Four months ago, the "cardiac tamponade" that Kawei spoke of was a very unfamiliar concept, and there was even no such word in the world. What the surgeons encountered at that time was another state before the symptoms became serious: pericardial effusion.
Four months later, cardiac tamponade was known to everyone, 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 was originally within the scope of internal medicine and was not the strong point of surgical treatment. Not everyone is familiar with the puncture techniques used in surgery, and opinions on heart surgery often arouse various objections because it is too risky.
"Typical severe pericardial effusion, cardiac tamponade has already occurred." Kawei made his own judgment at a glance, "Don't you know what pericardial effusion and cardiac tamponade look like?"
Everyone except Lucius and the two surgeons were shaking their heads.
"Sometimes the inside and outside are interconnected." Kawei thought of Fatorad who often rejected him. "If you have the opportunity, you should also go to the internal medicine department more frequently."
"Internal medicine? Internal medicine treatment is nothing more than those things."
"If it is pericardial effusion, internal medicine generally uses oral digitalis and mercury ointment for chest application and massage."
"If mercury didn't work, they would use calomel."
"Sometimes iodized salt and potassium salt are also added."
Listening to these inexplicable treatment methods, Kawei suddenly realized that he was the one who least understood the current medical treatments. Having said so much, the final thing that is really related to the heart is digitalis, which has a positive inotropic effect on the heart.
However, in pericardial effusion, digitalis does not actually play any role. 【2】
“The results of pericardial effusion are not good no matter what method is used.”
“It’s a miracle that someone with tamponade caused by cardiac trauma can survive to this day.”
"You don't really think that you will definitely die from cardiac trauma, do you?" Kawei simply made preparations for the operation and asked, "Trauma conditions are ever-changing, and no one can say that they can completely predict the possible outcomes of all traumas. , and it’s impossible to fully grasp how to deal with all trauma.”
"Whether cardiac trauma is fatal has always been a focus of discussion in military surgery."
"I remember that we have been arguing for decades, and there is no conclusion yet."
"What's the use of arguing? Only when I finally got to the front line did I realize that under those conditions these arguments 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." Kawei said the simplest conceptual description of cardiac tamponade caused by trauma , "You have already learned this."
Lucius replied: "What I have learned is that the manual does not say what 'healing beyond pericardial accident' means."
Kawei 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 urgent, we should perform pericardiocentesis first."
The syringe was already in Kawei's hands, but when he wanted to let the surgeons around him operate it, no one dared to step forward and try.
"Opportunities like this don't come often, why don't you do it?"
Lucius was a little embarrassed: "I haven't done it."
"I haven't done it either, I haven't even watched it." Others echoed, "There was no physical model for simulation during the training. Isn't it a bit too much to just start it like this?"
Kawei always thought that surgery in the 19th century had always been very liberal in its operations and not so particular. For a disease that has been identified for many years, there are many doctors who use it as a guide, and there are training introductions. It would be better to find at least one or two doctors who dare to operate it.
But now no one dares to do it, and Kawei is a little distressed: "None of you have done it?"
"Never done it."
"have not seen?"
"I have seen it before, but the method is a little different." Lucius said, "It is not the diagonally upward position below the sternum as mentioned in the military medical manual, but the left edge of the sternum."
"The left edge of the sternum is not impossible." Carvey quickly found the puncture site on Rogerini's left chest. "The fifth intercostal space is about 5cm to the left of the sternum, 2-3cm below the left head. Just put the needle here." [3]
The position has been determined, which logically has cleared the obstacles for him, but Lucius still waved his hand: "Heart puncture requires angle and feel, I'm afraid."
"You can do thoracentesis but don't dare to do pericardium?" Kawei smiled and felt strange, "Thoracentesis still requires positioning."
"Chest percussion positioning is actually not difficult. Practice makes perfect. [4]" Lucius looked at Rogelini's chest and laughed at himself, "But the heart is different. The pericardium and the heart are almost close to each other and pierce into the heart. That’s troublesome.”
Originally, Kawei only wanted to use pericardiocentesis as an appetizer for this operation, to give them practice, so that he could do it himself when encountering similar situations in the future. At the same time, I would also like to share a mature puncture point that has evolved over hundreds of years: substernal pericardiocentesis.
But looking at the surgeons with more than ten years of clinical operation experience, they seemed to be talking about a very dangerous surgical procedure, and they hesitated to speak, so he had no choice but to do it himself.
"Did the wounded come down from the front line?"
"Yes, I heard that he has arrived at the front line of Bohemia."
Kawei was not familiar with Bohemia and did not know where it was on the map, but he knew very well that the so-called front line was very far away from here: "It must have been a long time before it was sent here."
"The carriage had to travel for more than ten hours. When we got here, several of the horses were dying."
"Nurse, hurry up and find someone to prepare a blood transfusion." Kawei looked at the infusion bottle that Rogelini was hanging and suddenly said, "This liquid is not enough. Please bring some more saline."
This decision came suddenly, just like when he asked for the surgical instrument box just now. Lucius stood aside puzzled: "Just do a puncture and drain out the blood inside. Why does it need so much trouble?"
This is what other people think too.
"A puncture is a puncture, and an infusion is an infusion." Kawei asked two young assistants to disinfect the chest. "The two are independent and cannot be confused."
In ancient times when tumors were highly prevalent, pericardial effusion was not uncommon.
Mediastinal tumors can often invade the entire thoracic cavity, and various types of effusions can occur endlessly. The patient's pericardium and thoracic cavity may be filled with fluid before death, but doctors have no good solution. They didn't even know that these liquids directly affected people's heart beat and rhythmic breathing.
