List Archives

Wed, 9 Jan 2002 17:44:26 -0000

Dear Ron,

The key to successful management of your patient is ensuring that the
patient's pleura is adequately drained - the fact that your patient
developed progressive surgical emphysema despite a pleural drain implies the
opposite.

A further smaller point worth considering is that although massive surgical
emphysema itself is rarely (if ever) life threatening, it can be extremely
uncomfortable and indeed distressing particular if vision is compromised by
orbital swelling. PROVIDING the pleura is adequately drained, valuable
symptomatic relief can be achieved by simply milking (massaging) the
subcutaneous air away from the face and venting either through 14G cannula
placed subcutaneously or through all through very small(mms) subcutaneous
infraclavicular incisions. 

John Black
Emergency Department
John Radcliffe Hospital
Oxford 

-----Original Message-----
From: trauma-list-request@trauma.org
[mailto:trauma-list-request@trauma.org]
Sent: 9 January 2002 12:06
To: trauma-list@trauma.org
Subject: trauma-list digest, Vol 1 #1236 - 25 msgs

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Today's Topics:

   1. Re: bile fistula (Ronald Simon)
   2. Re: bile fistula (DocRickFry@aol.com)
   3. Re: bile fistula (Salim El-Hayek)
   4. forward aid team / medical aid team (CLAIRE FRASER)
   5. penetrating trauma definition (Kate Curtis)
   6. Re: bile fistula (=?iso-8859-1?Q?Jos=E9_M._Del_Pino?=)
   7. RE: penetrating trauma definition (Greg Benton)
   8. RE: Head injury (Karim Brohi)
   9. Re: penetrating trauma definition (DocRickFry@aol.com)
  10. Re: penetrating trauma definition (DocRickFry@aol.com)
  11. Venting subcutaneous emphysema (Ronald Simon)
  12. Re: Venting subcutaneous emphysema (MARK FORREST)
  13. Re: penetrating trauma definition (Enrique y Maritza Montbrun)
  14. Re: Venting subcutaneous emphysema (KMATTOX@aol.com)
  15. Re: Venting subcutaneous emphysema (KMATTOX@aol.com)
  16. Re: Venting subcutaneous emphysema (KMATTOX@aol.com)
  17. Re: Venting subcutaneous emphysema (KMATTOX@aol.com)
  18. Re: Venting subcutaneous emphysema (KMATTOX@aol.com)
  19. Re: bile fistula (Nappio@aol.com)
  20. Re: Venting subcutaneous emphysema (Ronald Simon)
  21. Re: Venting subcutaneous emphysema (Nappio@aol.com)
  22. Re: bile fistula (J.C. Goslings)
  23. Re: penetrating trauma definition (Ian Civil)
  24. RE: Venting subcutaneous emphysema (Thomas Anthony Horan)
  25. RE: Pneumothoracies and CT scans - a long time worry for me (Holmes
John)

--__--__--

Message: 1
Date: Tue, 08 Jan 2002 07:51:21 -0500
From: Ronald Simon <TraumaMD@nyc.rr.com>
To: trauma-list@trauma.org
Subject: Re: bile fistula
Reply-To: trauma-list@trauma.org

I believe an ERCP would help locate the fistula better and give you your 
options. If a leak is from the liver of bile ducts you might try passing 
a stent  to open the ampulla which may relieve enough pressure to close 
the fistula. If an injury to the GB it should just be taken out.
Ronald Simon, MD
Director of Trauma/SICU
Jacobi Medical Center
Bronx, NY

Honorio Ma. Jr. Pangilinan wrote:

>I have a 22 year old male patient who was referred to
>our facility after sustaining 2 GSWs to the back. He
>was initially admitted to a remote provincial hospital
>where he reportedly underwent laparotomy for repair of
>multiple intestinal perforations. He was subsequently
>transferred to our facility 33 hours post-injury.
>
>On admission he was stable, normotensive, afebrile. He
>had 2 GSWs at the back, one at level L1 left mid
>scapular line, and another at level T10 right
>posterior axillary line. Anteriorly he had a sutured
>midline laparotomy incision and there was a GSW of
>exit in the epigastrium, just to the right of the
>midline from which was oozing brownish fluid (bile).
>The abdomen was flat, soft, with slight tenderness on
>palpation around the incision, otherwise, everything
>was unremarkable. 2 days later, he was still afebrile,
>the abdomen was soft and non-tender, and he was
>hungry. The output from the GSW of exit was 700 cc.
>Suspecting a biliary-cutaneous fistula a soft Fr 10
>rubber catheter was inserted into the cutaneous
>opening and a fistulogram was done. This revealed
>opacification of the gall bladder and intra hepatic
>ducts. There was no spillage of contrast into the
>peritoneal cavity. Patient is now on his 5th day in
>our hospital, he is feeding, has passed flatus and
>stools, and remained afebrile. No abdominal
>complaints, no jaundice. Fistula output is 750 to 900
>cc bile per day. We plan to operate on him to try to
>locate the source of the bile leak.
>
>Is there room for non-operative management in this
>case? Any opinion from the list will be appreciated.
>
>Dr. Jun Pangilinan
>Baguio General Hospital
>Baguio City, Philippines 
>
>__________________________________________________
>Do You Yahoo!?
>Send FREE video emails in Yahoo! Mail!
>http://promo.yahoo.com/videomail/
>
>--
>trauma-list : TRAUMA.ORG
>To change your settings or unsubscribe visit:
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>

--__--__--

Message: 2
Date: Tue, 08 Jan 2002 09:53:47 EST
From: DocRickFry@aol.com
Subject: Re: bile fistula
To: <trauma-list@trauma.org>
Reply-To: trauma-list@trauma.org

There is no pressing need to operate on this, especially if your aim is just
to go in and "try to find the source"--it won't work!  Several nonop
measures can be tried--even if none work, simply letting it go as is should
be no problem--the patient is not being affected by this.
ERCP with internal ampullary stenting should help close this by
preferentially shunting thebile out the ampulla, as well as excluding a
possible site ofdistal obstruction to explain this unusual occurrrence.
Somatostatin mighthelp reduce fistula output.  Hepatic CT-angio may allow a
radiologic intervention to obliterate the bile leak--all depends on what
resources you have in your hospital
ERF

--__--__--

Message: 3
From: "Salim El-Hayek" <shayek@neoucom.edu>
To: <trauma-list@trauma.org>
Subject: Re: bile fistula
Date: Tue, 8 Jan 2002 16:01:32 -0500
Reply-To: trauma-list@trauma.org

There is really no reason to intervene at this stage unless there is
peritoneal spillage. If the biliary leak is contained and there is no distal
obstruction then it will dry out. However at a later date your patient may
require an elective cholecystectomy under much more ideal
circumstances...Good luck
----- Original Message -----
From: "Honorio Ma. Jr. Pangilinan" <junpangilinan@yahoo.com>
To: <trauma-list@trauma.org>
Sent: Tuesday, January 08, 2002 1:17 AM
Subject: bile fistula

> I have a 22 year old male patient who was referred to
> our facility after sustaining 2 GSWs to the back. He
> was initially admitted to a remote provincial hospital
> where he reportedly underwent laparotomy for repair of
> multiple intestinal perforations. He was subsequently
> transferred to our facility 33 hours post-injury.
>
> On admission he was stable, normotensive, afebrile. He
> had 2 GSWs at the back, one at level L1 left mid
> scapular line, and another at level T10 right
> posterior axillary line. Anteriorly he had a sutured
> midline laparotomy incision and there was a GSW of
> exit in the epigastrium, just to the right of the
> midline from which was oozing brownish fluid (bile).
> The abdomen was flat, soft, with slight tenderness on
> palpation around the incision, otherwise, everything
> was unremarkable. 2 days later, he was still afebrile,
> the abdomen was soft and non-tender, and he was
> hungry. The output from the GSW of exit was 700 cc.
> Suspecting a biliary-cutaneous fistula a soft Fr 10
> rubber catheter was inserted into the cutaneous
> opening and a fistulogram was done. This revealed
> opacification of the gall bladder and intra hepatic
> ducts. There was no spillage of contrast into the
> peritoneal cavity. Patient is now on his 5th day in
> our hospital, he is feeding, has passed flatus and
> stools, and remained afebrile. No abdominal
> complaints, no jaundice. Fistula output is 750 to 900
> cc bile per day. We plan to operate on him to try to
> locate the source of the bile leak.
>
> Is there room for non-operative management in this
> case? Any opinion from the list will be appreciated.
>
> Dr. Jun Pangilinan
> Baguio General Hospital
> Baguio City, Philippines
>
> __________________________________________________
> Do You Yahoo!?
> Send FREE video emails in Yahoo! Mail!
> http://promo.yahoo.com/videomail/
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/traumalist.html

--__--__--

Message: 4
From: "CLAIRE FRASER" <FRAZ@clairefraser.fsnet.co.uk>
To: <trauma-list@trauma.org>
Subject: forward aid team / medical aid team
Date: Mon, 7 Jan 2002 20:59:50 -0000
Reply-To: trauma-list@trauma.org

This is a multi-part message in MIME format.

