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The Role of Ultrasound in Patients with Possible Penetrating Cardiac Wounds: A Prospective Multicenter Study Grace S. Rozycki,RDMS, MD, David V. Feliciano, MD, M. Gage Ochsner, MD, M. Margaret Knudson, MD, David B. Hoyt, MD, Frank Davis, MD, David Hammerman, BS, Vincent Figueredo, MD, J. Duncan Harviel, MD, David C. Han, MD, and Judith A. Schmidt, DNSc Background: Ultrasound is quickly becoming part of the trauma surgeon�s practice, but its role in the patient with a penetrating truncal injury is not well defined. The purpose of this study was to evaluate the accuracy of emergency ultrasound as it was introduced into five Level I trauma centers for the diagnosis of acute hemopericardium. Methods: Surgeons or cardiologists (four centers) and technicians (one center) performed pericardial ultrasound examinations on patients with penetrating truncal wounds. By protocol, patients with positive examinations underwent immediate operation. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded. Results: Pericardial ultrasound examinations were performed in 261 patients. There were 225 (86.2%) true-negative, 29 (11.1%) true-positive, 0 false-negative, and 7 (2.7%) false-positive examinations, resulting in sensitivity of 100%, specificity of 96.9%, and accuracy of 97.3%. The mean time from ultrasound to operation was 12.1 + 5 minutes. Conclusion: Ultrasound should be the initial modality for the evaluation of patients with penetrating precordial wounds because it is accurate and rapid. References 1. Demetriades D, van der Veen BW. Penetrating injuries of the heart: experience over two years in South Africa. J Trauma 1983;23:1034-1041. 2. Ivatury RR, Rohman M, Steichen FM, et al. Penetrating cardiac injuries: twenty-year experience. Ann Surg 1987;53:310-317. 3. Ameli S, Shah PK. Cardiac tamponade: pathophysiology, diagnosis, and management. Cardiol Clin 1991;9:665-674. 4. Hancock EW. Cardiac tamponade. Heart Dis Stroke 1994;168-67-78. 5. Yao ST, Vanecko RM, Printen K, et al. Penetrating wounds of the heart: a review of 80 cases. Ann Surg 1968;168:67-78 6. Jimenez E, Martin M, Krukenkamp I, et al. Subxiphoid pericardiotomy versus echocardiography: a prospective evaluation of the diagnosis of occult penetrating cardiac injury. Surgery 1990;108:676-680 7. Duncan AO, Scalea TM, Sclafani SJ, et al. Evaluation of occult cardiac injuries using subxiphoid pericardial window. J Trauma 1989;29:955-960 8. Miller FB, Bond SJ, Shumate CR, et al. Diagnostic pericardial window: a safe alternative to exploratory thoracotomy for suspected heart injuries. Arch Surg 1987;122:605-609. 9. Andrade-Alegre R, Mon L. Subxiphoid pericardial window in the diagnosis of penetrating cardiac trauma. Ann Thorac Surg 1994;58:1139-1141 10. Rozycki GS, Ochsner MG, Jaffin JH, et al. Prospective evaluation of surgeons� use of ultrasound in the evaluation of trauma patients. J Trauma 1993;34:516-527 11. Rozycki GS, Ochsner MG, Schmidt JA, et al. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma 1995;39:492-500. 12. Rozycki GS, Feliciano DV, Schmidt JA, et al. The role of surgeon-performed ultrasound in patients with possible cardiac wounds. Ann Surg 1996;223:737-746. 13. Rozycki GS, Ballard RB, Feliciano DV, et al. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1,540 patients. Ann Surg 1998;228:557-567 14. Freshman SP, Wisner DH, Weber CJ. 2-D echocardiography: emergent use in the evaluation of penetrating precordial trauma. J Trauma 1991;31:902-906. 