2D or 3D TEEin penetrating cardiac injury

Fri Sep 7 02:57:17 BST 2007

Ivan,

That's what I was trying to say if I was unclear. I would do an ECHO and if
it was positive than proceed to a window, unless the patient was sick. If he
was sick then he needs an intervention that will allow you to repair his
injury.

Rob

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of IVAN HRONEK
Sent: Thursday, September 06, 2007 9:49 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: 2D or 3D TEEin penetrating cardiac injury

I agree the CVP is useless here.
I also agree with you Rob, that if the patient is tachycardic, hypotensive
etc. then the decision making is different.
If you don't have a good reason for the hypotension, then you have to look
at the effusion as a possibility. But that's where the ECHO helps you - it
will tell you if there is collapse of the right atrium first during
diastoly, then right ventricle and eventually the left side as well also
during systloy. There is really no other way to diagnose it so well. Don't
tell me you will just do a window without looking in a patient who is
moderately symptomatic.

Of course, there are other times, when the patient is really sick and you do
a thoracotomy right away in the ER.

However, your response must be graded and appropriate to the particular
situation. I understand these situations are extra attractive, when you save
the life of a patient with a brilliant superfast procedure. However, you
can't just cut open everybody because you have been trained how to do that.

Ours was an asymptomatic patient.Ivan Hronek MDChief, Critical Care & Trauma
AnesthesiaSFMC Gas, Inc.St. Francis Medical Center3630 E. Imperial
HighwayLynwood, CA 90262 Cell: 310 487-3288Pager: 310 636-6020

