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Tue Dec 2 21:26:52 GMT 2008

Thoracotomy.  
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-----Original Message-----
From: "William Bromberg" <brombwi1 at memorialhealth.com>

Date: Tue, 02 Dec 2008 14:45:14 
To: <trauma-list at trauma.org>
Subject: Re: SW to heart EMOTIONS and FACTS

So I remain confused -- to recap -- stable patient, "negative" FAST (but not useful because of presence of hemothorax), CT shows pericardial fluid but this is called "physiologic" tries to die the next day because of a missed cardiac injury and the argument is that because  FAST, chest CT, and physical exam is so good  you don't need to do a cardiac window.

So a couple of questions?

1. Where did the original poster make a mistake then? 
2. Or is the occasional emergent surgery to fix a life-threatening missed injury an acceptable outcome to avoid unnecessary pericardial windows?
3. Is a negative FAST in the presence of hemothorax actually negative?
4. Is the physical exam done by a surgeon that sees maybe 1-2 mediastinal stab wounds a year accurate enough to give them the same answers that Dr. Mattox can obtain?

>>> <KMATTOX at aol.com> 12/2/2008 12:31 PM >>>
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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