15. Arom KV, Richardson JD, Webb G, et al. Subxiphoid pericardial window in patients with suspected traumatic pericardial tamponade. Ann Thorac Surg 1977;23:545-549. 16. Nagy KK, Lohman C, Kim DO, et al. Role of echocardiography in the diagnosis of occult penetrating cardiac injury. J Trauma 1995;38:859-862. 17. Rozycki GS. Surgeon-performed ultrasound: its use in clinical practice. Ann Surg 1998;228:16-28. 18. Committee on Trauma. Initial Assessment and Management. Chicago,IL: American College of Surgeons; 1997. 19. Weyman AE. Pericardial disease. In: Weyman AE, ed. Cross-Sectional Echocardiography. Philadelphia, Pa: Lea & Febiger; 1982:480-491 20. Moore EE, Malangoni MA, Cogbill TH. Organ injury scaling. IV. Thoracic vascular, lung, cardiac, and diaphragm. J Trauma 1994;36:229-300 21. Wherrett LJ, Boulanger BR, McLellan BA, et al. Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage. J Trauma 1996;41:815-280. 22. McKennety MG, Martin L, Lentz K, et al. 1000 consecutive ultrasounds for blunt abdominal trauma. J Trauma 1996;40:607-612 23. Healey MA, Simons RK, Winchell RJ, et al. A prospective evaluation of abdominal ultrasound in blunt trauma: is it useful? J Trauma 1996;40:875-883. 24. Sisley AC, Rozycki GS, Ballard RB, et al. Rapid detection of traumatic effusion using surgeon-performed ultrasound. J Trauma 1998;44:291-297. 25. Boulanger BR, Breeneman FD, McLellan BA, et al. A prospective study of emergent abdominal sonography after blunt trauma. J Trauma 1995;39:325-330. 26. Boulanger BR, McLellan BA, Brenneman FD, et al. Emergent abdominal sonography as a screening test in a new diagnostic algorithm for blunt trauma. J Trauma 1996;40:867-874 27. Ballard RB, Rozycki GS, Knudson MM, et al. The surgeon�s use of ultrasound in the acute setting. In: Rozycki GS, et. Surgeon-Performed Ultrasound. Philadelphia, Pa: WB Saunders; 1998:9.1-9.23. 28. Rozycki GS, Feliciano DV, Davis TP. Ultrasound as used in thoracoabdominal trauma. In: Rozycki GS, ed. Surgeon-Performed Ultrasound. Philadelphia, Pa: WB Saunders; 1998:295-310 29. Knudson MM, Lewis FR, Atkinson K, et al. The role of duplex ultrasound arterial imaging in patients with penetrating extremity trauma. Arch Surg 1993;128:1033-1037. 30. Fry WR, Smith RS, Schneider JJ, et al. Ultrasonographic examination of wound tracts. Arch Surg 1995;130:605-608. 31. Thompson DA, Rowlands BJ, Walker WE. Urgent thoracotomy for pulmonary or tracheobronchial injury. J Trauma 1988;28:276-280. 32. Borlase BC, Metcalf BK, Moore EE. Penetrating wounds to the anterior chest: analysis of thoracotomy and laparotomy. Am J Surg 1986;152:649-653 33. Hegarty MM. A conservative approach to penetrating injuries of the chest: experience with 131 successive cases. Injury 1976;8:53-59. 34. Borja AR, Ransdell HT. Treatment of penetrating gunshot wounds of the chest: experience with 145 cases. Am J Surg 1971;122:81-84 35. Robison PD, Harman PK, Trinkle JK. Management of penetrating lung injuries in civilian practice. J Thorac Cardiovasc Surg 1988;95:184-190. 36. Knott-Craig CJ, Dalton RP, Rossouw GJ, et al. Penetrating cardiac trauma: management strategy based on 129 surgical emergencies over 2 years. Ann Thorac Surg. 1992; 53:1006-1009 37. Klinkenberg TJ, Kaan GL, lacquet LK. Delayed sequelae of penetrating chest trauma: a plea for early sternotomy. J Cardiovasc Surg. 1994;35:173-175. 38. Sayers RD, Underwood MJ, Bewes PC, et al. Surgical management of major thoracic injuries. Injury. 