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Wed Dec 3 15:08:37 GMT 2008

Fantastic clarity of thought. This is vintage Dr. Mattox and the reason why
I joined this list. Keep 'em coming.

S Muzammil, FRCS

>>> <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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