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Mon Dec 8 12:31:01 GMT 2008

"7) As soon as the sack in opened, general anesthesia in introduced,
8) the patient is intubated,
9) The chest is quickly opened "

I think Dr. McSwain has captured the essential piece of the window should it ever be used in clinical situations: to keep a patient in extremis with a known penetrating injury to the heart alive long enough to be able to anesthetize and crack the chest.  Frequently these patients manage to keep a barely sustainable SBP until the induction of anesthesia drops their SBP to nothing - and you've just lost the ball game unless you are prepared to do something really really fast!

Best to all,
Ron

________________________________
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of McSwain, Norman E Jr.
Sent: Saturday, December 06, 2008 3:19 PM
To: Trauma &amp
Subject: RE: SW to heart EMOTIONS (which have nothing to do with) the FACTS

I have stated what I believe to be the indications.

It is an operative procedure should be done in the operating room when the diagnosis of a compartment syndrome of the pericardial compartment (pericardial tampande) is strongly suspected. The goal is to relieve the tampanade while general anesthesia is introduced. This is to prevent cardiac arrest secondary to vasodilatation and the inability of the heart to increase the cardiac output to compensate for this vasodilatation.

The procedure is:
1) local anesthesia
2) vertical incision to the left of the xiphoid and down to but not through the lina alba under local anesthesia.
3) dissection is carried cephlad,  staying just posterior to the xiphoid and sternum into the mediastinum.
4) the pericardial sack in visualized,
5) grasped ( I use an Allis clamp)
6) opened with the Mitzimbalm scissors.
7) As soon as the sack in opened, general anesthesia in introduced,
8) the patient is intubated,
9) The chest is quickly opened
10) the source of the hemorrhage from the heart is controlled

I hope that this helps

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 Doc Holiday
Sent: Sat 12/6/2008 10:50 AM
To: .Trauma List
Subject: SW to heart EMOTIONS (which have nothing to do with) the FACTS

Before anyone else loses cognitive function, I was hoping to ask the list a question about this thread.

As much as I initially tried to ignore this thread and then gave up and tried to get involved and then tried to avoid it again, here I am back in...

I hope I am asking for something simple...

Could someone explain (or cut & paste an explanation) about this "xyphoid window" to me - someone who has never seen it being done and admits to knowing nothing useful about it. I'd like to know what it is, how (in basic detail) it is done, what it is useful for and what it is not useful for.

I can tell already that there will not be 100% agreement on the indications, but I am sure I will learn from both sides. The main problem I have with the current thread is that it is difficult for me to extract the details I need out of the "debate" which has developed.

Never mind whether CT is better or ultrasound faster than it - please assume for the sake of teaching me that it is still worth telling...

Thanks in advance,
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SW to heart EMOTIONS (which have nothing to do with) the FACTS