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Thu Dec 4 13:43:59 GMT 2008

Dr. McSwain,

Thank  you for sticking with this. My questions ARE IN CAPS. Dr. Mattox must
be too busy right now to answer my questions. Your previous post about
treating complications from negative thoracotomies made my point for me. We
basically do not have negative thoracotomies from this type of injury. 

1)Because we first do a sub-xyphoid window (which does not enter the
abdomen). 

2)We feel a subxyphoid window answers the question - is there any ongoing
bleeding into the pericardial space. An echo answers the question - is there
fluid in the pericardial space. DO YOU DISAGREE WITH THIS? If so why?

3)It is hard for me personally to imagine doing this to reliably answer the
question, is there ongoing bleeding. As Dr. Mattox has often said,
pericardiocentesis is often hit or miss and not often efficacious. At best
could see withdrawing some fluid once. I know in ATLS we used to say put in
a catheter with a stop cock. I've never done that or seen it done so I can't
comment on how reliable it is. IS THIS HOW YOU WOULD ANSWER THE QUESTION OF
ONGOING BLEEDING?

4), 5) Agreed

6) THIS IS MY MAIN QUESTION. I don't want to put words in anyone's mouth but
I get the idea that you and Dr. Mattox would advocate close observation for
patients who have fluid in the pericardial space and normal vital signs
after penetrating trauma to the heart. IS THAT CORRECT?

As I said before because of untoward events with this approach in some
cases, we no longer use that approach. We feel the time between small
changes in vital signs and collapse can be small. DO YOU DISAGREE WITH THIS?

I have tried to be respectful in my questions and comments. It is a
wonderful privilege that we get to discuss issues with yoursef and Dr.
Mattox in particular. If you guys want to say that I personally am an
ignorant slut who will never understand anything about trauma management
because I'm not a trauma surgeon, I'm fine with that. Then all I ask is that
you explain the errors in my thinking rather that say "this should never be
done". (And I appreciate you taking the time to set out your specific
approach and reasoning) However why posters would want to ridicule the
thoughtful and well reasoned approach of one of the oldest and most esteemed
trauma units in the country is not clear to me.

I don't know if it is scientifically feasible, but perhaps since there are
such "emotionally" fraught differences in thought on this subject, we could
compare approaches and outcomes.

Rob Smith

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of McSwain, Norman E Jr.
Sent: Wednesday, December 03, 2008 11:30 PM
To: Trauma &amp; Trauma &amp; Critical Care mailing list
Subject: RE: SW to heart EMOTIONS (which have nothing to do with) the FACTS

Sorry if I have misstated my position. Let me try again

1) the subxiphoid approach is NOT a diagnostic approach but a therapudic
procedure to decompress the pericardial sack BEFORE the institution of
general anesthesia. It is done under local anesthesia with the
anesthiologist ready to administer the appropriate drugs and do an immediate
intubation as soon as the pressure in the pericardial sack is relieved. The
patient is already prepped and draped for an immediate thoracotomy to sew up
the hole in the heart quickly. The indications for this procedure is
suspected pericardial tampanade when the clinical condition (signs and
symptoms) exist

2) If I needed a diagnostic procedure in the ED I would do a pericardial
sack aspiration. 

3) I would use a long spinal needle and follow the same procedure as was
discussed in the ATLS course several years ago I was opposed to dropping it
as an included procedure then and still am. I believe that there are
indications for it

4) I also believe that the pericardial aspiration is a therapeutic procedure
to be done in the ED while getting the patient to the OR. 

5) I would NOT do a subxiphoid open approach in the ED for therapeutic or
diagnostic reasons. 

6) In the case under discussion ( as I remember the original presentation)
stab wound in proximity of the heart, Chest tube with 500 cc of blood, vital
signs NOT indicative of a pericardial tampanade, negative FAST, small amount
of fluid noted on the CT, and no hard signs of pericardial tampanade----- I
would observe the patient closely with physical examination, cardiac
assessment for pulse pressure, development of other hard signs, repeat FAST.
Quickly to the OR if indications became apparent. Continued observation if
no signs.

As our population drifts back to more knife use since Katrina, We have seen
several of these type patients in the last year or so. I have not managed
them all nor have I directed them all but I have been directly involved in
some. The approach that I outlined is the approach that we use.

7) I do not believe these are enough indications to try to talk a patient
into a thoracotomy with the associated complications and to get an informed
consent. I would also not do it under these conditions as an 'emergency'
without an informed consent.

I hope I have cleared up my views and biases

Norman

Norman McSwain MD
Trauma Director, Charity Hospital
Professor of Surgery, Tulane University
New Orleans LA
504 988 5111
norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu> 

________________________________

From: trauma-list-bounces at trauma.org on behalf of Ben Reynolds
Sent: Wed 12/3/2008 9:46 PM
To: Trauma &amp; Critical Care mailing list
Subject: Re: SW to heart EMOTIONS (which have nothing to do with) the FACTS

Yes, Norm I think we can all agree that the risks and benefits must be
sufficiently weighed and explained to the patient.  And yes, I too have
treated complications of thoracotomy.   My memory is imperfect, but I can't
recall many thoracotomy complications in the young barrio warrior population
which makes up the bulk of this penetrating injury population as opposed to
the COPDers and smoking vasculopaths whose poor protoplasm lends to poor
healing.

But ultimately it's all a matter of what you believe.  If you believe that
approaching a problem of the heart is best achieved by an incision through
the abdomen then have at it.  You clearly are comfortable with this approach
and you should continue doing what you feel serves your ends best.  You are
a master surgeon, Norm.  No one will doubt that.

A small anterior thoracotomy affords many advantages over the subxiphoid
approach both for exposure and therapy should that become indicated in a
fashion delivered more rapidly with a simple stroke of the knife instead of
the uncertainty of whether a sternal saw is available, present, functioning
correctly, assembled correctly, are the batteries charged or nitrogen power
is in the room or plugged in or any of the other hundred 'maybes' that
accompany the sketchy logistics of performing the occasional median
sternotomy at 3am.   

Again, my opinion.

Ben Reynolds, PA-C
Pittsburgh, PA

________________________________
From: "McSwain, Norman E Jr." <nmcswai at tulane.edu>
To: trauma-list at trauma.org
Sent: Wednesday, December 3, 2008 4:07:50 PM
Subject: Re: SW to heart EMOTIONS (which have nothing to do with) the FACTS

Question

How many complications of negative thoracotomy have you treated? They are
far greater than those for negative. lapratomy and neck exploration.

When advising an operation one MUST consider the risks and benefits and be
able to discuss them with the patient prior to the patient signing the
INFORMED CONSENT.
I for one would have difficulty justifying to the patient a thoracotony
based on proximity,  500 cc of blood loss from a chest tube, a negative
FAST, a ??? CT and NO HARD signs of a pericardial tampanade.

I believe observation to be the correct management
Typed by the thumbs of
Norman on his BlackBerry

Norman McSwain, MD
Tulane Univ Surgery
504 988-5111

----- Original Message -----
From: trauma-list-bounces at trauma.org <trauma-list-bounces at trauma.org>
To: Trauma &amp; Critical Care mailing list <trauma-list at trauma.org>
Sent: Wed Dec 03 10:46:40 2008
Subject: Re: SW to heart EMOTIONS (which have nothing to do with) the FACTS

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