Pedestrian Question
	Date: 02.01.97 06:01 From: dulyatt@medeserv.com.au (David Ulyatt) I'm interested in your opinions on whether you would have obtained or think mandatory, a double contrast abdominal CT in the following circumstance. This 71 year old woman was dead in ICU when I came on duty this morning. She came to us moribund in the early hours from OT. 48 hours earlier she presented to the emergency department (metropolitan University teaching hospital, not Trauma centre) with little history obtained from Ambulance officers. Pedestrian hit by motor vehicle (no other info). Past medical history: nil relevent. Had been unconcious at scene. Duration? GCS @ scene? In ED: GCS 14, ABC OK (???), soft non tender abdo with no bruising &c, Bilateral nasty femoral #'s, # of right superior pubic ramus pelvis, SI jts and lower lumbar vertabrae NAD. C-spine : old but no #. CXR: NAD, thoracic and upper lumbar vertatabrae well seen and no #'s detected. Head CT: NAD. Who thinks an abdo CT should have been done? Who thinks it would be a waste of time money and resources? Should she be admitted to ICU or an Orthopaedic ward? Remainder of her course and operative findings available to responders. Thanks in advance, David David Ulyatt Director of Intensive Care Mater Misericordiae Private Hospital 301 Vulture St, South Brisbane Qld, 4101, Australia.
	Date: 02.01.97 10:34 From: dave adams [dcrad@ihug.co.nz] Certainly needed her belly assessed, but at the risk of sounding too much like an EMST instructor, I think she should have had a DPL (diagnostic lavage), and it should have been done before she went to have the CT head. a. She's got head and femoral injuries, => every reason to suspect something in between. b. Fractured pelvis = also good reason to do DPL c. She's going to become "inaccesible" for further evaluation of the abdo while the "pods" work on the femurs d.If you believe the EMST bibliography, DPL is more sensitive at picking bleeding, bowel & biliary injuries, and in my (anecdotal and very limited)experience better at finding pancreatic injuries early. e. After DPL you can still do CT abdo if you want. Sure there'll be some fluid in the belly, but so what. If you've done the DPL you know how much fluid there ought to be there and also what it is. Guess I might change my mind about the order of things when our hospital finally buys its spiral scanner, but there's still the inevitable delays of organising the scanner staff, and getting the patient there. Also the interpretation of a subtle CT is not always that easy. It's not uncommon that I have the radiology consultant point out something at the next Xray conference, that had eluded the registrar in the middle of the night. Dave Adams FRACS General & Vascular Surgeon - Director of Trauma Middlemore Hospital Auckland, NEW ZEALAND
	Date: 02.01.97 10:44 From: "Eric Frykberg M.D." [ERF.TRAUMAONE@mail.health.ufl.edu] There is nothing magic about an abdominal CT, but certainly the abdomen needed to be evaluated by some modality--the physical exam rules out nothing in the initial period following severe trauma--however, we would simply have ultrasounded or DPL'ed, not CT'd--much quicker, less expensive, and at least equally accurate. Most likely cause of death here is hemorrhage, with the abdomen or lowere extremity fracutres being the most likely sources--acute MI or arrhythmia also a possibility, but much less likely.
	Date: 02.01.97 15:30 From: "Smith, J. Stanley, MD" [JStanley.Smith@hmc.psu.edu] In an older woman with bilateral femoral fractures and severe pelvic fractures, an abdominal CT in an otherwise healthy patient is extremely helpful and should be done. The CT not only indicates intraabdominal injury, but also allows the surgeon to guage the extent of pelvic fracture bleeding and hematoma. She should have been admitted to the ICU under a general/trauma surgeon to properly evaluate her injuries and resuscitate her from shock. I would estimate she lost 5 units of blood and was underresuscitated as the scenario is presented.
