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Mon Dec 1 22:13:33 GMT 2008

What year were those abstracts?  Were they published?  

I like the algorithm.

E

Errington C. Thompson, MD
Trauma/Surgical Critical Care
Talk Show Host - WPEK
www.whereistheoutrage.net
Asheville, NC

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Robert Smith
Sent: Monday, December 01, 2008 11:37 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: SW to heart

Ok. The last time we had this discussion I'm not sure how productive it was.
But I'm totally sober now, so we'll try again.

I'll try to set down what we down at our institution and why, to the best of
my knowledge. All errors are mine and not the people actually doing the
work. Dr. Mattox, when you disagree with aspects of our approach, if you
could explain why you would do things differently in as much detail as
possible that would help.

Background: As a large urban trauma center, we see a reasonable amount of
penetrating cardiac trauma. Back in the day we had some patients who were
felt to be stable and had echos that showed minimal or "physiologic" fluid
who collapsed on the ward or in the ICU from tamponade. These experiences
prompted our current approach.

Work up for penetrating injuries to the anterior box. The box is three
dimensional and is defined anteriorly by the sterna notch, across the
superior border to the nipple lines, down to the costal margin and across
the epigastrium. 

If the injury is felt to be trans-mediastinal, the aerodigestive tract and
great vessels are evaluated. For SW to the anterior box, patients would get
a CXR looking for air in the mediastinum or pleural cavity or fluid in the
chest. 

All patients get an echo performed by the on-call cardiology fellow if
possible. If the echo showed any fluid the patient would get a sub xyphoid
window to look for blood. 

If there was no blood nothing further was done. 

If there was blood but it cleared with lavage, the pericardial sac would be
closed and a drain placed until there was no output. 

If the blood did not clear, the heart would be explored for injury through a
sternotomy if the patient was stable enough.

I have attached two abstracts that describe our experience to some
extent.Let me know if you can't open the attachments.

So Errington, yes we would have done a window initially and if the blood
cleared, not proceeded to a sternotomy.

Rob Smith

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of kmattox at aol.com
Sent: Monday, December 01, 2008 8:17 AM
To: Trauma &amp; Critical Care mailing list
Subject: Re: SW to heart

I would hAve NOT explored the cheSt
------Original Message------
From: Errington Thompson
Sender: trauma-list-bounces at trauma.org
To: Trauma International emailing list
ReplyTo: Trauma &amp; Critical Care mailing list
Sent: Dec 1, 2008 5:56 AM
Subject: SW to heart

Question - I had a gentleman who tried to end it all the other night.  He
had a SW (slash) to the neck and a single SW inside the cardiac box.  The
patient was hemodynamically stable.  CXR revealed a left effusion.  I did a
FAST in the ER then I CT of the chest with contrast.  My FAST was negative
for pericardial fluid.  The CT was read as a small amount of fluid at the
apex of the heart.  I took the patient to the OR and explored the neck
wound.  Left chest tube 500cc out then nothing.  Who would have explored
this patient's chest?  

Next morning the patient's heart rate was 100- 110.  BP 120/70.  Partner
takes the patient to the OR for a pericardial window.  It is positive.
Cardiac surgery finds a non-bleeding laceration to the left ventricle.  Who
would have taken this patient to the OR?

Thoughts?

Errington C. Thompson, MD, FACS, FCCM

Trauma/Surgical Critical Care

Talk Show Host - WPEK 880 AM

Asheville, NC 

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SW to heart