2D or 3D TEEin penetrating cardiac injury

[IVAN HRONEK]

Ben,
 
there is a problem. Either you guys are too rough or you are not able to look at a novel technique and accept it.
 
You look at the echo to see 1. how much fluid there is - a small amount is physiologic.
                                      2. whether or not you have a collapsing atrium and whether is in diastoly or systoly.
 
   These are accepted diagnostic tools that are done in every pericardial effusion and there are a lot all over s you know. 
 
There is nothing suspicious or experimental about it. You should like it as it just shows you a dynamic picture of the heart and it is extremely simple : one picture. 
 
It sounds very rigid to me c'mon, ECHO has been around for what 25 years ?
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



> Date: Thu, 6 Sep 2007 15:30:42 -0700> From: aneurysm_42 at yahoo.com> To: rfsmithmd at comcast.net> CC: trauma-list at trauma.org> Subject: RE: 2D or 3D TEEin penetrating cardiac injury> > Ivan:> > Using TEE is just like any other sonographic diagnostic tool (any abdominal ultrasound or FAST). They are VERY blunt instruments which can only answer a SINGLE question: Is fluid present?> > It can't answer what type of fluid it is, where it came from, or whether or not it's presence is pathologic. If you are echoing with suspicious mechanism (ie a GSW to the left chest) then I can only assume there was a degree of suspicion that the heart could have been involved, if not by pure proximity. > > Given that, not knowing all of the details of your example I probably would have been led to explore based on the POSITIVE findings of said test. If the positive test does not change what you do, why order it? > > Not having ever done it I can only imagine that "observation" of pericardial fluid in the face of penetrating mechanism would consist of watching for signs and symptoms of condition worsening which in the case presented range from chest pain and shortness of breath to asystole.> > Unacceptable in my view.> > Ben Reynolds, PA-C> Pittsburgh, PA> > Robert F. Smith wrote: > > 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 & 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 & 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 & 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 :> TRAUMA.ORG>> > To change> your settings or unsubscribe visit:>>>> > http://www.trauma.org/index.php?/community/--> trauma-list : TRAUMA.ORG> To>> > change your settings or unsubscribe visit:>>> > http://www.trauma.org/index.php?/community/> > --> trauma-list :> > TRAUMA.ORG>> To change your settings or unsubscribe visit:>>> > http://www.trauma.org/index.php?/community/--> trauma-list : TRAUMA.ORG> To> > change your settings or unsubscribe visit:>> > http://www.trauma.org/index.php?/community/> > --> trauma-list : TRAUMA.ORG>> > To change your settings or unsubscribe visit:>> > http://www.trauma.org/index.php?/community/--> > trauma-list : TRAUMA.ORG> > To change your settings or unsubscribe visit:> > http://www.trauma.org/index.php?/community/> > --> > trauma-list : TRAUMA.ORG> > To change your settings or unsubscribe visit:> > http://www.trauma.org/index.php?/community/> > --> trauma-list : TRAUMA.ORG> To change your settings or unsubscribe visit:> http://www.trauma.org/index.php?/community/