	Date: 02.01.97 16:25 From: Ken Mattox [KMATTOX@aol.com] This ladies abdomen should have been evaluated by some technique. The technique should vary with the experience and comfort level of the surgeons perfermorming the test. The evaluations can range from: Abdominal ultrasound DPL CT scan, plain CT scan, contrast enhanced Laparotomy. By far the safest thing to do in a general hospital without a trauma service would have been to do a laparotomy. Society will forgive a negative laparotomy, but will not forgive a missed injury. In todays world the basic test probabilly should have been an abdominal ultrasound and let the results of that test (which could have been repeated several times by the surgeon if necessary) guide additional tests. I would not of objected to a CT being the only examination initially. Whether or not it is contrast enhanced is dealers choice. k
	Date: 02.01.97 16:44 From: "John A. Aucar, M.D." [jaucar@bcm.tmc.edu] I seldom suggest "mandatory" anything (although I personally believe in mandatory colostomy for all infants until the age of three, I can't convince my wife or the pediatric surgeons to accept this policy despite the evident universal incontinence). I will make a few generalizations about trauma in the elderly: Even major trauma is survivable with reasonable expectation of functional recovery when the physiologic reserve is adequate and management is meticulous. Certainly, age reduces physiologic reserve and various scoring systems show a higher (statistical) risk of death at lower injury scores, but scoring systems average effects and can't predict the outcome of an individual patient. If this patient were 60 or 40 would she have met your criteria for a CT? With significant blunt trauma and distracting injuries (femur and pelvic fractures) I think that most people would do some sort of abdominal evaluation. A triage decision to withhold aggressive care in favor of comfort care based on a predictably low chance of survival may be appropriate if you consider carefully the risk factors, resource factors and social/ethical factors. Unless one is ready to discuss and defend such a decision, taking a different approach based on age is a bit risky (and then, why was she in the ICU). Nothing in the presentation above accounts for the patients demise and the question of a preventable death remains open. This does not account for your hint that she was operated. I may have misunderstood the presentation. Laparotomy is usually an adequate abdominal evaluation and CT doesn't add much to it. If you had isolated pelvic and femur injuries and the CT would keep you from doing a negative lap, then I think it's worth it, especially in the elderly, presuming hemodynamic stability. Under no circumstances, should a patient like this (even with isolated Ortho injuries) be primarily managed by anything other than a general surgeon with expertise and experience in trauma care. JAA -- ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ! John A. Aucar, M.D.,F.A.C.S. ! ! Dept. of Surgery ! ! One Baylor Plaza ! ! Houston, TX 77030 ! ! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ! ! Assistant Professor, Surgery, Baylor College of Medicine ! ! Ben Taub Gen. Hospital; http://www.bcm.tmc.edu/surgery/ ! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
	Date: 02.01.97 17:26 From: Gail Waldby MD [gwaldby@iw.net] Admit to ICU I'll vote for the CT because of unconsciousness and pelvic fractures. Gail Waldby, MD Huron Clinic SD
	Date: 02.01.97 20:20 From: Jeffrey S. Guy [JSGUY@aol.com] Given the bilateral femur and pelvic fractures you patient certainly had a high enough MOI to warrent either a CT scan of the abdomen/pelvis or a supraumbilical DPL. Another consideration for the patient demise is fat emboli syndrome. We would have placed the patient in a monitored setting at the onset to monitor for the sequela of fat emboli. Furthermore, if the CT scan was performed and was read as negative I would have maintained a high index of suspicion for hollow viscus injury given the large amount of energy in the MOI. Jeffrey S. Guy, MD, MSc Chief resident, general surgery Akron General Medical Center Akron, Ohio USA JSGuy@aol.com JeffreyGuy@worldnet.att.net
	Date: 02.01.97 23:10 From: Keith Wesley [drwesley@primenet.com] I believe that in light of the womans age, uncertain initial condition and after review of her severe injuries I would have gotten a CT of the abdomen and pelvis. The liklihood of injury to the abdomen is significantly increased in the presence of multiple long bone and particularly pelvic fractures. The fact that there is little information to go on as to the injury forces (poor documentation of the accident) one must have a heightened suspicion for occult injuries. You did not indicate what the post mortem revealed. I assume it has not been done. Other considerations would have been to the possibility of acute MI secondary to the stress of injury and the possibility of myocardial contusion. Was an EKG done and cardiac enzymes? Was she placed on telemetry to assess arrhthmias? The presence of long bone fractures places her at greater risk for pulmonary embolus as well. All in all I would suggest that based on what you said she should have been placed in the ICU for closer monitoring. Keith Wesley, MD, FACEP Director, EMS Education & Trauma Care Sacred Heart Hospital Eau Claire, WI
	Date: 03.01.97 00:24 From: "Lisa S. Dresner" [71211.2533@compuserve.com] We follow a specific protocol for all elderly patients with significant trauma, as we admit 2-4 of these type patients a week. This protocol was designed and reported by Scalea et al in the Journal of Trauma. Although the study was not a prospective trial, it has provided us with a framework for managing these patients. All elderly patients with a head injury and/or a long bone fracture are managed agressively, with early (in ED or within several hours in SICU) hemodynamic monitoring. We evaluate abdomens by DPL initially, get a quick head CT and transfer the patient to the SICU, (unless hemodynamically unstable with a pelvis fracture) where we manage the often covert shock, respiratory failure etc. This allows earlier precise management of blood loss and shock. We reserve CT for those with continued instability or HCT drop. Early fracture fixation and caval filter once hemodynamically stable. Despite all of this, the return to function in a seriously head injured elderly patient is dismal and family should be counseled as such.
