Dr <tch at sun.ac.za>"
<tch at sun.ac.za> wrote:

> 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'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 :
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2D or 3D TEEin penetrating cardiac injury