It wasn't until 1653 that a bold surgeon performed the first cardiac decompression.
There was no paper record of the operation, but after two and a half centuries of testing, this technology went through bone drilling for decompression, then intercostal opening drainage, and finally formed blind percutaneous puncture in 1840. Drainage.
In 1866, pericardiocentesis had developed into a prototype, and the insertion point would wander around the sternum. The most common one was what Lucius said was the left edge of the sternum. As for the choice of intercostal space, many doctors will choose the lower fifth and sixth ribs, and some will choose between the third and fourth ribs. People have different opinions.
In fact, the current pericardiocentesis technology has already taken a certain form, which is not much different from modern surgery.
But at a time when cardiopulmonary circulation has not yet been fully understood, the reasons for doing this are all kinds of strange.
Some doctors say that pericardial effusion is a special body fluid that can cause a series of symptoms, so it must be drained; some doctors say that pericardial effusion contains toxins, so it needs to be drained; and some doctors say that there is a large amount of pericardial effusion. Useless blood and lymph fluid destroy the balance of the four fluids.
Among these reasons, there was naturally the saying that fluid accumulation affects the beating of the heart, but it was quickly buried under other voices.
"The difficulty is actually not as high as thoracentesis." Kawei explained, "Given the position and angle, there is no need to change the body position. You only need to penetrate a fixed distance to reach the pericardium. As for the puncture into the ventricle you just mentioned Wall, this 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 give it a try!" Just when no one dared to step forward, Goram, who was standing in the outermost circle, raised his hand, "Can I give it a try? Although I am an assistant here, but in Ge Lam Lanz Hospital has been doing this for several years."
"No problem." Kawei didn't care about his resume. He handed over the syringe and pointed to the determined insertion point under the sternum and said, "This position is at an upward angle."
Goram squeezed past the somewhat confused surgeons, stood where Kawei was standing just now, took the syringe, and pressed the tip of the needle against the newly sterilized skin. By this time, everyone, including Lucius, realized the seriousness of the problem.
Once again, they missed an opportunity to score points for themselves.
Regardless of whether this puncture attempt is successful or not, Kawei will not deduct points at least, but if it is successful, extra points will be inevitable. Because just now, Lucius was praised for his boldness.
But now it's too late to regret.
"Lower your left hand a little lower and raise the needle a little higher. Don't be afraid." Kawei taught him the piercing technique step by step. "Okay, just like this, go in slowly."
The long needle entered Rogelini's skin under the push of Golam's hands. The needle tip slowly advanced and soon passed through the subcutaneous tissue and muscles and entered the chest cavity.
"Continue, you can go further."
Suddenly Goram's hand was empty, and an obvious piercing sensation passed through the syringe and fingertips to the nerves, and quickly penetrated into his brain: "It seems to have gone in."
Kawei nodded: "Try to pull back."
The entire puncture process was very fast, and there were no obstacles in the way. Although Goram was a beginner, his years of surgical work made his technique very stable. The choice of the insertion point was definitely correct, and the angle was also correct. He could even feel the needle tip entering the pericardium.
According to common sense, as long as the syringe is pulled slightly later, the blood should enter the tube along the needle.
However, things did not go as smoothly as they thought. It was difficult to aspirate the syringe, and the strong negative pressure in the syringe did not bring out the blood in the pericardial cavity.
"No blood?"
"Yes, but few."
"If there is blood, it means it has entered the pericardial cavity. If there is not much blood, it means it has not entered the heart. There should be no problem with the position."
"Does the suction device need to be replaced?"
"What's the difference between that thing and a syringe? It's so troublesome to use, but it's not as powerful as syringe suction."
"What's your blood pressure and heart rate now?"
"The blood has not been drawn out, how could these values change?"
Everyone was talking about various suggestions. Listening to the vital signs given by the nurse, these suggestions became more and more anxious, and even some negative voices were said: "I feel that this wound is not that simple, maybe there are other damage."
"It's just this bullet entry point. Where are there other injuries?"
"What if there is?"
"Stop arguing." Kawei stopped them and asked, "How much blood have been drawn now?"
"Probably less than 10ml, it's very viscous." Everyone looked at the huge syringe and looked at each other, "Is there a problem diagnosed? He doesn't have pericardial tamponade?"
"Yes, how could it not be?"
Carvey quickly asked two assistants to change Rogelini's position, and tried several times in succession to no avail.
But unlike other people who were panicking, he behaved quite calmly, as if he had expected the result: "I have already mentioned the symptoms of cardiac tamponade before, and his performance is very typical: he is very irritable and talks nonsense. , rapid heart rate, shock, distended jugular veins, and very distant pulsating heart sounds.
Especially the last three are very obvious symptoms of cardiac tamponade, and their positions are so ambiguous that they are unmistakable! "
For this reason, many people naturally took out their notebooks that had been dusty for a long time and wrote down all these symptoms.
From observing, listening to lectures, and now taking notes, some surgeons finally discovered the problem through repeated studies: "Could it be that the blood is coagulated?"
"Yes, coagulated blood accumulates in the pericardial cavity, preventing the heart from rapid blood loss!" Lucius finally reacted, "Is this the 'healing' that Dr. Carvey just said?"
"Yes, blood cannot be drawn out of cardiac tamponade caused by cardiac trauma."
"Can't draw blood? What should I do?"
Kawei had already put on a mask and gloves, got a scalpel from the nurse, and stood back where he had just stood: "Goram, you did a good job. Next, do the pericardiotomy with me." Window surgery to decompress his heart."
(End of chapter)
