Prospective validation of protocol for occult penetrating cardiac injury

OBJECTIVE: Preliminary studies done at the Philippine General Hospital have documented the reliability of pericardial ultrasound in the diagnosis of occult penetrating cardiac injury. This study sought to validate a protocol formulated from these studies in a larger trauma patient population at a high-volume center. METHODS: Over a 2-year period, all hemodynamically stable patients with penetrating injury to the precordial area were managed according to the occult penetrating cardiac injury protocol. Patients with a negative result on pericardial ultrasound were admitted for 24-hour observation. Those with minimal fluid or equivocal findings underwent a subxiphoid pericardiotomy. Patients with moderate to large amounts of fluid on ultrasound, as well as those with positive results on subxiphoid pericardiotomy, underwent definitive surgery. Demographic data, wounding patterns, and clinical course were studied. RESULTS: Three hundred forty patients were analyzed. Majority (91%) had negative ultrasound results, and where either discharged after 24-hour observation, or were treated for other associated injuries. None developed signs or symptoms of cardiac tamponade on follow-up. Twenty-six patients (8%) had either minimal fluid or equivocal findings. These underwent subxiphoid pericardiotomy, of which 10 had positive cardiac injury while nine had serous fluid. Three had moderate amount of fluid on ultrasound and underwent immediate thoracotomy; all had significant cardiac injury. There were no late complications noted. CONCLUSION: Our data provides further validation that subxiphoid pericardial ultrasound is effective as an initial tool in ruling out cardiac injury. Because of a significant number of false positives in Filipino patients, those with minimal fluid should undergo subxiphoid pericardiotomy. The finding of moderate fluid is an indication for definitive surgery.

Defining the ideal resuscitation strategy for the hypotensive trauma patient

The traditional approach to treatment of posttraumatic hypotension generally follows the principle of aggressive fluid resuscitation espoused by the American College of Surgeons in its Advanced Trauma Life Support course. A number of reports published in the last decade however, have questioned the safety and clinical appropriateness of this traditional approach, with recent data demonstrating support for delayed or limited resuscitation. This review discusses the controversies and presents recommendations for the ideal resuscitation strategy for the Filipino trauma patient with hypotension. (Author)