Nineteenth Century Medical Guide

Chapter 234. 230. Decompression of the Heart

Four months ago, the "cardiac tamponade" that Carvey said was still a very unfamiliar concept, and there was no such word in the world.The surgeons at that time encountered another state before the symptoms became serious: pericardial effusion.

After four months, cardiac tamponade was well-known, but the scope of "everyone" was a bit narrow, limited to Austrian doctors who joined the army.

Under the circumstances at that time, pericardial effusion should be called pericardial effusion in strict medical terms.The concept was clear in the 16th and 17th centuries, and cardiac tamponade was documented by an Italian surgeon as early as the early 18th century. 【1】

As a battlefield with a high incidence of cardiac tamponade, it is not easy to complete the medical cycle of diagnosis, rescue, and cure.

After all, the treatment of pericardial effusion belonged to the category of internal medicine at the beginning, and it was not the strong point of surgical treatment.Not everyone knows the puncture technique used in surgery, and the views on heart surgery often cause various objections because of the high risk.

"Typical severe pericardial effusion, pericardial tamponade has already occurred." Carvey gave his own judgment at a glance, "Don't you know what pericardial effusion and pericardial tamponade look like?"

Everyone except Lucius and the two surgeons was shaking their heads.

"Sometimes the inside and the outside are interconnected." Carvey thought of Fatolad, who often rejected him. "If you have the opportunity, you should also go to the internal medicine department more often."

"Internal medicine? Internal medicine treatment is nothing more than those few things."

"If it is pericardial effusion, internal medicine generally uses oral digitalis and mercury ointment for chest smear and massage."

"If mercury doesn't work, they'll use calomel."

"Sometimes iodized and potassium salts are added."

Listening to these inexplicable treatment methods, Carvey suddenly discovered that it turned out that he was the one who knew the least about modern medical treatments.Having said so much, the last thing that is really related to the heart is the digitalis that gives the heart a positive inotropic effect.

However, in pericardial effusion, digitalis does not actually play a role. 【2】

"No matter what pericardial effusion is used, the results are not very good"

"It's a miracle that a tamponade caused by a traumatic heart can survive to this day."

"You don't really think that you will die from a traumatic heart, do you?" Carvey asked simply as he made preparations before the operation, "The situation of trauma is ever-changing, and it is impossible for anyone to say that he can fully predict the possible outcomes of all traumas. , and it is impossible to fully master the coping methods of all traumas.”

"Whether cardiac trauma is fatal has always been the focus of discussion in military surgeons."

"I remember it has been arguing for decades, and there is no conclusion now."

"What's the use of arguing? I didn't know until I went to the front line. Under those conditions, these quarrels were completely meaningless. Life and death depended entirely on the health and luck of the wounded."

This can be regarded as some of their insights after working as clinical surgeons for many years.

"When the gap in the pericardial injury is significantly smaller than the heart, or the pericardial defect 'heals' unexpectedly, the space between the heart and the outer pericardium will be filled with blood." Carvey said the simplest concept description of trauma-induced cardiac tamponade , "You have already learned this."

Lucius replied: "I've learned it before, but what exactly does 'healing other than a pericardial accident' mean? The manual doesn't say anything."

Carvey nodded: "That booklet is indeed missing a lot of things, and the content is a bit thin. This statement is also ambiguous, but you will see the reason later. Now that the wounded are important, we should do pericardiocentesis first."

The syringe was already in Kavi's hands, but when he wanted to let the surgeons around him operate it, no one dared to step forward and try.

"This kind of opportunity is rare, don't you do it?"

Lucius was a little embarrassed: "I haven't done it."

"I haven't done it, and I haven't even seen it." Others echoed, "There is no physical model for simulation during the training. Isn't it a bit too much to just get started like this?"

Carvey always thought that surgery in the 19th century was very liberal in operation and not so particular.For a disease that has been identified for many years, there are many doctors operating it as a guide, and there are also training introductions. At least one or two doctors who dare to operate it can be found.

But now no one dares to do it, and Carvey is a little distressed: "You haven't done it?"

