stabbed heart

[Ronald Gross]

First, the meds may precipitate the patients hypotension.  Second, the positive pressure will increase the intrathoracic pressure, further complicating an already obstructed venous return due to the tamponade.

>>> "Phil Hoffman" <phoffman at charlevoixmfg.com> 5/1/2007 10:05 PM >>>
Dr. Gross,

Why (or perhaps, how) would intubation hasten this patient's crash?

Phil Hoffman
EMTP

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] 
On Behalf Of Ronald Gross
Sent: Tuesday, May 01, 2007 5:57 PM
To: Critical Care mailing list Trauma &amp
Subject: Re: stabbed heart

First off - intubation probably hastened this kid's crash (would have
crashed any way - just sped up the process.
Answer to your question is F!  Pt needs a clamshell thoracotomy with
digital/foley/staple control of cardiac wound.  Then to OR immediately.

>>> "caesar ursic" <cmursic at gmail.com> 5/1/2007 4:51 PM >>>
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
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