stabbed heart

[caesar ursic]

True story:

16 yo previously healthy male stabbed once in anterior chest.  Confused and
combative at scene.  Minimal external blood loss noted.  Paramedics scoop
and run - one antecubital IV, minimal fluid given en route (less than 20
mL), no attempt at intubation.  Eight minute interval from first patient
contact at scene to arrival in ED.

On arrival to ED he's even more combative; very diaphoretic, ashen-colored
lips, cool periphery; carotid pulses not palpable (but he's thrashing about
too much to really tell).  Only obvious external injury is a 3-4 cm stab
wound just to the left of the xyphoid.  Breath sounds are equal.

Patient intubated (rapid sequence orotracheal) within three minutes of
arrival.  FAST shows fluid around heart, no fluid in abdomen.  He's been in
the ED for about four-five minutes.  Now it is clear he has no palpable
pulses.  Cardiac monitor: sinus tachycardia at 150 bpm.  Nobody can feel a
pulse in this thin 16 y.o. boy.

The on-call surgeon is in the room and is trained and willing to open chest,
put in chest tubes, insert a central line, etc. The OR will be ready to take
the patient in 5-10 minutes, but not immediately.

What is the next step?

A. bilateral large bore tube thoracostomies
B. resuscitative left anterolateral thoracotomy (in the ED)
C. fluid bolus or o-positive packed RBCs (i.e. volume-expand)
D. start epinephrine, calcium
E. subxyphoind pericardiocentesis
F. none of the above

I am not trying to trick you - there are no other hidden injuries.

Many thanks, etc.

Caesar Ursic, MD
Santa Fe, USA