Timing of Operation
	Date: 02.04.97 10:58 From: "Alexander N. Chelnokov" [alex@uniito.e-burg.su] Hi all! A female patient ~30 y.o. transferred yesterday to our clinic from a little town. 8 days ago she was injuried in a car accident (she was inside a vehicle). She has moderate cerebral contision and diaphyseal fractures of both femurs (32C1.1 and 32B2.2). Except this, focal ishaemic ECG changes were found - interpreted as cardiac contusion. Today her condition seems to be stable - at sceletal traction. Hemodynamically and neurologically she is normal. So the question is when should osteosythesis be performed? Anesthesiologists are shouting that not earlier than 2 weeks since today because of ECG changes. What would you recommend? Any additional laboratory analyses? When osteosynthesis should be perfomed? --- Best regards, Alexander N. Chelnokov Ural Scientific Institute of Traumatology and Orthopaedics str.Bankovsky, 7. Ekaterinburg 620014 Russia
	Date: 02.04.97 17:07 From: "Dr. Mark Perni" [drperni@citynet.net] Obtain echocardiogram or thalium scan to evaluate myocardial status and if not severely compromised, go to O.R. The risk of further delays of operative fixation far out weigh the rare complications of myocardial contusion.
	Date: 02.04.97 20:40 From: "Louis Brusco Jr., M.D." [lb86@columbia.edu] What will change for the anesthesiologist in two weeks? If it is healthy 29 year old, she should be at no increased risk for anything that will change in that period of time. Waiting two weeks would not seem to be an option for me - you just go ahead and do it when surgically you feel it shoulc be done. I would ask them what they are worried about happening. -- Louis Brusco Jr., M.D. Director, Critical Care Anesthesiology Co-Director, SICU St. Luke's-Roosevelt Hospital Center, NYC
	Date: 03.04.97 01:33 From: pablodelucas [pablodelucas@pulso.com] At my Hospital . (h. Ramón y Cajal) in Madrid Spain. this case may be treated as soon as her conditions are stabilised.
	Date: 03.04.97 02:31 From: "Stephen M. Stowe, M.D." [102747.3140@CompuServe.COM] By focal ischemic changes I assume that you mean ST segment elevation or depression. This finding is common after brain trauma and in this setting I do not think that it should prevent the orthopedic procedures Stephen M. Stowe, M.D.
	Date: 03.04.97 02:31 From: H. Scott Bjerke [TraumaDoc3@aol.com] I would concur with the thallium scan or echo...see if there is any real cardiac insufficiency which might make surgery less safe. The diagnosis of "cardiac contusion" is still considered questionable by some very well published trauma/critical care people, so I think you need to "prove" there is cardiac compromise. Also controversial but with more science behind it, use of the pulmonary artery catheter for pre- and intra op management in documented myocardial infartion has been shown to improve outcomes. If this patient had a perforated bowel you wouldn't wait, why wait for the eventual fat emboli if you don't have to. H. Scott Bjerke, MD Associate Professor of Surgery Chief - Division of Surgical Critical Care University of Nevada School of Medicine 2040 W. Charleston Blvd., Suite 601 Las Vegas, NV 89102
	Date: 03.04.97 02:3 From: "Dino Aguilar MD." [daguilar@ibw.com.ni] Surgery must be done asap. In you are waiting to improve conditions, that's not a good options. Get a lot information about it in Instructional Course in Orthopaedic at the AAOS. Don't loose your time (or patient's time life!) Bye. Dino Aguilar, MD PO Box: 2261 Managua, Nicaragua
	Date: 03.04.97 13:25 From: Chris Taylor [chris@knakee.demon.co.uk] what is an echo or thalium scan going to tell you that you're not going to elicit better by asking the patient "how are you today ?" the only anaethetic risk I know of in myocardial contusion is that of an arrythmia - and the critical period for that has long since passed. I would have said "get on with it, the sooner the better". -- Chris Taylor
	Date: 04.04.97 17:33 From: "Smith, J. Stanley, MD" [JStanley.Smith@hmc.psu.edu] I concur with echo. If there is any contractile compromise, then monitor with PA catheter and take to OR.