	Date: 03.01.97 02:59 From: "Louis Brusco Jr., M.D." [lb86@columbia.edu] We generally get an abdomino/pelvic CT on all of our pelvic fractures, looking for a big hematoma that gives us an indication of potential for future blood loss. If we see a big hematoma, if they drop their hematocrit we can go straight to angio for embolization. Most of out MVA-Ped struck patients with significant mechanism of injury also get abd CT, although I ma not clear on the indications for them. A patient as you describe would get both femurs either rodded that night or at least put into traction, and would get admitted to the ICU for 24 hours for frequent hct. checks. -- Louis Brusco Jr., M.D. Director, Critical Care Anesthesiology Co-Director, SICU St. Luke's-Roosevelt Hospital Center, NYC
	Date: 03.01.97 10:42 From: Simon Carley [106025.677@compuserve.com] This patient has a severe lower limb injury and a head injury (one presumes as GCS down at scene). Unless they have been hit by a giant horseshoe (and few people are) there is likely to be something going on in the Torso! Our practice in this case would be to spiral CT the abdomen. Our practice is not to DPL as we have few experienced operators and we have had lots of false positives (user error) in the past, our CT unit is fast and 40 metres from Resus. Alternatively the radiologists will come and do an USS in resus if this is warranted. This should be done before theatre as it is then even more difficult to assess an injured torso. We accept that there will be a significant number of negative investigations with this approach but that it is extremely difficult to assess an abdomen for blunt trauma in a patient with a decreased GCS. In this case the patient had a CT head (although I'm not sure at which point), it would have taken very little time/effort to scan the abdomen. It should have been done whilst the patient was in the scanner. All opinions are tempered by the judiscious use of the retrospectoscope. Simon Carley Hillsborough Research Fellow Royal College of Surgeons of England 106025,677@compuserve.com
	Date: 03.01.97 10:01 From: dulyatt@medeserv.com.au (David Ulyatt) Thankyou to all who responded to the question regarding appropriate management of the patient, and specifically the abdo, in the car versus ped MOI with head and lower limb injury. There are too many to reply to individually. The case notes had been seized by the police for the coroners inquiry by the time I had finished the ward round of the survivors. Hence the details are sketchy but I think accurate. NB I wasn't there so it is always possible things appeared differently to those in the ED at the time. I didnt mention she had extensive facial trauma but an intact airway. She had a tachycardia and SBP of 90 O/A in ED. Harts 1litre in transit. Corrected with "minimal" polygeline infused and then she remained haemodynamically stable with IV fluid ? how much and at what rate I dont know. She did not have any objective evaluation of the abdomen. She was sent to an orthopaedic ward for planned EFF#'s in the am. That next morning she had an Hb of 6.3g/dl. Had femoral #'s plated and screwed as appropriate and came to ICU postop stable with Hb about 13g/dl. Stable that pm until early hours of following morning when came unstable and abdo now noted to be grossly distended (IAP not measured). 0400 taken back to OT by general surgeons- Laparotomy: free clear fluid in peritoneal cavity ? urine. Similar fluid in retroperitoneum particularly around L kidney. Exploration for ? ruptured calyx unfortunately provoked heavy blood loss from an inadvertently ruptured renal vein. Gross instability ensued resulting in probable myocardial infarction. Anaesthesia unable to regain circulation ? cardiogenic shock. Returned to ICU in idioventricular rhythm and died soon after. I will post the coroners post mortem if it comes to hand. At this stage I agree with those respondents who advocated an expectant approach with close observation by personnell used to dealing with severe trauma. As she had a head CT scan in a spiral scanner the time and effort involved in obtaining an abdominal scan is minimal. I would have asked (?insisted) for one because of the MOI and the unknown speed of the vehicle. I would not have done a s/u dpl as it would have not given any retroperitoneal info like avulsion of kidney or extent of retroperit bleeding. DPL indicated for undiagnosed blood loss, or abdo injured but pt stable. The pelvis had only one ramus #'d and I would not have expected exsanguinating H'ge from there requiring angio or Ext fix, as mentioned by some.. Most, but not all, ageed with an objective evaluatiuon of some