2D or 3D TEEin penetrating cardiac injury

[Ben Reynolds]

Ivan:

Ivan wrote:  "... You are just forcing to make it a
black or white situation and threatining with big
dramatic words..."

My response:  I'm not sure to what big words you are
referring to.  You presented this case and as
presented it IS black and white.  If there are other
details you would care to share to persuade us
otherwise now is the time.  

Ivan wrote:  "...If you say any amount than minimal of
pericadial effusion is pathologic you're just plain
wrong..."

My response:  Here, you and I would be in agreement,
IF THAT IS WHAT I SAID.  What I said was:  "...For me,
a "physiologic" amount of fluid is a thin meniscus
between the myocardium and the pericardium. 
More than that, with appropriate mechanism and
suspicion is PATHOLOGIC..."  Without any other
information about why an otherwise healthy (young)
person who suffered a penetrating wound to the left
chest would have an effusion (preexisting condition,
perhaps), I stand by that statement.

Ivan wrote:  "...It seems to me your approach is quite
heavy-handed..."

My response:  I have been involved in and and have
treated more than my fair share of penetrating wounds
to the chest and mediastinum.  This experience is
across multiple institutions with high penetrating
volumes and surgeons over the course of nearly twenty
years.  I also stay quite current with the state of
the art in how these wounds are managed.  Like
everyone else, I would argue that my answers reflect a
tendancy of treatment which, in my anecdotal
experience trends toward a positive outcome.  My
experience has led me to observe that part of enabling
a positive outcome will ALWAYS involve nontherapeutic
explorations when given a choice between morbid
endpoints with equivocal evidence.  

In recent years there has been a trend toward a heavy
reliance on imaging as the final arbitor of whether
one should or shouldn't perform an operation despite
conventional evidence to the contrary (ie physical
exam, vital signs, etc.).  Tangential truncal wounds
are a perfect example of where CT is changing the
standard of care from mandatory exploration to
observation.  FAST has all but replaced DPL.  More and
more cardiac and vascular surgeons are repairing blunt
aortic injuries on the basis of good quality CTAs
instead of antecdent aortography.  In the properly
selected populations, these are all examples of how
imaging has changed the way we do things for the
better.

What you have presented is just the opposite.  Your
patient was subjected to a morbid procedure which had
a positive finding and nothing different was done as a
result.  It was, as Ken so aptly puts it a VOMIT.  

I'm not suggesting that this is an indictment of all
TEEs;  I part ways with Ken on this issue as I think
it has a great deal of potential.  I am trying to make
the point that if you have the conviction to perform
the test that you should also have the conviction to
be able to change what you do based on it's results if
you believe what you are seeing.  You must have
believed it as you advised "...to watch the patient as
the etiology of the effusion obviously at that one
instance of examination wasn't clear..."  

That statement doesn't make sense to me as presented.

