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Tue Dec 2 17:51:44 GMT 2008

HELLO to the world.     

1.    THIS IS A MAJOR ANNOUNCEMENT
2.    I am happy because the author below agreed with me,  but that does not 
matter.
3.    The author below has been silent for several months  because of an 
advance in his career and a move to a new medical center.

4.   To my knowledge, this is the FIRST coming out in his new  role and new 
position, that Dr. Ron Gross has had in coming back into the world  of 
education, chatting, giving opinions, etc.     
5.   Join me in welcoming Ron Gross back and encouraging him to  express his 
opinions freely, especially if he agrees with those that post, and  more 
especially if he gives reason for his counter opinions.   
6.   That is what this list is all about.

WELCOME RON GROSS.   

In a message dated 12/2/2008 11:39:40 A.M. Central Standard Time,  
Ronald.Gross at bhs.org writes:

As  usual, I have to agree with Ken's entire post.  A pericardial window - in 
 my opinion - should be relegated to one of 2 places: (1) the medical service 
 for the patient with tamponade due to uremic pericardial effusion, or (2) 
the  Smithsonian!

Just my 2 cents!

Ron

-----Original  Message-----
From: trauma-list-bounces at trauma.org  [mailto:trauma-list-bounces at trauma.org] 
On Behalf Of KMATTOX at aol.com
Sent:  Tuesday, December 02, 2008 12:31 PM
To: trauma-list at trauma.org
Subject:  SW to heart EMOTIONS and FACTS

Penetrating wounds to the heart do still  KILL people, most prior to ever
seeing an EMT, emergency physician, or  surgeon.

Some patients present to a facility with clear signs of a  hemopericardium
and cardiac constriction:   Narrowed pulse  pressure, decreased  systolic BP,
distended neck veins,  etc.   These individuals need a  THORACOTOMY with or
without  a confirmatory study.   Currently the FAST  is a good study,  when 
positive.
If the FAST is negative, then  a CT or  echocardiogram might be helpful.
For these  individuals it is foolish  to make an abdominal incision (either in
the ER or in  the OR) as  there is a heart injury that needs fixing from the
chest.    If  you want to do a mediansternotomy or a left   anterolateral
thoracotomy, that is your preference.  In  this  case, I ask the patient to 
Valsalva
and if the pulse goes away,  they  have an OR thoracotomy in just a few 
minutes
later as for me that is  a  positive sign enough.   There are also other
signs,  apprehension,  fecal incontinent,  etc.

Some patients have a  wound somewhere in the methodical box (fine,  that is
OK, I have never  used that term, but you can if you wish), and who   present
"stable".    If this patient has any sign of a   hemopericardium or 
tamponade, then
they fall under the paragraph   above.    If they have a wide pulse pressure,
they  virtually  never have an cardiac injury.   If the FAST is  negative and
you want  to do a CT of the chest or an echocardiogram,  OK, but most of the 
time
it is  totally negative.   I really  see no reason  to do negative tests in
patients who have totally  negative physical  findings and negative history, 
etc.
I  really see no reason to  do a sub xyphoid pericardiotomy in a  patient
with a totally negative FAST,  negative physical exam, and a  VOMIT on the CT
scan with a hint of a suggestion  of a wisp of fluid  in the pericardium, 
with the
FAST showing full contractions  and  relaxations, and NO narrowing of the
pulse pressure.   The   subxyphoid pericardiotomy will always in such a 
patient
yield no  meaningful  results.

The subxyphoid pericardiotomy was developed  prior to the widespread
availability of the FAST and CT of the chest.   It is no longer  needed as a
diagnostic modality.    AND it was never suggested as a  therapeutic modality.

Just for  the record.   I have personally seen and managed as  many or  more
cardiac injuries than most persons on this list, with the   exception of 
about 6
people and you know who you are.   I  have  seen none of those 6 persons
screaming for subxyphoid  pericardiotomy or any  other fancy tests.    It may 
be  a
matter of  experience.

This is not rocket  science.   It is relatively straight  forward.     LOOK AT
THE PATIENT.   Feel their  pulse.      Look at their neck veins.   Look at the
pulse  pressure,   Feel the leg and pedal  pulse.       Talk to the patient,
Do a FAST  or other echocardiogram.     Do a CT if you really  need it.   If
you order an  echo or CT - LOOK AT THE TEST YOURSELF, do  not just look at  
the
report.

Do not make a simple job  hard.

k

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SW to heart EMOTIONS and FACTS - HELLO