sort: U/S, DPL (supra umbilical) or abdo CT but this reflected to some extent either the known fatal outcome or the regular practice of the institution. Eg if you have and use abdo U/S in your resus why on earth not use it on a patient such as this. It would have been negative. DPL would have been negative. Abdo CT double contrast may have detected the urine leak which may have provoked a different management plan ? ureteric stent ??? perc nephrostomy. This approach may have avoided the fatal laparotomy. I can see no indication for early laparotomy as suggested by some respondents "as she was going to theatre anyway". She was stable with no clinical evidence of abdominal injury: noone would really have done an early lap. This case also indicates that the operative approach is not necessarily the safest. Need to remember that the ATLS/EMST approach are guidelines for universal efficient safe management that all of us can apply in the EARLY management in virtually any environment. There is more to the definitive management of trauma to prevent late trauma deaths and reduce morbidity. Also I believe all severe trauma that can get to a trauma centre should go there. Cant really comment on trauma surgeons looking after these patients exclusively as it does not apply in our environment anyway. An elderly patient with these injuries inour environment should go to an ICU for hge, fat embolism, headinjury and pain monitoring. Cant do this anywhere else inour world. Finally of course the retrospectoscope is not only a powerful instrument but also an important educator. Thankyou for your help, as it is clear we would not have all approached this in the same way. Further comments now you have the operative course are very welcome. David David Ulyatt Director of Intensive Care Mater Misericordiae Private Hospital 301 Vulture St, South Brisbane Qld, 4101, Australia.
	Date: 03.01.97 14:34 From: Keith Wesley [drwesley@primenet.com] In reply to Dave Adams: DPL is somewhat controversal in the face of pelvic fractures and if done should be done using an open approach rather than closed. The incidence of false positive DPL is higher in patients with pelvic fractures. The only reason to do a DPL is if the patient is crashing before your eyes and you need to know if the abdomen should be explored. A CT reveals more detail and would eliminate the unnecessary laparotomy caused by the false positive DPL.
	Date: 03.01.97 17:05 From: "Smith, J. Stanley, MD" [JStanley.Smith@hmc.psu.edu] For those who do not believe in magic, a comprehensive look at the entire torso as in CT is more often than not worth the "price".
	Date: 04.01.97 01:26 From: dave adams [dcrad@ihug.co.nz] Agreed but.. Pelvic fracture was only one of the reasons I suggested DPL in this case Sure there's a false positive rate of between 15 an 50% depending on who you read, but if it's negative it's reassuring that the abdo's OK. It still doesn't rule out retroperitoneal injury, and if in doubt I'd certainly go for CT. I personally use the closed technique, and would go above the umbilicus for a pelvic fracture but I have no argument against open except for the time it takes. Depends on what your used to I guess.
	Date: 04.01.97 03:48 From: Wendy Mosiman [wmosiman@feist.com] I think the answer is Abd. US. Very little money, no extra time. Wendy.
	Date: 04.01.97 04:26 From: dulyatt@medeserv.com.au (David Ulyatt) >Lisa S. Dresner <71211.2533@compuserve.com> wrote: > >We follow a specific protocol for all elderly patients with significant >trauma, as we admit 2-4 of these type patients a week. This protocol >was > snip Thankyou for your response, and I think your approach is laudable, measurable and auditable. Many hospitals have along way to go to achieving a consistent approach and some should probably not accept trauma admissions. Given the result that I posted yesterday would you care to comment on what would have taken place in your location following the orthopaedic fix. David Ulyatt
	Date: 04.01.97 04:41 From: dulyatt@medeserv.com.au (David Ulyatt) >Simon Carley [106025.677@compuserve.com] wrote: > >This patient has a severe lower limb injury and a head injury (one >presumes >as GCS down at scene). Unless they have been hit by a giant horseshoe >(and few people are) there is likely to be something >going on in the Torso! I love the "horseshoe" analogy. I have a prospective series of 120 cases of this "horseshoe" scenario to write up wherein a protocol for objective evaluation of the abdomen was agreed to by all players: surgeons, radiologists and intensivists although U/S was not available at the time. All patients were ventilated for severe head injury. I'll let you know the result if your interested. David Ulyatt
