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Wed Dec 3 07:43:38 GMT 2008

i think that surface echo is ok for looking for fluid but further evaluation of intracardiac derangement needs more sophisticated imaging, such as TEE or more thorough echocardiography. Repearing a laceration of the cardiac wall is not going to address the intracardiac structures that might have been injured along with the wall.

in the case of the CT that i shared yesterday, the patient underwent repair of a cardiac laceration. postoperative surface echo was read as normal. The postoperative CT was done because of persistent base deficit, and we were most surprised to identify a significant ventriculoseptal defect. A subsequent Echo was suspicious for this finding and the TEE was clearly confirmatory. After repair patient responded quickly. 

i am not advocating CT just yet for these cases. But as the scanners get better at delineating cardiac and coronary structures, CT may be more valuable. 

But as Roentgen said when asked what he thought about the luminescence coming from the barium cyanoplatinum plate when exposed to xrays: "I did not think, i investigated"

sal

-----Original Message-----
From: Errington Thompson <errington at erringtonthompson.com>
To: 'Trauma &amp; Critical Care mailing list' <trauma-list at trauma.org>
Sent: Tue, 2 Dec 2008 11:50 pm
Subject: RE: SW to heart

Now, this is a great question.  Sal, as you and most on this list server
knows TEE was all of the rage in the mid-1990's.  Everyone wanted to learn
how to use the TEE.  We are going to use it for fluid resuscitation and for
other heart and aortic evaluations.  Then that paper from Fabian's group
came out and everyone lost their zeal.  

I think that most trauma surgeons didn't learn how to use a TEE and
therefore we aren't using it.  If we can't get a "good" echo then I "might"
have called in a cardiologist to look at the heart.  Now, since I was taking
this patient to the OR there are a couple of anesthesia guys who do TEE's
for the cardiac surgeon - I might have asked them to take a look.  

I would like to hear your thoughts.

E 

Errington C. Thompson, MD, FACS, FCCM
Trauma/Surgical Critical Care
Radio Talk Host - WPEK 880 AM
Author - Letter to America
Asheville, NC

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of sjasmd at aol.com
Sent: Monday, December 01, 2008 8:56 PM
To: trauma-list at trauma.org
Subject: Re: SW to heart

Would anyone perform a TEE for sw to left ventricle

sal

-----Original Message-----
From: Doc Holiday <drydok at hotmail.com>
To: .Trauma List <trauma-list at trauma.org>
Sent: Mon, 1 Dec 2008 6:00 pm
Subject: RE: SW to heart

From: brombwi1 at memorialhealth.com> My understanding is that a negative FAST
(or 
formal echo) is unreliable in the setting of hemothorax as it is possible
that 
the hemopericardium is decompressing into the chest (as in this case)

--> Again, as a non-surgeon, I cannot take this as far as others. I can only

address a couple of the early management issues.
I think you are correct in what you are thinking about FAST here, but it's
not 
"to blame"... It is NOT SUPPOSED to be reliable in what people seem to be 
expecting it to do (if I mis-read you, please forgive). It is not at all 
supposed to exclude cardiac injury or cardiac bleeding of any intensity or 
timing. It is not a great ruler out of anythi
ng.

Having said that, ultrasound WOULD have a role in my management of this
case, as 
I explain below...

From: Errington Thompson <errington at erringtonthompson.com>> ... a single SW 
inside the cardiac box... hemodynamically stable. CXR...

--> This sort of patient, if I see one, is heading for a CT. Seems stable
enough 
to have it and I can't see us getting away without one. One thing I'd worry 
about, which can APPEAR stable, then deteriorate rapidly, is a pericarial 
EFFUSION, which to my simple mind is a COLLECTION of blood within the sac.
So 
I'd pick up the ultrasound and do a 2-second look at the heart, only looking
for 
a substantial effusion (if it's not there by now, it should stay away for
the 
duration of the CT). I would NOT do a FAST - just look at the heart for an 
effusion and nothing else, as nothing else in the heart of a stable patient
will 
keep me out of CT. The rest of the FAST, in the abdomen, is another thing I 
would skip - if I have ANY questions about the abdomen (quite likely that I 
would with a stab), I'll CT that as well.

Would anyone disagree that
1. Stable patient, thus goes to CT
2. No collection on ultrasound, thus should survive it?

> My FAST was negative for pericardial fluid

--> OK. We're thinking alike. Off to CT...

> The CT was read as a small amount of fluid at t
he apex of the heart

--> OK. My knowledge stops here with this case. Only wanted to comment on
the 
ultrasound use...

But hope it's OK to ask questions...

> Left chest tube 500cc out then nothing. Who would have explored this
patient's 
chest?

--> Please tell me whether I am getting this correctly (sorry for sounding
like 
an amateur)...
- "Something" cardiac is/was bleeding after a stab - Coronary vessel? 
Myocardium? Aortic root?
- 500ml in chest may/not be from that something
- It's stopped now, but we can't tell what "it" was... Despite contrast... 
Possibly because it stopped...

So the question is whether we should sit on it, hoping it stays stopped and 
heals, rather than sticking scal
pels in chest and making a big hole in
patient 
only to find out that OUR hole is the only problem at the end of the whole
thing 
- am I getting the question at least? 'Cause I have no idea which to opt for
- 
sit or cut... I'll watch you surgeons debate that one...

> Next morning the patient's heart rate was 100- 110. BP 120/70. Partner
takes 
the patient to the OR...

--> This one does not make sense to me. YOU had decided (right or wrong) to 
"sit" and watch for trouble. And next morning, voila, trouble is NOT there!
So 
why go to the OR? Why not simply check how much more blood is in the drain &
a 
quick ultrasound of pericardium. If no more bleed AND no collection AND
patient 
evidently stable, keep "sitting". If bleed and/or collection (but patient 
STABLE) then contrast again, as now we do have bleeding so we should be able
to 
see where it's from...

Nice case...
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SW to heart