"Never did."

"have not seen?"

"I've seen it before, but the method is a bit different." Lucius said, "It's not the oblique position below the sternum as mentioned in the military doctor's manual, but the left edge of the sternum."

"The left side of the sternum is not bad." Carvey quickly found the puncture site on Rogerini's left chest, "the fifth intercostal space about 5cm to the left of the sternum, 2-3cm below the left head, Let’s put the needle here.”【3】

The location has been determined, and logically it has helped him remove the obstacles, but Lucius still waved his hand: "The heart puncture requires an angle and a feel, I'm afraid."

"You can do thoracentesis but dare not do pericardium?" Carvey smiled and felt strange, "Thoracentesis still needs positioning."

"Chest percussion positioning is actually not difficult, practice makes perfect." Lucius looked at Rogerini's chest and laughed at himself, "but the heart is different, the pericardium and the heart are almost stuck together, piercing into the heart It's troublesome."

Originally, Carvey just wanted to use pericardiocentesis as a prelude to this operation, to give them practice, and he could do it himself in similar situations in the future.At the same time, I also want to share the mature puncture point after hundreds of years of evolution: substernal pericardiocentesis.

But looking at those surgeons with more than ten years of clinical operation experience as if they were talking about a very dangerous operation, each of them hesitated to speak, so he could only do it by himself.

"Did the wounded come from the front?"

"Yes, I heard that they have already reached the Bohemian front."

Carvey is not familiar with Bohemia, and he doesn't know where it is on the map, but he knows that the so-called front line is very far away: "It must have been a long time since it was sent here."

"The carriage has to run for more than ten hours. After arriving here, several horses are dying."

"Nurse, go find someone to prepare for blood transfusion." Carvey looked at the infusion bottle that Rogerini was hanging, and said suddenly, "This liquid is not enough, bring more saline."

This decision came very suddenly, just like he asked for the surgical instrument box just now.Lucius stood aside, puzzled: "It's just a puncture and the blood in it is drained, there's no need for such trouble."

This is what other people think too.

"A puncture is a puncture, and an infusion is an infusion." Carvey asked two young assistants to disinfect the chest. "The two are independent and cannot be confused."

In ancient times with high tumor incidence, pericardial effusion was not uncommon.

Mediastinal tumors can often invade the entire thoracic cavity, and all kinds of exudates emerge one after another. Before death, the patient's pericardium and pleural cavity may be full of fluid, but the doctor has no good solution.They don't even know that these fluids directly affect the heartbeat and rhythm of breathing.

It wasn't until 1653 that bold surgeons decompressed the heart for the first time.

The operation failed to leave a paper record, but after two and a half centuries of testing, this technology experienced the initial decompression of the drilled bone, drainage to the intercostal opening, and finally formed a percutaneous blind puncture in 1840. Drainage.

In 1866, the pericardiocentesis had already developed its prototype, and the insertion point would wander around the sternum, the most common being what Lucius called the left border of the sternum.As for the choice of intercostal space, many doctors will choose the lower fifth and sixth ribs, and some choose between the third and fourth ribs. Different people have different opinions.

In fact, the current pericardiocentesis technology has a certain prototype, which is not much different from modern surgery.

But at a time when cardiopulmonary circulation is not yet fully understood, the reasons for such treatment are varied.

Some doctors say that pericardial effusion is a special body fluid that will cause a series of symptoms, so it must be drained; some doctors say that there is toxin in pericardial effusion, so it needs to be drained; Useless blood and lymph disrupt the balance of the four fluids.

Among these reasons, there are naturally claims that the effusion affects the beating of the heart, but it is quickly overshadowed by other voices.

"The difficulty is actually not as high as a thoracentesis." Carvey explained, "Given the position and angle, the body position does not need to be changed, as long as the puncture is a fixed distance, it can reach the pericardium. As for the puncture into the ventricle you just mentioned This kind of situation does happen, but as long as you are careful, you should be able to feel the rebound force after the needle tip touches the myocardium."

