Echocardiographic diagnosis of acute pericardial effusion in penetrating chest trauma

Ultrasound Rounds: Anesthesiologist-Performed Intraoperative Point-of-Care Focused Assessment With Sonography in Trauma Examination Changes Surgical Management

Focused Assessment with Sonography in Trauma (FAST) examinations have been performed for decades by surgeons during initial patient presentation for emergency care and surgical planning, as well as for guiding resuscitation. This case highlights how use of intraoperative FAST examinations performed by anesthesiologists can dramatically change patient management. Use by anesthesiologists perioperatively is an important skill, although it is not widely practiced.

Cardiac Ultrasound in the Intensive Care Unit: A Review

Transthoracic echocardiography (TTE) is an incredibly valuable tool in today’s emergency rooms and intensive care units (ICUs). It has the ability to provide a complete evaluation of the structure and function of the heart, the valves, stroke volume, ejection fraction, and much more. Previous academic studies have also determined that point-of-care TTE done by non-cardiologist physicians can also provide higher accuracy in patient assessment and management, with potential prognostic impact by assessing the severity of cardiac dysfunction and response to treatment. The aim of this review article is to examine further these point-of-care evaluations, what they entail, their benefits, and where further research would better our own understanding.

Is There a Role for Secondary Thoracic Ultrasound in Patients with Penetrating Injuries to the Anterior Mediastinum?

Pericardial tamponade (PT) after penetrating thoracic injury can be lethal if not diagnosed and treated promptly. Most patients present with PT shortly after their injuries occur, but delayed presentation of PT (delayed pericardial tamponade [DPT]) has occurred as late as 73 days after initial injury. Initial evaluation of patients with an anterior mediastinal penetrating injury includes physical examination, chest x-ray, and echocardiography. CT scans of the chest can clarify the tracts of penetrating injuries in stable patients. With increased accessibility to these radio-graphic modalities, PT has been diagnosed in a more timely fashion, and the incidence of DPT has decreased. However, the absence of pericardial effusions on all of these studies at initial presentation does not clear the patient from risk for developing DPT.

Impending cardiac tamponade: A case report highlighting the value of bedside echocardiography

Cardiac tamponade is a life-threatening process that must be diagnosed and treated in a timely fashion. As blood fills the pericardial sac, right ventricular filling is impeded and cardiac output is diminished, ultimately leading to cardiovascular collapse. Fortunately, emergency ultrasonography has improved the way we manage these patients today. In this report, we discuss a patient with hypotension and tachycardia who was found to have a massive loculated posterior pericardial effusion with impending cardiac tamponade. The diagnosis and appropriate treatment of this patient were rapidly ascertained with the use of bedside echocardiography. We review the literature on emergency ultrasonography, and consider the numerous instances in which emergency echocardiography can be life-saving.

Emergency department ultrasound and echocardiography

Bedside sonography has become an important tool in the emergency physician's diagnostic armamentarium. Sonography is useful in the evaluation of a number of conditions, including cholecystitis, abdominal aortic aneurysm, and ectopic pregnancy. Applied to the heart, sonography aids in the assessment of pericardial tamponade, electromechanical dissection, pulmonary embolus, and other cardiorespiratory emergencies. Echocardiography also has a role in differentiating patients with cardiac activity from those in ventricular standstill and in estimating central venous pressure. This article reviews these and other clinical applications and the physics of ultrasound, techniques for sonographic evaluation, and the practical aspects of emergency department use, such as strategic placement of the equipment for quick activation and storage of collected data.

The evaluation of eye pain with a normal ocular exam

Eye pain with or without associated head or face pain is a common complaint to the ophthalmologist. The ocular exam may reveal the etiology (e.g., corneal disease, angle closure glaucoma) but typically the exam is normal. This paper reviews the evaluation and management of eye pain with a "normal" ocular exam, including: 1) subtle findings on ocular exam; 2) transient findings on exam, and 3) no abnormal ocular findings. Ophthalmologists should be aware of the various etiologies for eye pain and the specific and distinctive features that make the diagnosis.

Current evaluation of cardiac stab wounds

BACKGROUND

Patients with penetrating cardiac injuries may be stable or only mildly shocked, especially if the laceration has sealed off and the patient has been aggressively resuscitated. Clinical signs, chest roentgenograms, pericardiocentesis, and subxiphoid window are not always helpful in establishing the diagnosis. We reflect on the current evaluation based on 128 patients.

