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Tue Dec 2 02:05:24 GMT 2008

ken

Attached find an image that shows value of CT of the chest. This one was performed after repair of a stab wound of the right ventricle was repaired and patient's base deficit did not clear.

sal

-----Original Message-----
From: kmattox at aol.com
To: Trauma &amp; Critical Care mailing list <trauma-list at trauma.org>
Sent: Mon, 1 Dec 2008 6:09 pm
Subject: Re: SW to heart

The further along I get, the less I gain forn any CT of the chest in the acute 
evalusyion of chest injury, except for trajectory.    Otherwise the chest x ray 
tells me everything I gaiN from CT.   

K
Sent via BlackBerry by AT&T

-----Original Message-----
From: Doc Holiday <drydok at hotmail.com>

Date: Mon, 1 Dec 2008 23:00:07 
To: .Trauma List<trauma-list at trauma.org>
Subject: RE: SW to heart

From: brombwi1 at memorialhealth.com> My understanding is that a negative FAST (or 
formal echo) is unreliable in the setting of hemothorax as it is possible that 
the hemopericardium is decompressing into the chest (as in this case)

--> Again, as a non-surgeon, I cannot take this as far as others. I can only 
address a couple of the early management issues.
I think you are correct in what you are thinking about FAST here, but it's not 
"to blame"... It is NOT SUPPOSED to be reliable in what people seem to be 
expecting it to do (if I mis-read you, please forgive). It is not at all 
supposed to exclude cardiac injury or cardiac bleeding of any intensity or 
timing. It is not a great ruler out of anything.

Having said that, ultrasound WOULD have a role in my management of this case, as 
I explain below...

From: Errington Thompson <errington at erringtonthompson.com>> ... a single SW 
inside the cardiac box... hemodynamically stable. CXR...

--> This sort of patient, if I see one, is heading for a CT. Seems stable enough 
to have it and I can't see us getting away without one. One thing I'd worry 
about, which can APPEAR stable, then deteriorate rapidly, is a pericarial 
EFFUSION, which to my simple mind is a COLLECTION of blood within the sac. So 
I'd pick up the ultrasound and do a 2-second look at the heart, only looking for 
a substantial effusion (if it's not there by now, it should stay away for the 
duration of the CT). I would NOT do a FAST - just look at the heart for an 
effusion and nothing else, as nothing else in the heart of a stable patient will 
keep me out of CT. The rest of the FAST, in the abdomen, is 
another thing I 
would skip - if I have ANY questions about the abdomen (quite likely that I 
would with a stab), I'll CT that as well.

Would anyone disagree that
1. Stable patient, thus goes to CT
2. No collection on ultrasound, thus should survive it?

> My FAST was negative for pericardial fluid

--> OK. We're thinking alike. Off to CT...

> The CT was read as a small amount of fluid at the apex of the heart

--> OK. My knowledge stops here with this case. Only wanted to comment on the 
ultrasound use...

But hope it's OK to ask questions...

> Left chest tube 500cc out then nothing. Who would have explored this patient's 
chest?

--> Please tell me whether I am getting this correctly (sorry for sounding like 
an amateur)...
- "Something" cardiac is/was bleeding after a stab - Coronary vessel? 
Myocardium? Aortic root?
- 500ml in chest may/not be from that something
- It's stopped now, but we can't tell what "it" was... Despite contrast... 
Possibly because it stopped...

So the question is whether we should sit on it, hoping it stays stopped and 
heals, rather than sticking scalpels in chest and making a big hole in patient 
only to find out that OUR hole is the only problem at the end of the whole thing 
- am I getting the question at least? 'Cause I have no idea which to opt for - 
sit or cut... I'll watch you surgeons debate that one...

> Next morning the patient's heart rate was 100- 110. BP 120/70. Partner takes 
the patient to the OR...

--> This one does not make sense to me. YOU had decided (right or wrong) to 
"sit" and watch for trouble. And next morning, voila, trouble is NOT there! So 
why go to the OR? Why not simply check how much more blood is in the drain & a 
quick ultrasound of pericardium. If no more bleed AND no collection AND patient 
evidently stable, keep "sitting". If bleed and/or collection (but patient 
STABLE) then contrast again, as now we do have bleeding so we should be able to 
see where it's from...

Nice case...
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