List Archives

Tue Dec 2 15:51:31 GMT 2008

This is very true. Eric Frykberg has certainly been a proponent of this.
However when has it stopped is the question. If almost any vessel was
thought to have stopped bleeding but then bleeds another 100-150cc no one
would care. That would need be true if it bled into the pericardial
potential space.

Rob Smith

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of McSwain, Norman E Jr.
Sent: Tuesday, December 02, 2008 8:43 AM
To: Trauma &amp; Critical Care mailing list
Subject: RE: SW to heart

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 

--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

List Archives

For your convenience, find the Trauma List Archive Below

SW to heart