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Wed Dec 3 16:46:40 GMT 2008

I'm going to have to side with Rob on this (sorry Rob).

Ken's near textbook treatise on tamponade not withstanding I'm not sure what relevance it has to Errington's situation.  The choices as I see them are either explore or not explore the pericardium.  

Fact: The patient as presented is stabbed in an anatomic area of the chest which by most accounts is strongly associated with a potential penetrating injury to the heart.

Fact: On presentation he did not have tamponade physiology as eloquently defined by Mattox.

Fact:  He had a 500ml hemothorax in the left chest and a negative FAST of the pericardium. 

The compelling reason to operate isn't for the presence of tamponade, it is to rule out a potentially life threatening injury to the heart in the absence of tamponade.  Those things which are life threatening include uncontrolled hemorrhage and the potential interval development of tamponade.     

There is not a single imaging study, TEE, CT or otherwise which can reliably help you navigate this decision tree under these circumstances successfully.

Ergo, he gets explored or not explored.  If I am to choose, I prefer the left thoracotomy and like many do not believe in the utility of the subxyphoid pericardial window if you are ONLY interested in the heart INDEPENDENT of a laparotomy.  It is a truly pointless procedure and I have seen  many a good surgeon struggle at performing it.  

Errington, in my view did a very defendable thing in observing this patient.  The chest tube only put out 500ml and stopped which in this instance represented bleeding cessation from a wound to the heart (proven in the posthoc analysis after the thoracotomy by his partner).

My opinion reflected a belief that he (in sum) indeed had a mechanism suspicious for penetrating cardiac injury and that EVEN IF the chest tube output stopped it may represent a clot burden over the hole in the pericardium which now predisposes him to eventual tamponade; in my experience an event which happens at exactly 4am when the nurses are all getting coffee and the rest of the surgical house staff are getting ready for rounds and no one is watching the chicken coop.  So until someone builds a reliable crystal ball, at time zero I would choose explore.  

I too have treated many penetrating cardiac injuries and like everyone else experience molds my practice and bias hand in hand with a firm understanding of what the science says about the standard of care in the treatment of this problem.  For my part, sudden death  from acute pericardial tamponade is a phenomenon I have seen and am rightfully fearful of it.  All this being said, I believe it is easier to heal an incision than it is to revive the dead.

My opinion.

Ben Reynolds, PA-C
Pittsburgh, PA

________________________________
From: Robert Smith <rfsmithmd at comcast.net>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Wednesday, December 3, 2008 6:27:07 AM
Subject: RE: SW to heart EMOTIONS and FACTS

Dr. Mattox,

I'm just a guy who worked in a busy trauma center. Of course you have more
experience than me and most everyone else. I'm not screaming for anything,
I'm just trying to understand your thinking on a particular issue.

So. Let's say the patient is a young male who has sustained a single stab
wound to an area you believe may involve the heart. His vital signs are
normal.

Would you get an echo? If not why?

If you would, what action would you take based on the information you get?

For us the results of an echo are basically binary. Either it is stone cold
bone dry negative or it is positive. Is that too simplistic? It is something
that practitioners who are not experts in echocardiography can decide on in
the middle of the night.

Of course a very small amount of blood in the pericardial space is not going
to harm the patient. The problem is that this is an injury that may evolve
over time. Do we disagree that patients with stab wounds to the heart can
present as normal and deteriorate? We have seen them do so abruptly. Do we
disagree on that?

Within the last 8 weeks two patients presented with stab wounds to the heart
that required emergent thoracotomies. One patient in the resuscitation area.
The other patient who was taken care of by a close friend, was said to have
normal vital signs. His echo was apparently markedly abnormal even showing
compromise of the RV. He was taken to the OR. Before the case could be
started, he arrested. Because the attending trauma surgeon was with the
patient, she was able to do an immediate thoracotomy and save the patient.
It is her belief that in this day the surgical residents ( and they agreed )
cannot take this type of action independently.

I admit I forgot to confirm whether the plan was to start with a subxyphoid
window or not, so you can take me to task for that. And I realize I am
anatomically challenged compared to you but I thought the point of doing a
subxyphoid window was to avoid entering the abdomen. On the few I have seen
that was how it was done.

What I'm asking you and Dr. McSwain and Dr. Gross is this. When you see
stable patients with blood in the pericardial space but without physiologic
derangements what do you do with them? 

If you choose to observe them I guess you are confident that you can
intervene in time if they deteriorate. We feel that may be problematic. If
the persons doing the observing cannot intervene in time then the patient
dies, which is why we do the subxyphoid window. This procedure is only
diagnostic in the sense that it is used to see if there is any ongoing
bleeding or if the bleeding has completely stopped. I don't know of any
other test that does that so reliably. This approach does not seem overly
complicated to me and it seems safe for the patient.

Rob Smith

-----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 (which have nothing to do with) the FACTS