Priorities Question Part 1
	Date: Fri, 21 Jun 1996 17:55:42 From: Aviel Roy-Shapira, M.D. [avir@bgumail.bgu.ac.il] This is not a rare problem. A 59 years old man was knocked of his motor-scooter by a running car. Intubated en route to the hospital. An hour later he is in the ER with GCS of 4, decerbrate posturing, BP 200/90, HR 66. Over the next 30 minutes, BP drops to 110/90 HR rises to 136. Abdominal lavage is done, and fresh blood is drawn when the Arrow catheter is inserted. CXR shows a questionable widening of the upper mediastinum, C-spine (XTL) and Pelvis are clear. He is ready to be moved. What now? Head CT or Exploratory lap?
	Date: Fri, 21 Jun 1996 15:01:24 From: John A. Aucar [jaucar@bcm.tmc.edu] Hi Avi, Choice: A. Laparotomy and simultaneous blind burr holes (up to 6) B. If there's pupillary asymetry do the burr holes first C. Wait five more minutes and the choice will be made for you. So, how did it go?
	Date: Fri, 21 Jun 1996 17:18:04 From: Roy L. Alson, PhD, MD, FACEP [ralson@bgsm.edu] With the postive tap, he most likely is bleeding in his abdomen. However, with the reported widened mediastinum, he also could have a great vessel injury. Since we are fortunate enough to have a helical scan CT in our ED, I would scan this patients head and chest, in the event that he needs operative intervention for these problems, on my way to the OR for his lap.
	Date: Sat, 22 Jun 1996 00:33:10 From: Aviel Roy-Shapira, M.D. [avir@bgumail.bgu.ac.il] I took him up stat. There was a grade I liver lac, with about 1L of blood, mostly right gutter and pelvis. Nothing much. He dropped BP 10 minutes into the OR. Cracked chest. Hematoma around the root of the aorta. some blood tinged percardial fluid. Neurosurgeon would not blind burr. On PM there was a linear skull fracture. Epidural, subdural and intracerebral bleed. Herniation. Not compatible with life. He was probably brain dead when we took him up. Probably should blind burr anyway.
	Date: Sat, 22 Jun 1996 09:58:36 From: Dr William Griggs [griggs@medicine.adelaide.edu.au] In our institution he would get an expolaratory laparotomy. The reasons (1) A,B,C,D - C comes before D (simplistic perhaps but a reasonable starting point) (2) If his GCS has been 4 since the scene it is quite likely that he does not have a surgically remedial head injury. (3) Our CT scanner is two floors and 100 mtrs away from our resus room. The emergency OR is 20 mtrs only. The caveats (1) If his initial GCS was much higher i.e. lucid interval and his CVS could apparently cope with the delay I would consider CT first. I would balance this against his apparent CVS stability. (2) If we had a CT in/next to the resus room I would have a lower threshold for CT first. (3) If he remains "stable" enough, he may need his arch investigated as well either by aortography or in the right hands by TEE. A big issue which this touches on is "cardiovascular stability" Everyone bases decisions (Lavage vs immediate Lap etc) on whether or not the patient is "stable", but no-one defines what is "stable" It is not clear how stable this patient is - Has he had 6 units of blood in the last hour or 200 mls crystalloid? Obviously, stability needs to be judged on more than whether the systolic blood pressure has two or three digits - although it is amazing how often response to the question "Is he stable?" is "What is the blood pressure?" and the attitude to that response is "Three digits good, two digits bad". Does anyone out there have a definition for stability and if so what validation has it had?
	Date: Fri, 21 Jun 1996 17:32:10 From: Dr. Jay Smith [SSMITH4@surg.hmc.psu.edu] Exploratory Lap with Burr holes if there are lateralizing signs, ICP monitor if no lateralizing signs, and Transesophageal echocardiography for evaluation of aorta in the OR. Stability implies more than one measurement. To be stable, requires several measurements nearly equal. For instance, 200/90 decreasing to 110/70 is not stable, neither is 110/70 increasing to 150/90. Rather than using the word "stable", I prefer "perfusing". Perfusing requires a bp > 90, A pulse rate < 120, urine output > 0.5 cc/kg, and no base deficit. Nonperfusion would be outside these limits. The base deficit is a good guide to perfusion no matter what the measurements of vital signs are.