Priorities Question Part 2
	Date: Sun, 23 Jun 1996 14:25:51 From: Aviel Roy-Shapira, M.D. [avir@bgumail.bgu.ac.il] Most everyone supported immediate lap, with burr holes if there were laterlizing signs. Some suggested burrs all around. Or ICP. Well, the patient was taken for a lap. Neurosurgeon won't burr without CT or lateralizing signs, and advised aggressive ICP reduction with manitol and hyperventilation, while lap is being performed. At laparotomy, a grade I liver lac is found. About 750 of fresh blood in the peritoneal cavitity, no other injuries. Bleeding easilly controlled with a couple of buttressed stitches. 20 mintues into the procedure, we are about to close, when BP falls to 30 systolic, by the arterial line. HR around 90. Anesthesiologist complains that the patient is hypovolemic, and is pushing fluids like crazy. No response. What now?
	Date: Mon, 24 Jun 1996 10:48:13 From: William Griggs [wgriggs@medicine.adelaide.edu.au] Again we need a bit more information. There are a number of things which might be happening here. (1) Concealed blood loss - into the chest is most likely in this case. Has his torn aorta let go? This seems unlikely as they usually die immediately, but another intrathoracic bleeding point is possible. (2) Tension pneumothorax - common things occur commonly. Is he hard to ventilate? What are the breath sounds? Mediastinal shift? (3) Cardiac tamponade - less common but consistent with the presentation. Do you have central venous pressures available? Neck veins up? (4) Coning - immediately after coning, profound hypotension can occur. If this is the cause, it's too late, so eliminate other options first. Pupils would be fixed. (5) Anaphylaxis/anaphylactoid reaction - any other signs, flushing, bronchospasm, immediately after antibiotic/new blood bag? Other options such as large intraoperative myocardial infarction, and gas embolism are possible also although again less common. No response to fluids suggests that this is a big problem. Is there any more clinical information to help guide us as to the problem as this will determine which path to follow?
	Date: Mon, 24 Jun 1996 18:53:29 From: John A. Aucar, M.D. [jaucar@bcm.tmc.edu] Having brought the subject up, I don't mind clarifying. Blind burr holes are an act of despiration that no-one in thier right mind would prefer if there is any other resonable alturnative. In cases like the one described, which I agree is not uncommon, going to the CT scanner is not reasonable. The only (small) chance a patient like this has for a favorable outcome is early double-teaming with simultaneous laparotomy/decompressive craniotomy. It may have been a worse hepatic injury or his head injury may have been diffuse and not drainable, but the therapy wouldn't have made it any worse (cost/benefit is another subject). But, if he herniated during laparotomy for a low grade liver injury due to an epidural or subdural hematoma (unilateral or bilateral, then to not do blind burr holes is like me refusing to put in bilateral chest tubes for hypotensive chest injuries because because I need an x-ray to diagnose the tension pnuemothoraces. If I have time for an x-ray, I'll use it, tough luck if I don't. If patients like this one also have an aortic injury, you better hope the adventitia holds. To fix a transected aorta supine (the patient) isn't much of an option and turning him up on his left side with a bleeding liver and who knows what in his head is bolder than I'll ever admit to being. Similar patients die in my hands with some regularity and sometimes I think a coin toss is better than my judgement. Remember, making tough decisions with limited information is why we are paid the big bucks (or should be).
	Date: Mon, 24 Jun 1996 20:20:32 From: Moshe Schein [mschein@planet.earthcom.net] Avi, There must be a "catch" here because otherwise you would'nt post this case... There is no evidence of long bone fractures, no other source of bleeding into the soft tissue compartments; you have assessed the retroperitoenum and it is normal. Well, now I would have opened the chest, assessing the heart and great thoracic vessels. Finding no cause for hypotension also in the chest I would diagnose the so called agonal hypotension associated with severe brain injury, due to failure of the centers controlling vasoconstriction.... Now what is the "catch" ? did you find air emboli in the heart? Moshe Schein, Brooklyn
	Date: Mon, 24 Jun 1996 21:41:38 From: Dr. Jay Smith [SSMITH4@surg.hmc.psu.edu] Patient has either ruptured aorta or herniated.