	Date: 04.01.97 10:40 From: "Eric Frykberg M.D." [ERF.TRAUMAONE@mail.health.ufl.edu] In reply to the contention that DPL should only be done in the face of a patient who is "crashing before your eyes"--this is decidedly NOT true or appropriate--in fact, as the ATLS course has made clear since its inception, as well as all literature on this procedure that I am aware of, DPL should only be done in the stable patient--the patient who is crashing belongs in the O.R. for an emergent thoracotomy or celiotomy--the idea that DPL should be done in a crashing patient is decidedly misguided Eric Frykberg, M.D. Jacksonville, Fl
	Date: 04.01.97 19:40 From: "Aviel Roy-Shapira" [avir@bgumail.bgu.ac.il] If I get the data streight, the patient described was hit by a motor vehicle, and sustained brief LOC at the scene, a small pelvic fracture and bilateral femoral fractures. Had ORIF of the femoral fractures and died on the orthopedic service a couple of days later. To my mind, the main issue in this case is not how the abdomen should have been evaluated, but where and by whom. . There are several ways to evaluate the abdomen, from serial physical examination to laparotomy, and this patient needed to have at least one of them. I would go against the grain of most previous posters, and suggest that serial evaluation is not unacceptable, PROVIDED it is done by an experienced trauma surgeon. At the time of admission, the patient was stable and concious. In such patients, serial evaluations by an experienced trauma surgeon, are probably the most sensitive and specific methods of evaluating the abdomen (other than laparotomy, of course) , I am saying serial evaluations and not physical examinations, since there is more to the assessment than looking for peritoneal signs. No matter how one would choose to evaluate the abdomen, this patient should remain in the care of a general surgeon with trauma experience, and should have been admitted to the ICU. Elderly patients with blunt trauma are a known pitfall. They tend to suddenly die on you, even with a normal CT. Bilateral femoral fracture are MAJOR trauma, and these patients should never go the orthopedic department, at least for the first few days after the injury. If I had to put this patient in the Orthopedic department, and leave town, I think that the safest course would be to explore. Even if I were to admit the patient to the surgery service, I would certainly do a CT if there is no available ICU bed. Lastly, unless I am missing something, it is far from certain that this patient died from a missed intra-abdominal injury. Although it could be a delayed splenic rupture, with the information given, I would rather suspect a massive PE: .elederly woman, femoral fractures, sudden deterioration 48 hours after the injury. Was a PM done? Avi Aviel Roy-Shapira, M.D. Dept. of Surgery A, and the Critical Care Unit, Soroka University Hospital POBox 151, Beer Sheva, Israel
	Date: 05.01.97 04:38 From: Aaron Waxman [aaron.waxman@yale.edu] Based on the information above, even with hemodynamic instability and normal neuro exam, I would be very concerned about the mechanism of injury. With bilateral femoral fractures and a pelvic fracture there is a good chance of visceral injury. From the sounds of things here exam was not suggestive. I am curious, however, what her overnight course was. Were there any signs or symptoms of abd injury as time went on. Was there hematuria? Rectal negative? Labsi.e Hct? With just the data presented it is hard to justify an ICU admission, I think a abdominal/Pelvic CT could be justified though. -- ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Aaron B. Waxman, MD, Ph.D. Section of Pulmonary and Critical Care Medicine Yale University School of Medicine E-mail: Aaron.Waxman@Yale.Edu ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
	Date: 05.01.97 04:38 From: dulyatt@medeserv.com.au (David Ulyatt) See subsequent post , and specifically there was no mention of any followup exams, but her Haemoglobin in the morning was 6.3g/l so I can only assume they looked at her then at the very least. PR exams are getting more common with our version of ATLS but I wou;d very much doubt that even with a pelvic # that a rectal was performed. Can only guess why it is so difficult to get these performed routinely. Could be wrong but can't get to case notes now. Also cant check that haematuria was or was not noted but I think that would have been mentioned. David David Ulyatt Director of Intensive Care Mater Misericordiae Private Hospital 301 Vulture St, South Brisbane Qld, 4101, Australia.