METHODS

There were four groups of patients, ranging from lifeless (group I) to stable (group IV). Patients in groups I and II were prepared immediately for operation. Those in groups III and IV were often investigated further (chest roentgenogram and cardiac ultrasound).

RESULTS

Mortality was 8%. Significant findings were a precordial stab, central venous pressure of more than 15 cm of water, one or more clinical signs of tamponade, and initial shock. Cardiac ultrasound was performed in 5 patients in group II (15%), 14 patients in group III (48%), and 37 patients in group IV (86%). There were no false positives, and 6 false negatives (11%). Thirty-one patients (24%) had clotted lacerations. There were no negative sternotomies.

CONCLUSIONS

Efficient fluid resuscitation and rapid confirmation of diagnosis with cardiac ultrasound should decrease mortality. Stable patients with a precordial wound should undergo cardiac ultrasound or echocardiogram. Diagnosis may be reliably confirmed in these patients whose clinical signs often fluctuate (or rapidly deteriorate).

Penetrating cardiac injuries

Penetrating cardiac injuries pose a tremendous challenge to any trauma surgeon. Time, sound judgment, aggressive intervention, and surgical technique are the most important factors contributing to positive outcomes. This article extensively reviews the history, surgical management, and techniques needed to deal with these critical injuries. This year commemorates the one hundredth anniversary of the first successful repair of a cardiac injury.

Emergency department echocardiography improves outcome in penetrating cardiac injury

STUDY OBJECTIVES

To determine the effect of immediate two-dimensional echocardiography on the time to diagnosis, survival rate, and neurologic outcome of patients with penetrating cardiac injury.

DESIGN

A ten-year retrospective review.

SETTING

Regional trauma center serving a population base of 1.25 million with 85,000 visits yearly.

TYPE OF PARTICIPANTS

All patients presenting to the emergency department with penetrating cardiac injury.

MEASUREMENTS AND MAIN RESULTS

The records of 49 patients with penetrating cardiac injury were reviewed. Of these, 28 received immediate two-dimensional echocardiography in the ED (echo group) and 21 did not (nonecho group). The probability of survival was derived using TRISS methodology. Differences between groups were determined using either the two sample t-test for parametric data or the Mann-Whitney test for nonparametric data. The overall probability of survival was 33.2%, and the actual survival rate was 81.6%. The probability of survival was 34.2% and 31.8% for the echo group and nonecho group, respectively. The actual survival was 100% in the echo group and 57.1% in the nonecho group. The average time to diagnosis and disposition for surgical intervention was 15.5 +/- 11.4 minutes for the echo group and 42.4 +/- 21.7 minutes for the nonecho group (P less than .001). The Glasgow Outcome Score was 5.0 for the echo group and 4.2 for the nonecho group (P = .007).

CONCLUSION

Since the introduction of immediate ED two-dimensional echocardiography, the time to diagnosis of penetrating cardiac injury has decreased and both the survival rate and neurologic outcome of survivors has improved.

Emergency department echocardiography in the diagnosis and therapy of cardiac tamponade

A 44-year-old male presented to the emergency department in shock with jugular venous distension and upper chest cyanosis. Superior vena cava syndrome was ruled out by computed tomography (CT scan). However, a large pericardial effusion was found on CT scan and confirmed by sonography. Pericardial tamponade was diagnosed by emergency physicians and sonography-guided pericardiocentesis was performed with marked improvement in symptomatology.

A pediatric survivor of left ventricular rupture after blunt chest trauma

The case of a patient with left ventricular rupture as a result of blunt chest trauma from a motor vehicle accident is presented. This is the first reported case of a pediatric survivor of this rare and usually lethal injury and only the fourth report of a survivor. This condition can be treated if the patient survives long enough to reach a trauma center, if the diagnosis is entertained early, and if the appropriate diagnostic studies are obtained in an expeditious manner. We believe that echocardiography is the diagnostic method of choice for pericardial tamponade, whether it is the result of penetrating or blunt trauma, and that early use of this modality may improve survivability.

Principles of emergency ultrasound and echocardiography

Ultrasound is a form of imaging that addresses many needs in emergency medicine. It is fast, accurate, safe, noninvasive, and painless. It rapidly diagnoses immediately life-threatening conditions and reduces the number of invasive or delayed diagnostic methods. However, successful imaging requires an understanding of ultrasonic principles. The physical principles of ultrasound imaging with emphasis on its limitations and the benefits of emergency echocardiography are highlighted.