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Tue Dec 2 21:02:32 GMT 2008

I partially agree with Ken but not totally. I agree that a subxiphoid
window is not of diagnostic benefit. However I do a subxiphoid window
prior to the induction of general to prevent a cardiac arrest secondary
to the decreased cardiac return associated with the drugs of the
anesthesia. In my mind this is a therapeutic not diagnostic maneuver. It
is the first step in the thoracotomy for cardiac tamponade. It is NOT
done in isolation

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 KMATTOX at aol.com
Sent: Tuesday, December 02, 2008 11:31 AM
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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