2D or 3D TEEin penetrating cardiac injury

[Ben Reynolds]

Not true at all.

All of our trauma patients who go to OR from the
trauma bay get a TEE.  In my experience it is helpful
in the following instances:
-clear views of the ascending aorta and aortic isthmus
to see a transection in the patient to unstable to get
further imaging.
-older patients with poor cardiac function or patients
with known poor cardiac function(segmental
dyskinesias, wall motion abnormalities)
-traumatic valvular dysfunction (or preexisting
hemodynamically significant valvular dysfunction).
-pericardial effusions.

But like other diagnostic modalities it's a tool whose
utility is directly proportional to whoever is
operating it.  If it's done correctly and expertly it
can be invaluable.  In the wrong hands it can be
deadly.

But that's not the point.  A patient with a gunshot
wound to the left chest doesn't typically get anything
beyond a FAST of the pericardium.  As I said before,
there must have been some reason why you wanted the
test, some suspicion to force you to subject your
patient to the morbidity of sedating him, compromising
his airway and ramming a probe down his esophagus
(which if the bullet traveled close enough to in the
left chest may also have been injured).

Your test showed a "small effusion" around the heart. 
I didn't see the pictures but you say that it was
"physiologic".  In the patient presented, that would
be a radiologic diagnosis I'd be hard pressed to sign
my name to and to have ascribed the course of
"observation" to afterward (whether successful or
not).  

The TEE doesn't distinguish between blood and
pericardial fluid.  Tamponade may not be obvious, but
is there a hole in the pericardium causing it to
decompress into the left chest thereby not allowing a
large effusion to accumulate?  Is the effusion really
a large clot overlying a rent in the left ventricle?  


Now that you see there is an effusion (which is a
positive finding on your TEE) do you watch the patient
any more closely than you would have otherwise having
suffered a GSW to the left chest?  You have a positive
finding on your test, what did it change?

Ben Reynolds, PA-C
Pittsburgh, PA

--- IVAN HRONEK <ih7 at msn.com> wrote:

> 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
> &quot;observation&quot; 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 &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> > -->
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