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Tue Dec 2 13:43:25 GMT 2008

To view the other side. The heart is like any other vessel. If it has stopped bleeding there is no reason to fix it because there is nothing to fix. Like any other part of the body (almost). Operate if there are hard signs or other significant indications. Carter Nance taught us in 1969 that all stab wounds do not need an operation. Yes he was reporting on the abdomen but the same logic applies.

Norman

Norman McSwain Jr, MD FACS
Trauma Director Charity Hospital
Professor of Surgery
Tulane University School of Medicine
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Ben Reynolds
Sent: Monday, December 01, 2008 12:47 PM
To: Trauma &amp; Critical Care mailing list
Subject: Re: SW to heart

E:

For my own part, I would have advocated exploration after the chest tube put out 500ml, NOT the next morning as your partner did.

Why?

A stab wound within the anatomic boundaries of the box if deep enough is highly SPECIFIC for cardiac injury and less likely, pleural injury.  The question then is where did the blood in the left chest come from?  If your clinical suspicion is that this is a noncardiac injury and likely something from the chest wall or noncardiac adjacent structure, I would assume other stigmata on the CT scan (small pneumothorax, air tracking into the pleural cavity and not near the heart, lung contusion etc).  That said, I assume the CT was with contrast to evaluate for possible extrapercardial great vessel injury.  You looked at the CT, not me.

If, on the other hand you can envision a situation where the stab wound may have injured the heart then rented the left pericardium and the blood is decompressing into the hemithorax, then you may have a situation which requires an operation forthwith.  I have seen this happen in exactly the scenario you have described for us, but only for ongoing blood loss through the chest tube as the patient never accumulated a large enough pericardial effusion to manifest tamponade physiology.

All that being said, he passed, in my opinion successful test of time and did well with just observation and watchful waiting indicating that he would have probably did well with continued observation.  If you ask me AT BEST (I say that because it is just as defendable to not image this poor guy further if he has no other symptoms) a formal echo was indicated not a operation that next morning. 

My opinion.

Season's Greetings.

Ben Reynolds, PA-C
Pittsburgh, PA    

________________________________
From: Errington Thompson <errington at erringtonthompson.com>
To: Trauma International emailing list <trauma-list at trauma.org>
Sent: Monday, December 1, 2008 6:56:43 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