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I am trying to devise documentation to be utilised whilst on a call out. =
Any existing documentation or ideas would be great !

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<META content=3D"MSHTML 5.00.2919.6307" name=3DGENERATOR>
<STYLE></STYLE>
</HEAD>
<BODY bgColor=3D#ffffff>
<DIV><FONT face=3DArial size=3D2>I am trying to devise documentation to =
be utilised=20
whilst on a call out. Any existing documentation or ideas would be great =

!</FONT></DIV></BODY></HTML>

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--__--__--

Message: 5
From: Kate Curtis <CurtisK@sesahs.nsw.GOV.AU>
To: trauma-list@trauma.org
Subject: penetrating trauma definition
Date: Tue, 8 Jan 2002 17:15:43 +1100 
Reply-To: trauma-list@trauma.org

Hi all

We're compiling a regional trauma data dictionary, and have conflicting
views on the definition of penetrating trauma.  Obviously a gsw or stabbing
is likely to be penetrating, what about falling through a glass window and
getting a laceration?  What about a chainsaw injury?  

Can anyone provide their concise definition from their data dicitonary?

Many thanks

Kate

Kate Curtis
Trauma Coordinator
St George Hospital
Gray St, Kogarah
NSW, 2217
ph:   (02) 9350 3499 or (02) 3950 1111 page 019
fax:   (02) 9350 3974
email: curtisk@sesahs.nsw.gov.au

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Message: 6
From: =?iso-8859-1?Q?Jos=E9_M._Del_Pino?= <delpino@comtf.es>
To: <trauma-list@trauma.org>
Subject: Re: bile fistula
Date: Tue, 8 Jan 2002 10:35:26 -0000
Reply-To: trauma-list@trauma.org

This is a multi-part message in MIME format.

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Perhaps you must try to perform an ERCP wich would be not only =
diagnostic where the biliary duct injury is, but con allow complete =
biliary diversion to duodenum by plastic endostenting or sphincterotomy =
with nasobiliary drainage. These technics are proved to heal =
postraumatic biliary fistula without any operative intervention.

Jos=E9 M. Del Pino, MD
Digestive Surgery Service
Hosp. Universitario Ntra. Sra. de Candelaria
Tenerife, Canary Islands, Spain
  ----- Original Message -----=20
  From: SJASMD@aol.com=20
  To: trauma-list@trauma.org=20
  Sent: Tuesday, January 08, 2002 9:02 AM
  Subject: Re: bile fistula

  In a message dated 1/8/2002 1:21:01 AM Eastern Standard Time, =
junpangilinan@yahoo.com writes:

    Suspecting a biliary-cutaneous fistula a soft Fr 10
    rubber catheter was inserted into the cutaneous
    opening and a fistulogram was done. This revealed
    opacification of the gall bladder and intra hepatic
    ducts. There was no spillage of contrast into the
    peritoneal cavity

  seems like the fistulogram failed and should be repeated=20
  it showed a connection between the biliary tree and the surface you =
just didnt identify how the contrast media arrived in the biliary tree.=20
  whether there is aplace for nonoperative management depends upon the =
location of the fistula and the condition of the outflow tract of the =
biliary tree. If there is no obstruction you probably can control the =
fistula by drainage
  if the main duct is injured or obstructed, then percutaneous drainage =
wont work