1994;25:75-79 39. Bolton JWR, Bynoe RP, Lazar HL, et al. Two-dimensional echocardiography in the evaluation of penetrating intra pericardial injuries. Ann Thorac Surg 1993;56:506-509 40. Meyer D, Jessen ME, Grayburn PA. The use of echocardiography to detect cardiac injury after penetrating thoracic trauma: a prospective study. J Trauma 1995;39:902-907 41. Karalis DG, Victor MG, Davis GA, et al. The role of echocardiography in blunt chest trauma: a transthoracic and transesophageal echocardiographic study. J Trauma 1994;36:53-58. 42. Sanders RC, et. Clinical Sonography: A Practical Guide. 2nd ed. Boston, Mass: Little, Brown; 1991;4-10. 43. Rozycki GS, Kraut EJ. Isolated blunt rupture of the infra renal vena cava: the role of ultrasound and computed tomography in an occult injury. J Trauma 1995;38:402-405 44. Han DC, Rozycki GS, Schmidt JA, et al. Ultrasound training during ATLS: an early start for surgical interns. J Trauma 1996;41:208-213. 45. O�Malley KF, Ochsner MG. Use of ultrasound in the traumatized patient. Trauma Q 1997;13:153-228. 46. Wisner DH, Reed WH, Riddick RS. Suspected myocardial contusion: triage and indications for monitoring. Ann Surg 1990;212:82-86. 47. Rothlin MA, Naf R, Amgwerd M, et al. Ultrasound in blunt abdominal and thoracic trauma. J Trauma 1993;34:488-495. 48. Committee on Trauma. Advanced Trauma Life Support Course for Physicians. Chicago, Il: American College of Surgeons; 1997:166. 49. Rozycki GS, Shackford SR. Ultrasound: what every trauma surgeon should know. J Trauma 1996;40:1-4. 50. Rutherford EJ, Morris JJA, Reed GW, et al. Base deficit stratifies mortality and determines therapy. J Trauma 1992;33:417-423. 51. Davis JW, Kaups KL, Parks SN. Base deficit is superior to pH in evaluating clearance of acidosis after traumatic shock. J Trauma 1998;44:114-118. 52. Aaland MO, Sherman RT. Delayed pericardial tamponade in penetrating chest trauma: case report. J Trauma 1991;31:1563-1565. 53. Grewal H, Ivatury RR, Divaker M, et al. Evaluation of subxiphoid pericardial window used in the detection of occult cardiac injury. Injury 1995;5:305-310. 54. Pastor BH, Betts RH. Late symptoms due to traumatic hemopericardium. N Engl J Med 1961;265:1139. 55. Martin R, Mitchell A, Dhalla N. Late pericardial tamponade and coronary arteriovenous fistula after trauma. Br Heart J 1986;55:216 56. Symbas PN, DiOrio DA, Tyras DH, et al. Penetrating cardiac wounds: significant residual and delayed sequelae. J Thorac Cardiovasc Surg 1973;66:526-532 57. Ali J, Rozycki GS, Campbell JP, et al. Trauma ultrasound workshop improves physician detection of peritoneal and pericardial fluid. J Clin Res. 1996;63:275 58. Thomas B, Falcone RE, Vasquez D, et al. Ultrasound evaluation of blunt abdominal trauma: program implementation, initial experience, and learning curve. J Trauma 1997;42:384-390. 59. Goldberg SP, Karalis DG, Ross JJ Jr, et al. Severe right ventricular contusion mimicking cardiac tamponade: the value of transesophagealechocardiography in blunt chest trauma. Ann Emerg Med 1993;22:745-747. 60. Ochsner MG, Rozycki GS, Lucente F, et al. Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: a preliminary report. J Trauma 1993;34:704-710. 61. Mack MJ, Landreneau RJ, Hazelrigg SR, et al. Video thoracoscopic management of Benign and Malignant Pericardial Effusions. Chest 1993;103:390S. 62. Galandiuk S, Polk HCJ. Dissolution of traditional surgical disciplinary boundaries. 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