"Let me try it!" Just when everyone was afraid to step forward, Goram, who was standing in the outermost circle, raised his hand, "Can I try? Although I am an assistant here, but in Grid Lanz Hospital has been doing it for several years."

"No problem." Carvey didn't care about his resume, handed over the syringe, and pointed to the confirmed insertion point under the sternum, and said, "This position is at an upward angle."

Gorham squeezed past the doubtful chief surgeons, stood where Kavi had been just now, took the syringe, and held the needle tip against the freshly sterilized skin.At this time, everyone including Lucius realized the seriousness of the problem.

Once again they missed the opportunity to add points for themselves.

Regardless of whether this puncture attempt is successful or not, Kawei will at least not deduct points, but if it succeeds, bonus points are inevitable.Because just now, Lucius was praised for his boldness.

But it was too late to regret now.

"Let your left hand be lower, and the needle should be turned up, don't be afraid." Carvey taught him how to puncture, "Okay, that's it, go in slowly."

Pushed by Goram's hands, the long needle entered Rogerini's skin. The needle tip slowly advanced, and soon passed through the subcutaneous tissue and muscle and entered the chest cavity.

"Go on, you can go on."

Suddenly Goram's hand was empty, and an obvious piercing sensation was transmitted to the nerve through the needle and the fingertips, and quickly penetrated into his brain: "It seems to have gone in."

Kavey nodded: "Try drawing back."

The whole process of puncture was very fast, and there were no obstacles in the middle. Although Gorham was a beginner, his technique was very stable due to years of surgical work.The selection of the puncture point was definitely no problem, and the angle was also correct. He could even feel the needle tip entering the pericardium.

According to common sense, at this time, as long as the needle barrel is pulled a little later, the blood should enter the tube along the needle.

However, things did not go as smoothly as they thought. The syringe was difficult to aspirate, and the strong negative pressure inside the syringe did not bring out the blood in the pericardial cavity.

"No blood?"

"Some, but less."

"Blood means that it has entered the pericardial cavity. Not much blood means that it has not entered the heart. The location should be fine."

"Do you need to replace the suction device?"

"What's the difference between that thing and a syringe? It's terribly troublesome to use, and it's not as strong as a syringe."

"What's your blood pressure and heart rate now?"

"The blood hasn't been drawn yet, how could these values ​​have changed?"

Everyone was talking about various suggestions, and listening to the vital signs given by the nurse, these suggestions became more and more anxious, and there were even some negative voices: "I feel that this wound is not that simple, maybe there are other wounds. damage."

"Just this one bullet entry point, where is there any other damage?"

"What if"

"Stop arguing." Kavi stopped them and asked, "How much blood have you drawn now?"

"Probably less than 10ml, it's very viscous." Everyone looked at the huge syringe and looked at each other, "Is there something wrong with the diagnosis? Does he have cardiac tamponade?"

"Yes, why not."

Carvey quickly asked two assistants to change Rogerini's position, and tried several times in a row but failed.

But he is different from other flustered people, he behaves quite calmly, and seems to have expected this result: "I have already mentioned the symptoms of cardiac tamponade, and his performance is very typical: people are very irritable, talking nonsense , fast heart rate, shock, distended jugular veins, pulsating heart sounds that are particularly distant
Especially the last three are very obvious symptoms of cardiac tamponade, the location is so ambiguous, it can't be wrong! "

Speaking of this, many people naturally took out their dusty notebooks and wrote down all these symptoms.

From observation to listening to lectures, and now writing notes, some surgeons finally noticed the problem after repeated learning: "Could it be blood coagulation?"

"That's right, the clotted blood accumulated in the pericardial cavity, preventing the heart from bleeding rapidly!" Lucius finally came to his senses, "Is this the 'healing' that Dr. Carvey just said?"

"Yes, a tamponade from a traumatic heart often doesn't draw blood."

"Can't draw blood? What should I do?"

Kavi had already put on the mask and gloves at this time, and took the scalpel from the nurse, and stood on the position he had just stood on again: "Gorham, you did a good job, and then do pericardiotomy with me." Window technique, to decompress his heart."

(End of this chapter)