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Sun Dec 14 13:09:01 GMT 2008

From: McSwain, Norman E Jr. (nmcswai at tulane.edu)  > If I needed a diagnostic procedure in the ED I would do a pericardial sack aspiration...

--> As a non-surgeon and one who has just picked up on this list a vague idea of what this "window" is all about, I don't see it as something I need look at further for my ED (as many others have indicated). So I consider the pericardial aspiration as the only "window" I will be using. I have performed it a number of times in the past, including for trauma.

However, as of a few years ago, I consider and instruct my trainees that it SHOULD NOT be used in the ED as a DIAGNOSTIC PROCEDURE by Emergency Physicians (in the UK, trauma teams are generally led by EPs, with various surgeons among the team's members). We have ultrasound for this purpose. As much as there are so many limitations to ultrasound, ruling out HAEMODYNAMICALLY SIGNIFICANT pericardial collections is one thing it does safer than any needle! Hence DIAGNOSTIC pericardial aspiration is banned if an ultrasound machine is available.

> ...long spinal needle and follow the same procedure as was discussed in the ATLS course several years ago...

--> This is STILL a very useful procedure in the ED, although rarely indicated and, as stated, NOT for diagnosis. I recall giving a lecture to an audience of EM trainees, many of whom were well aware of how UN-enthusiastic I am about FAST. So, when I got on to how to do the procedure (exactly as in ATLS), quite a number put their hands up and said that they were not interested in the skill, as they had ultrasound... I then used a very quick case example to show them how the most they could do about a rapidly-lethal pericardial effusion with an ultrasound machine was to video it killing their patient... Then they listened.

But we have very little penetrating thoracic trauma in the UK, so we don't get much opportunity to stick the needle in...

> opposed to dropping it as an included procedure then and still am

--> On this I am with you 100%. NOT because I think many patients in the UK will suffer if our EPs don't know how to do it, but mainly because I think it is a skill which requires a good understanding of WHAT is going on and the thinking of WHY you are doing something and HOW to interpret what you get - good brain exercises for trauma clinicians. Hence, on the ATLS courses I direct, the skill is still demonstrated and explained in detail and I make sure candidates are tested on their understanding of its principles.

(BTW, for similar reasons, I still ensure DPL is demonstrated on the ATLS course and dealt with in the same detail)

> pericardial aspiration is a therapeutic procedure to be done in the ED while getting the patient to the OR

--> I am with you on this as well.

> As our population drifts back to more knife use since Katrina

--> Why? Did all the guns get water-damaged?

From: kmattox at aol.com  > Most often when blood is obtained during needle aspiration it has come from the right ventricle and at thoracotomy the only hole in the heart was produced by the needle.

--> This scenario is now ELIMINATED by the appropriate use of ultrasound in the ED!To simplify how we go about it:1. If patient is not in shock, unstable, etc, we do CT, so this issue will not arise2. If the patient is not CT-fit (which is VERY VERY RARE for us the way we are set up and with our patient mix), then we'll chase after the bleeds3. AMONG OTHERS, this will include the need to rule out pericardial collections, for which we will use ultrasound first. If there is no significant collection, then no needle goes in4. Only time a needle goes in is when there is shock & too unstable for CT, etc, AND it appears not to be 100% extra-cardiac in cause AND there is a US-VISIBLE SIGNIFICANT collection.5. With such a collection AND with the aid of ultrasound, is it still possible to ding the RV? Sure. But it IS necessary, under the circumstances, to try to prevent PEA... And it won't be the "only hole" ;-)

Since I have had ultrasound, I have only required around 2-3 needles to go in. None have dinged anything as far as I know... As much as I can be negative about the "ultrasound revolution" in the ED, this is one aspect it has helped with!
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