Chapter 234 230. Decompress the heart

Four months ago, the "cardiac tamponade" that Kawei spoke of was a very unfamiliar concept, and even the word did not exist in the world. What the surgeon 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 had been clear in the 16th and 17th centuries, and cardiac tamponade had been described by an Italian surgeon as early as the early 18th century.

Recorded in writing.【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, at the beginning, the treatment of pericardial effusion was within the scope of internal medicine and was not the strong point of surgical treatment. And not everyone was familiar with the puncture techniques used in surgery. Views on cardiac surgery often aroused various objections because of the excessive risks.

"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 turned him away. "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 doesn't work, they use calomel."

"Sometimes, iodized salt and potassium salt are also added."

Listening to these inexplicable treatment methods, Kawei suddenly discovered that he was the one who knew the least about current medical treatments. After talking about so many things, in the end, what really had something to do with the heart was the inotropic effect of the heart on the heart.

The ground is yellow.

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 situations are ever-changing, and no one can say that they can completely predict the possible outcomes of all traumas.

, and it is impossible to fully master all coping methods for 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 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 are rare, 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 have training introductions. At least one or two can be found.

Only doctors are brave enough to operate.

But now no one dares to do it. Kawei is a little distressed: "None of you have done it?"

"Never done it."

"Haven't seen it?"

"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 thought it was 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 would be troublesome."

Originally, Kawei only wanted to treat pericardiocentesis as an appetizer for this operation, to give them a practice so that he could do it himself in similar situations in the future. At the same time, he also wanted to share the mature puncture point that has evolved over hundreds of years: the substernal heart.

Bag puncture.

But looking at the surgeons with more than ten years of clinical surgical 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: "It must have been a long time before it was sent here."

"The carriage had to travel for more than ten hours, and 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 very suddenly, just like when he asked for the surgical instrument box just now. Lucius stood aside and was puzzled: "It's just a puncture and the blood inside is drained. Why is it so troublesome?"

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 in an endless stream. The patient's pericardium and thoracic cavity may be filled with fluid before death, but doctors have no good solution. They don't even know that these fluids directly affect the human heart.

Pulsation, and rhythmic breathing.

It wasn't until 1653 that a bold surgeon performed the first cardiac decompression.

The operation failed to leave a paper record, but after two and a half centuries of testing, this technology went through the initial decompression by drilling bones, then drainage through intercostal openings, and finally formed blind percutaneous puncture in 1840.

Drainage technique.

In 1866, pericardiocentesis had already developed its prototype. The insertion point would wander around the sternum. The most common one was the left edge of the sternum as Lucius said. As for the choice of intercostal space, many doctors would choose a lower one.

For the fifth and sixth ribs, there is also a choice between the third and fourth ribs, a matter of opinion.

In fact, the current pericardiocentesis technology has already taken a certain shape, and it is not much different from modern surgery.

However, at a time when cardiopulmonary circulation is not yet fully understood, the reasons for this approach are all kinds of strange.

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 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 covered up by other voices.

"The difficulty is actually not as high as thoracentesis." Kawei explained, "Given the position and the angle, there is no need to change the body position. You only need to pierce a fixed distance to reach the pericardium. As for the piercing the ventricle you just mentioned

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, Golam, 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

Lantz 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 doubtful surgeons, stood where Kawei was standing just now, took the syringe, and pressed the tip of the needle against the newly sterilized skin. At this time, including Lucius,

Only then did everyone realize the seriousness of the problem.

Once again, they missed an opportunity to add points to themselves.

Regardless of whether this puncture attempt is successful or not, Kawei will at least not deduct points, 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 tilt the needle up a little. Don't be afraid." Kawei taught him the piercing technique step by step, "Okay, just like this, just put it 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 Golam was a beginner, his years of surgical work made his technique very stable. There was definitely no problem with the choice of the puncture point, and the angle was also correct. He even

You can feel the tip of the needle entering the pericardium.

According to common sense, as long as you pull the syringe a little later, the blood should enter the tube along the needle.
To be continued...