Ben Reynolds, PA-C
Pittsburgh, PA      


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

> You are just forcing to make it a black or white
> situation and threatining with big dramatic words.
> It would be great if medicine was this easy.
> If you say any amount than minimal of pericadial
> effusion is pathologic you're just plain wrong.
> It seems to me your approach is quite heavy-handed.
> Either way I think we exhausted the theme now, thank
> you for discussing this, I will not respond any
> further.Ivan
> 
> 
> 
> > Date: Fri, 7 Sep 2007 06:45:51 -0700> From:
> aneurysm_42 at yahoo.com> To: trauma-list at trauma.org>
> Subject: RE: 2D or 3D TEEin penetrating cardiac
> injury> > Au contraire. Any reoperation sucks and I,
> like> everyone else have "been there", perhaps more
> than> most. > > But if what you are suggesting is
> that we choose> between potentially preventing
> sudden death in a 19> year old patient with HARD
> proof of a penetrating> cardiac injury or saving a
> cardiac surgeon a little> extra work when that same
> patient is forty years older> and needs a four
> vessel CABG, I'm afraid my answer may> seem a little
> callous.> > My point in this whole string, if I need
> to be> repetitive is that whoever this person was
> that was> shot in the left chest and then got a TEE
> is no better> off and no less sicker than he was
> before he received> the TEE. The TEE added nothing
> to the diagnosis,> added nothing to the treatment,
> and added nothing to> the outcome. Because of the
> morbid nature of the> actually performance of the
> test, it had the potential> to WORSEN his outcome.>
> > If TEE wasn't available this gentleman, presuming
> he> didn't have tamponade physiology, a positive>
> pericardial FAST, or was exanguinating in a way not>
> easily explained by his mechanism would have been>
> managed the same way every other GSW to the chest
> is> managed. > > So I ask again, what was gained
> with the use of the> TEE? A "small effusion" was
> seen. Is this an ESRD> patient with a uremic
> effusion? Is this a cancer> patient with a
> paraneoplastic effusion? Do we have> reason to
> believe that this patient has viral> pericarditis?
> The only history I've heard is that> this gentleman
> was shot in the left chest. > > For me, a
> "physiologic" amount of fluid is a thin> meniscus
> between the myocardium and the pericardium. > More
> than that, with appropriate mechanism and> suspicion
> is PATHOLOGIC. Using TEE in this instance> as I
> stated earlier is a YES or NO algorithm: Is> fluid
> around the heart? If yes then your test leads> you
> to operate, PERIOD. > > If your test doesn't have
> the potential to change the> patient's management,
> then don't order it.> > Ben Reynolds, PA-C>
> Pittsburgh, PA> > > > > > > --- "Hardcastle, Tim, Dr
> <tch at sun.ac.za>"> <tch at sun.ac.za> wrote:> > > Ben> >
> > > You have obviously never had to re-open a
> sternum on> > a previous sternotomy patient. I know
> of too many> > cases of sternal saw to hear in
> redo's to not want> > to open a chest
> unnecessarily.> > > > Echo / Sonar has been shown to
> be overly sensitive.> > Only react to an effusion of
> over 5mm (some people> > even use 8mm) in the stable
> patient. If unstable -> > operate, no question.
> There is extensive evidence> > from South Africa and
> the USA that this is safe and> > indeed prudent.
> Echo is often confounded by> > associated pleural
> fluid too.> > > > Regards> > Tim> > Dr T C
> Hardcastle> > M.B.,Ch.B.(Stell); M.Med(Chir);
> FCS(SA)> > Senior Surgeon / Senior Lecturer: Surgery
> (Trauma> > and ICU)> > ATLS instructor and DSTC Cape
> Town Course Director> > Intern program Coordinator:
> Surgery> > M.Med (Emergency Medicine) Executive
> Committee> > member> > Clinical Head (Director):
> Diana Princess of Wales> > Trauma Unit> > Division
> of Surgery (General) Room 4064> > Department of
> Surgical Sciences> > Tygerberg Hospital / University
> of Stellenbosch> > PO Box 19063> > Tygerberg 7505> >
> Western Cape> > South Africa> > e-mail:
> tch at sun.ac.za> > Cell: +27824681615> > Office:
> +27219389281 or 4911 pager 0302> > > > > > > >
> -----Original Message-----> > From:
> trauma-list-bounces at trauma.org> >
> [mailto:trauma-list-bounces at trauma.org]On Behalf Of>
> > Ben Reynolds> > Sent: Thursday, September 06, 2007
> 10:17 PM> > To: ih7 at msn.com> > Cc:
> trauma-list at trauma.org> > Subject: RE: 2D or 3D
> TEEin penetrating cardiac> > injury> > > > > > I am
> one of those people who don't believe in> >
> &quot;observation&quot; or &quot;conservative> >
> management&quot; of penetrating wounds to the> >
> heart. Seeing blood on echo (whether 2D or
> whatever)> > in my mind is the same as a positive
> pericardial> > window: Exploration becomes
> mandatory. > > > > Rare is the instance that one
> loses sleep over a> > nontherapeutic exploration.> >
> > > Ben Reynolds, PA-C> > > > IVAN HRONEK wrote: > >
> > 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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