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Wed Dec 3 20:39:26 GMT 2008

This discussion has been a bit long so I already forgot on which side I am, but I think subxyphoid pericardial window does help in some cases: if FAST is undetermined (fat patients, subcutaneous emphysema, etc) and you are still not confident in living patient without further dx workout, a SPW can rule out a cardiac injury before thoracotomy.  I went back to my T-list archives (I have some discussions saved) and found this from 1999 when I was new at that time on the list.  It is from Dr Ferrada from Colombia, hope it helps:

Ruy Cabello-Pasini, MD
Hospital Central Militar
MEXICO

"" I cannot agree with condemming an established surgical procedure out of hand. Subxyphoid Pericardial Window (SPW) is still widely accepted by many physicians. Here is why: 
1. FAST is very reliable when the result is positive, but if negative it does not exclude a cardiac wound. As matter of fact we have had cases, as have many others. Accordingly we use FAST for detecting abdominal and pericardial effusion, but if the test is negative, we do something else.
2. I have had the opportunity of visiting many large hospitals in Latin American countries to give lectures. With a few exeptions, all of them have no ECO machine in the emergency room. This is the real situation in Latin America today.
3. In 1998 in a meeting in Miami we presented one thousand one hundred and one (1101) cases of SPW performed in our institution. Of this number we found 262 (23.8%) positive, which is quite similar to other studies. This means that a patient with a stab or gunshot on the pericardium, who is stable and has no symptoms or signs has a 23-24% chance of a cardiac wound. If you do not have FAST, or the FAST is doubtful, what do you do? Observe? Send your pt home? Perform a thoracotomy? I think a quick and 100% reliable test is SPW. Morbidity is 0.7%, no mortality so far in our experience.
4. Patients arrive to emergency with wounds, and at this moment nobody knows if they have a cardiac injury or not. If the pts with cardiac wounds are isolated, the number with obvious cardiac wounds during first examination is about 54%. The other 46% has a penetrating wound but there are neither symptoms nor signs. That was what we found in 517 cardiac wounds due to pentrating trauma we treated during a 6 year period. Patients with obvious Cardiac Wounds, go directly to a thoracotomy. SPW is not a test for these kind of patients, or those with instability in their vital signs. It is a test for stable pts. with precordial wounds, who potentially have a cardiac injury instead. And the procedure is not designed for managing the cardiac wound. I don’t know if anybody has ever tried, but it would seem like managing a vascular abdominal trauma through a Peritoneal Lavage incision.
	In summary in my opinion ECO FAST avoids many pericardial windows, but it does not replace them. They are complementary, not excluding tests. And in many hospitals in today’s world SPW is the only realistic possibility.

Ricardo Ferrada, Trauma & Burns. University of Valle. Cali, Colombia, South America.""

--- On Wed, 12/3/08, Ben Reynolds <aneurysm_42 at yahoo.com> wrote:

> From: Ben Reynolds <aneurysm_42 at yahoo.com>
> Subject: Re: SW to heart EMOTIONS (which have nothing to do with) the FACTS
> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> Date: Wednesday, December 3, 2008, 4:46 PM
> 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
> 
> 
> **************Life should be easier. So should your
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> AOL.com. 
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> 002)
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SW to heart EMOTIONS (which have nothing to do with) the FACTS