	Date: 05.01.97 11:52 From: Glen Hawkins [glenhawk@ozemail.com.au] >Wendy Mosiman wmosiman@feist.com wrote: > >I think the answer is Abd. US. Very little money, no extra time. >Wendy. This is interesting in that Abdo U/S is not a widely used modality in Australia and we often find it easier to obtain a spiral CT scan of the abdomen. I am intrigued as to the value and effectiveness of abdo U/S in the acute setting of abdominal trauma. What are peoples opinions of this? Cheers Glen
	Date: 05.01.97 15:42 From: PH Cosman [phcosman@mypostbox.com] Hi all, I can see us all really getting bogged down on the approach to evaluation of the traumatised abdomen: To CT or to DPL? This is a question which will never be answered definitively. That is not to say that there is no adequate answer: At Westmead, we probably tend to favour the scan, because -- at most times of the day and night -- it takes about as long as a DPL to scan the head (if required) and abdopelvis, and much more information is gleaned about the peritoneal cavity, as well as the retroperitoneum. At Liverpool, the inclination is towards DPL. Neither approach is incorrect; the ultimate decision depends on the capabilities of the staff and the facilities available, and, of course, the details of the case at hand. With all due respect to Dr Adams, if the patient was craching before my eyes, I wouldn't waste time with either method: it would be more appropriate to transfer the patient to theatre, and to further investigate there. If the laparotomy turns out to be negative, nothing is lost (despite claims of the traditional theoretical 5% -- where does this figure come from? -- morbidity), but if there is significant bleeding into the abdomen (which must be assumed if there is no evidence of chest trauma, and no other explanation) this is where it should be dealt with. Whether CT or DPL is the way to go, certainly elderly trauma patients require vigorous and aggressive ongoing assessment. Regards, PHC
	Date: 06.01.97 01:34 From: dulyatt@medeserv.com.au (David Ulyatt) Thanks for your input, but the question I would be interested to know is whether at your hosp you would have CT'd the abdo in this patient when you did the head. She was GCS 14/15 with no lateralisation, pupils = may not have had a head scan anyway. No evidence of abdo trauma and haemodynamically stable, having had less IV resus than you would have expected to cover the losses of her manifest injuries. No reason to suspect the abdo apart from the mechanism of injury and the pattern of head and lower limb trauma. She subsequently dies from surgical intervention with hamodynamic instability and distended abdo. Urine leak from somewhere. Would have been managed differently possibly if CT had demonstrated urine leak. Now, would your team have done an abdo CT at the time of admission or not? David David Ulyatt
	Date: 06.01.97 04:48 From: dulyatt@medeserv.com.au (David Ulyatt) Avi, thankyou for your thoughtful response which I attempt to discuss below >Aviel Roy-Shapira [avir@bgumail.bgu.ac.il] wrote: > >If I get the data streight, the patient described was hit by a motor >vehicle, and sustained brief LOC at the scene, a small pelvic >fracture and bilateral femoral fractures. Had ORIF of the femoral >fractures and died on the orthopedic service a couple of days later. Came to ICU following femoral fix'n. Deteriorated 12 hours later, please refer to subsequent post. >In my mind, the main issue in this case is not how the abdomen should >have been evaluated, but where and by whom. . > >There are several ways to evaluate the abdomen, from serial physical >examination to laparotomy, and this patient needed to have at least one >of them. I would go against the grain of most previous posters, and >suggest >that serial evaluation is not unacceptable, PROVIDED it is >done by an experienced trauma surgeon. I have seen poor abdominal management by so many experienced general surgeons that I could not agree with you. However I have no experience of observing surgeons who specialise in trauma following these patients with serial evaluations. The serial evaluation was always left to more junior staff who are then corrected when everything goes wrong. Usually too little too late, not responding to subtle changes. >At the time of admission, the patient was stable and concious. In >such patients, serial evaluations by an experienced trauma surgeon, >are probably the most sensitive and specific methods of >evaluating the abdomen (other than laparotomy, of course) , Given the outcome that I subsequently posted, do you still think that laparotomy in this patient is the "ultimate weapon". >I am saying serial evaluations and not physical examinations, since >there is more to the assessment than looking for peritoneal signs. Absolutely, and well said. >No matter how one would choose to evaluate the abdomen, this patient >should remain in the care of a general surgeon with trauma >experience, and should have been admitted to the ICU. Elderly patients >with >blunt trauma are a known pitfall. They tend to suddenly die on you, >even with a normal CT. Bilateral femoral fracture are MAJOR trauma, >and these patients should never go the orthopedic department, at >least for the first few days after the injury. I agree and will be referring to these reponses when I present this case at surgical grand rounds. >If