> From: rfsmithmd at comcast.net> To: trauma-list at trauma.org> Date: Thu, 6 Sep
2007 18:16:57 -0400> Subject: RE: 2D or 3D TEEin penetrating cardiac injury>
> Ivan,> > Well. As you know, in acute trauma, the absence of these signs
means little.> Beck's triad is actually present in trauma in only about 15%
of patients.> (who could appreciate muffled heart tones). Your patient may
be tachycardic> or hypovolemic for a variety of reason. I would absolutely
never rule out> tamponade based on the absence of those clinical signs until
of course the> patient is hypotensive. And then you're definitely behind the
curve if not> the eight ball. And in case you're going to advocate using a
CVP line to> "monitor" the patient, I would never do that either. Same
thing. Watching,> watching watching, pt. and CVP fine, and then they're not.
At the critical> point the pressure goes up abruptly for a small change in
volume.> > Rob> > -----Original Message-----> From:
trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]> On
Behalf Of IVAN HRONEK> Sent: Thursday, September 06, 2007 5:46 PM> To:
Trauma &amp; Critical Care mailing list> Subject: RE: 2D or 3D TEEin
penetrating cardiac injury> > Rob,> > don't be dramatic. You would watch the
patient for clinical signs of> tamponade : dilated jugular veins,
tachycardia and hypotension. Don't tell> me these signs mean nothing to
you.> > If you're talking about needle pericardiocentesis, then perhaps.> I
haven't seen it done for ages, I wonder if cardiologists still do it>
anywhere (not here) ?Ivan Hronek MDChief, Critical Care & Trauma>
AnesthesiaSFMC Gas, Inc.St. Francis Medical Center3630 E. Imperial>
HighwayLynwood, CA 90262 Cell: 310 487-3288Pager: 310 636-6020> > > > >
From: rfsmithmd at comcast.net> To: trauma-list at trauma.org> Date: Thu, 6 Sep>
2007 17:26:31 -0400> Subject: RE: 2D or 3D TEEin penetrating cardiac
injury>> > No, I do want a window to assess the nature of the fluid. No
blood, or>> persistently lavages perfectly clear. Fine, I'm good to go.
Blood that>> doesn't clear, I want my injury repaired. We take penetrating
injuries to>> the box fairly seriously because what are you going to watch
for? Arrest?> As> you point out, the curve on the pressure volume
relationship beneath a> young> taut pericardium is pretty steep.> > Rob > >
-----Original> Message-----> From: trauma-list-bounces at trauma.org>
[mailto:trauma-list-bounces at trauma.org]> On Behalf Of IVAN HRONEK> Sent:>
Thursday, September 06, 2007 5:15 PM> To: Trauma &amp; Critical Care
mailing> list> Subject: RE: 2D or 3D TEEin penetrating cardiac injury> >
Rob,> >> don't tell me you want a thoracotomy with a pericardial window for
a>> physiological pericardial effusion,> I just don't believe that.> > I
think> this is the hard part where the surgeon has to be gentle..and do a>
little> of medical management..> > And also: the presence of a small amount
of> pericardial effusion without any> other clinical signs of > tamponade I
do> not think is an indication for a thoracotomy.Ivan Hronek> MDChief,
Critical> Care & Trauma AnesthesiaSFMC Gas, Inc.St. Francis Medical>
Center3630 E.> Imperial HighwayLynwood, CA 90262 Cell: 310 487-3288Pager:
310> 636-6020> >> > > > From: rfsmithmd at comcast.net> To:
trauma-list at trauma.org> Date: Thu, 6> Sep> 2007 17:04:02 -0400> Subject: RE:
2D or 3D TEEin penetrating cardiac> injury>> > Well if a big shard of glass
or piece of metal somehow managed to> pierce> my> chest in the area of the
box, I'd feel great about being worked> up and>> getting a window at least.
We wouldn't echo unless penetrating> injury. And>> I'm not tough (total
wimp), weathered (just aging), or a> surgeon (you don't>> even want to
know), lol.> > Rob Smith> > -----Original> Message-----> From:>
trauma-list-bounces at trauma.org> [mailto:trauma-list-bounces at trauma.org]> On>
Behalf Of IVAN HRONEK> Sent:> Thursday, September 06, 2007 4:54 PM> To:>
Trauma &amp; Critical Care> mailing list> Subject: RE: 2D or 3D TEEin>
penetrating cardiac injury> > ok,> you guys are tough weathered surgeons I>
understand...> However...a small> amount of pericardial effusin is present
in> a ceertain> percentage of> normal people, perhaps you have some.> How
are you> going to feel if you> have a small (or medium-sized)> fender-bender
and your> trauma surgeons> opens your chest and pericardium for> your
physiological> pericardial> effusion ?Ivan Hronek MD Chief, Critical Care> &
Trauma> AnesthesiaSFMC Gas,> Inc.St. Francis Medical Center3630 E.
Imperial>> HighwayLynwood, CA 90262> Cell: 310 487-3288Pager: 310 636-6020>
> > > >> From: rfsmithmd at comcast.net>> To: trauma-list at trauma.org> Date:
Thu, 6 Sep>> 2007 16:44:36 -0400> Subject:> RE: 2D or 3D TEEin penetrating
cardiac> injury>> > Ivan,> > I was just> skimming your post and noticed the
"even> small amounts> of> fluid... etc."> so I figured you would intervene
for same.> A long long> time> ago in a> hospital far away, the cardiologist
would> sometimes say> "Echo> positive> only for small amount of physiologic
fluid."> Then one of> those> patients> fell over while having a bowel
movement because> he had> tamponade.> Since> then all penetrating injuries
to the "box" gets an> echo> ANY fluid>> requires surgical intervention. This
approach has proven>> beneficial many>> times.> > Rob Smith> > -----Original
Message-----> From:>>> trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]> On>>> Behalf Of IVAN HRONEK> Sent:
Thursday, September 06, 2007 2:49 PM> To:>>> Trauma &amp; Critical Care
mailing list> Subject: 2D or 3D TEEin>> penetrating> cardiac injury> >
Matt,> > obviously, you know 2D TEE is best,>> and now 3D> TEE is becoming
available.> We recently found a small>> pericardial effusion> in a GSW to L
chest - > I advised to watch the> patient> as the etiology of> the effusion
obviously at> that one instance> of> examination wasn't clear.>> As you know
acute pericardial tamponade can>> happen even with small volumes>> of
effusion as the peridcardium hasn't> been> "stretched" by a slowly>>
accumulating effusion.> > What are people's>> experiences with tamponade -
I> am sure there are millions> of horrendous>> stories....> > Anybody has a>
better way than just watching the patient ?>>> Ivan Hronek MDChief,
Critical> Care & Trauma AnesthesiaSFMC Gas, Inc.> > >> >> > Date: Thu, 6 Sep
2007> 19:35:45 +0100> From: mgreeds at reeds.uk.com>> To:>>
trauma-list at trauma.org>> Subject: ECG in penetrating cardiac injury>> >>>
Sa'ad,> > I once questioned> the role of ECGs in demonstrating>
penentrating>> cardiac > injury.> Unfortunately, I never got round to>
conducting a full>> review of > the> literature but I have cited a few>
articles below which I >>> provisionally> found some time ago.> > I am not>
aware of any significantly>> powered and> properly conducted > studies to>
demonstrate the effectiveness> of> ECGs (I> would nevertheless be > keen to>
hear from others on the list> who> have any> enlightening data > either>
way.) My belief is that it does> not have> any> real role as there > have>
been a number of penetrating> cardiac injuries>> documented which do > not>
demonstrate any ECG changes and> would have been>> missed if relied upon >>
as a single diagnostic test.> > >> Absence of>> hemodynamic and ECG changes>
in a patient with traumatic left >> ventricular>> injury and puncture of
the> left anterior descending branch. >> Südkamp M,>> Geissler HJ, de Vivie
ER.> Thorac Cardiovasc Surg. 2000 Dec;48>> (6):373-5.>> >> Penetrating
cardiac> trauma: follow-up study including >>> electrocardiography,>>
echocardiography, and functional test. Duque HA, >>> Florez LE, Moreno A,>>
Jurado H, Jaramillo CJ, Restrepo MC. World J Surg. >>> 1999>
Dec;23(12):1254-7.> (About post-operative monitoring NOT diagnostics)>>> >>
Dysrhythymia from an> intrapericardial air gun pellet: a case report. >>>>
Willemsen P, Kuo J, Azzu> A. Eur J Cardiothorac Surg. 1996;10(6):461-2. >>>>
(Anecdotal case.)> > > The> literature mostly refers to echocardiography>>>
being a much more useful > test> (greater sensitivity and specificity.)>>>
Although the last publication > above> refers to ECG changes being better>>
at> diagnosing penetrating > cardiac> injury in that particular case than>>>
echocardiography.> > I feel that nothing> can compare to appropriate>>>
histroy, examination of > the patient, mechanism> of injury (e.g. knife>>
stab> wound to anterior chest > = high probability of> cardiac injury
until>> proved> otherwised etc.) and > echo/FAST etc. are more> appropriate
in>> making a> proper diagnosis.> > > Matthew> > --> trauma-list :>
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