I had to put this patient in the Orthopedic department, and leave >town, I think that the safest course would be to explore. Explore with no clinical indication apart from mechanism and pattern of injury ? Really? >Even if I >were to admit the patient to the surgery service, I would >certainly do a CT if there is no available ICU bed. >Lastly, unless I am missing something, it is far from certain that this >patient >died from a missed intra-abdominal injury. Although it could be >a delayed splenic rupture, with the information >given, I would rather suspect a massive PE: .elederly woman, femoral >fractures, sudden deterioration 48 hours after the injury. > >Was a PM done? Will be done by the coroner and I will inform you. However it appears she had a rupture of her urinary tract, became unstable as a result of bleeding that developed during renal exploration, perhaps infarcted and died. As indicated in my followup post I wonder whether she would have been managed conservatively had she had a CT. This is an outlyer, an unusual death given that most of the comments are appropriately directed towards occult hemorrhage rather than perforated hollow viscus. We surely are interested in preventing all "potentially preventable" deaths and wonder whether this sort of case warrants revising our approach to the detection of occult abdominal injury not just hemorrhage. >Avi. > thanks, David David Ulyatt
	Date: 06.01.97 09:36 From: dave adams [dcrad@ihug.co.nz] Hi Dr Cosman Agree almost entirely with your comments. The EMST/ATLS dictum is that the only absolute contraindication to a DPL is a patient who clearly needs a laparotomy. I understood that in the case presented the patient wasn't crashing in front of our eyes so there was time to evaluate the belly with one of these techniques. Having said that let me make one more plug for DPL. Several times I've seen multiple victims simultaneously through our resusc. room from multi-vehicle accidents (like the truck & trailer unit that ran over the minibus - 3 dead at scene and 8 in varying degrees of instability, with a convincing M.O.I.). You can't put them all through the scanner at once, but you can run DPL's simultaneously. Cheers, Dave
	Date: 06.01.97 11:06 From: "Eric Frykberg M.D." [ERF.TRAUMAONE@mail.health.ufl.edu] Glen-- The accuracy and value of U/S in the evaluation of the abdomen following trauma is far beyond the realm of opinion at this time in the U.S., and even farther beyond it in Europe, where it has been used for several years--and unlike DPL, it also provides a good look at the heart, pericardium, thorax for rapid diagnosis of hemopthorax, and some retroperitoneal structures(i.e. the kidneys). Unlike DPL, too, but like CT, it is not proven to be accurate for detecting early bowel injury, but the possibility of nicely imaging the diaphragm for injury to it remains a potential possibility. Unlike CT, it is INEXPENSIVE! Eric Frykberg, M.D. Jacksonville, Fl
	Date: 06.01.97 18:54 From: "Lisa S. Dresner" [71211.2533@compuserve.com] David Ulyatt wrote >Given the result that I posted yesterday would you care to comment on what >would have taken place in your location following the orthopaedic fix. The patient would return to the SICU and remain under the care of the trauma service. We have an open ICU (that functions like a closed ICU) and she would remain there until ready for minimal nursing care on the ward or transfer to a rehab center. Rarely, would a multiple trauma patient be transferred to the orthopod service, and only after all other problems are resolved. We think of this patient as a multi-trauma patient and those patients remain on the trauma service until discharge unless thay are awaiting only complicated single service care (like a free flap on an open fracture, or joint reconstruction. I hope this answers your question Lisa Dresner
	Date: 06.01.97 20:25 From: Aviel Roy-Shapira On Mon, 6 Jan 1997, David Ulyatt wrote: > Came to ICU following femoral fix'n. Deteriorated 12 hours later, please > refer to subsequent post. I have answered before reading the subsequent post. Having read it, I think this is a case where the US, DPL, and even CT may not have identified the injury. A double contrast spiral CT may have identified a renal injury, but not the urinary leak. I recall one such patient where the only clue was that the BUN rose much higher than the creatinine. In fact, the leak was identified by logitudinal evaluation in the ICU, and by laparotomy. The death was caused by a technical problem at laparotomy, not because the injury was missed. I am not sure about the best management of a urinary leak in these cirumstances. It is possible that instead to reaching for the kidney, one should have obtained an IVP on the table, and deciding on the approach based on where the leak came from. If the patient is bleeding from the L. kidney, the fastest way to control the bleeding is to do a Mattox maneuver (medial rotation of the viscera) and cross clamp the pedicle. > >At the time of admission, the patient was stable and concious. In > >such patients, serial evaluations by an experienced trauma surgeon, > >are probably the most sensitive and specific methods of > >evaluating the abdomen (other than laparotomy, of course) , > > Given the outcome that I subsequently posted, do you still think that > laparotomy in this patient is the "ultimate weapon". See above. It would have identfied the injury, and if properly done, should not have led to the patient's demise. > >If I had to put this patient in the Orthopedic department, and leave > >town, I think that the safest course would be to explore. > > Explore with no clinical indication apart from mechanism and pattern of > injury ? Really? Well, the cirumstances (leave patient in ortho and leave town) are a bit far fetched. Still, a non-therapeutic laparotomy is better than missing a serious injury. I believe Mattox made a similar comment - no wonder, since I did my trauma fellowship at Ben Taub. > that developed during renal exploration, perhaps infarcted and died. As > indicated in my followup post I wonder whether she would have been managed > conservatively had she had a CT. As I said, I am not sure a CT would have identified the leak, particularly early on. On the contrary, a negative CT might have lead to a false sense of security, and further delays in the diagonosis. > This is an outlyer, an unusual death given > that most of the comments are appropriately directed towards occult > hemorrhage rather than perforated hollow viscus. We surely are interested > in preventing all "potentially preventable" deaths and wonder whether this > sort of case warrants revising our approach to the detection of occult > abdominal injury not just hemorrhage. Perfect is the enemy of good. I would not change policy based on an odd case such as this. Avi ================================================================ Aviel Roy-Shapira, M.D. Ben-Gurion University Medical School Dept. of Surgery A. POB 151, Beer Sheva, Israel
	Date: 07.01.97 12:30 From: Simon Carley [106025.677@compuserve.com] >The accuracy and value of U/S in the evaluation of the >abdomen following trauma is far beyond the realm of opinion at >this time in the U.S., and even farther beyond it in Europe, >where it has been used for several years--and unlike DPL, it also >provides a good look at the heart, pericardium, thorax for rapid >diagnosis of hemopthorax, and some retroperitoneal >structures(i.e. the kidneys). Unlike DPL, too, but like CT, it >is not proven to be accurate for detecting early bowel injury, >but the possibility of nicely imaging the diaphragm for injury to >it remains a potential possibility. Unlike CT, it is >INEXPENSIVE! I agree with all the above but would wish to point out that USS is user dependant (like everything else) but can be safely taught and practised by Emergency Medicine/Trauma Surgery docs. A previous discussion on the EMED-L list quoted papers showing this and demonstrated a learning curve of about 30 patients to spot gross intra-abdominal (and thoracic) pathologies. I'm afraid I have lost the references. The DPL/USS/CT debate has been running for a long time and I have read several papers advocating one or all of them. I suspect that on many occasions the results are predominantly affected by the setting and experience of the operators. Just my 2 cents worth. As I have previously said our practice is generally to spiral CT abdomens as we have a nearby scanner. However, USS is great for the patient who is too sick to move to scan as it can be done very quickly in the resus room. So I would like to add PORTABILITY to the benefits list given above. Simon Carley
	Date: 07.01.97 14:19 From: "Eric Frykberg M.D." [ERF.TRAUMAONE@mail.health.ufl.edu] Glen--I was talking about real life--the abundant literature and clinical experience has led to no dispute about its REAL (not potential)) accuracy in the setting of abdominal evaluation following blunt trauma. Now, like any method of evaluation we talk about, that presumes that the operator knows what he/she is doing, is trained in its proper use,etc--if you have some doubt about that in your particular institution, I guess U/S mmay not be of value for you, but understand that doubt should not exist--this is one of the reasons it is advocated that surgeons learn the technique themselves, which is very easy to learn--what you say about inconsistency you see in its application to gallbladder, etc, suggests your institution is not up to current standfards, and maybe you should take that up with your radiologists. We have been using U/S as the routine method for screening for abdominal injury in this setting for the past 2 years, and our residenrts now complain they no longer know how to do DPL's--because we never do them anymore--it is obvious to us how effective it is and how accurate, especially when negative for intra-abdominal blood. Rarely do we ever get abdominal CT's anymore, either. Eric Frykberg, M.D. Jacksonville, Fl
	Date: 07.01.97 14:47 From: Glen Hawkins [glenhawk@ozemail.com.au] I agree with the potential benefits of U/S in the emergency room for the rapid evaluation of blunt abdominal trauma in particular and accept that you can also use it to evaluate other injuries such as diaphragmatic rupture and to a degree cardiac injury. My main concern is that in my limited experience with U/S the technique and results are very variable for _simple_ procedures (gallstones, solid tumours etc) and I am concerned that in a resuscitation situation this may lead to problems (ie missed injuries). DPL and CT tend to be a little less variable as far as I can see. I was wondering more what the real life situation may be in this respect. Cheers Glen