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	charset="iso-8859-1"
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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<HTML><HEAD>
<META http-equiv=3DContent-Type content=3D"text/html; =
charset=3Diso-8859-1">
<META content=3D"MSHTML 6.00.2600.0" name=3DGENERATOR>
<STYLE></STYLE>
</HEAD>
<BODY bgColor=3D#ffffff>
<DIV><FONT face=3DArial size=3D2>Perhaps you must try to perform an ERCP =
wich would=20
be not only diagnostic where the biliary duct injury is, but con allow =
complete=20
biliary diversion to duodenum by plastic endostenting or sphincterotomy =
with=20
nasobiliary drainage. These technics are proved to =
heal&nbsp;postraumatic=20
biliary&nbsp;fistula without any operative intervention.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Jos=E9 M. Del Pino, MD</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Digestive Surgery Service</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Hosp. Universitario Ntra. Sra. de=20
Candelaria</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Tenerife, Canary Islands, =
Spain</FONT></DIV>
<BLOCKQUOTE=20
style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
  <DIV style=3D"FONT: 10pt arial">----- Original Message ----- </DIV>
  <DIV=20
  style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
  <A title=3DSJASMD@aol.com =
href=3D"mailto:SJASMD@aol.com">SJASMD@aol.com</A> </DIV>
  <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A =
title=3Dtrauma-list@trauma.org=20
  href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =
</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Tuesday, January 08, 2002 =
9:02=20
  AM</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> Re: bile fistula</DIV>
  <DIV><BR></DIV><FONT face=3Darial,helvetica><FONT=20
  style=3D"BACKGROUND-COLOR: #ffffff" size=3D2>In a message dated =
1/8/2002 1:21:01=20
  AM Eastern Standard Time, <A=20
  href=3D"mailto:junpangilinan@yahoo.com">junpangilinan@yahoo.com</A>=20
  writes:<BR><BR><BR>
  <BLOCKQUOTE=20
  style=3D"PADDING-LEFT: 5px; MARGIN-LEFT: 5px; BORDER-LEFT: #0000ff 2px =
solid; MARGIN-RIGHT: 0px"=20
  TYPE=3D"CITE">Suspecting a biliary-cutaneous fistula a soft Fr =
10<BR>rubber=20
    catheter was inserted into the cutaneous<BR>opening and a =
fistulogram was=20
    done. This revealed<BR>opacification of the gall bladder and intra=20
    hepatic<BR>ducts. There was no spillage of contrast into =
the<BR>peritoneal=20
    cavity</BLOCKQUOTE><BR><BR>seems like the fistulogram failed and =
should be=20
  repeated <BR>it showed a connection between the biliary tree and the =
surface=20
  you just didnt identify how the contrast media arrived in the biliary =
tree.=20
  <BR>whether there is aplace for nonoperative management depends upon =
the=20
  location of the fistula and the condition of the outflow tract of the =
biliary=20
  tree. If there is no obstruction you probably can control the fistula =
by=20
  drainage<BR>if the main duct is injured or obstructed, then =
percutaneous=20
  drainage wont work<BR></BLOCKQUOTE></FONT></FONT></BODY></HTML>

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Message: 7
From: Greg Benton <Greg.Benton@wdbh.hume.org.au>
To: "'trauma-list@trauma.org'" <trauma-list@trauma.org>
Subject: RE: penetrating trauma definition
Date: Wed, 9 Jan 2002 08:36:37 +1100 
Reply-To: trauma-list@trauma.org

"Trauma Caused by force distributed over a small area of the body surface
causing an object or projectile to enter a body cavity"

Greg Benton
Nurse Unit Manager
Emergency Department

Wangaratta District Base Hospital
Green St Wangaratta 3677

E-mail 	Greg.Benton@wdbh.hume.org.au
Ph 	03 57220162
Fax 	03 57220236

	-----Original Message-----
	From:	Kate Curtis [SMTP:CurtisK@sesahs.nsw.GOV.AU]
	Sent:	Tuesday, 8 January 2002 17:16
	To:	trauma-list@trauma.org
	Subject:	penetrating trauma definition

	Hi all

	We're compiling a regional trauma data dictionary, and have
conflicting
	views on the definition of penetrating trauma.  Obviously a gsw or
stabbing
	is likely to be penetrating, what about falling through a glass
window and
	getting a laceration?  What about a chainsaw injury?  

	Can anyone provide their concise definition from their data
dicitonary?

	Many thanks

	Kate

	Kate Curtis
	Trauma Coordinator
	St George Hospital
	Gray St, Kogarah
	NSW, 2217
	ph:   (02) 9350 3499 or (02) 3950 1111 page 019
	fax:   (02) 9350 3974
	email: curtisk@sesahs.nsw.gov.au

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	This note also confirms that this email message has been virus
scanned and although no computer viruses were detected, South East Health
accepts no liability for any consequential damage resulting from email
containing any computer viruses.

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Message: 8
From: "Karim Brohi" <karim@trauma.org>
To: <trauma-list@trauma.org>
Subject: RE: Head injury
Date: Tue, 8 Jan 2002 22:49:43 -0000
Reply-To: trauma-list@trauma.org

This is a multi-part message in MIME format.

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Clive

Hyperventilation leads to vasoconstriction - which leads to a reduction in
perfusion and cerebral ischaemia.

You can have a 'play' with this on the website's neurotrauma physiology
simulator at:

http://www.trauma.org/resus/neuromoulage/index.html

Karim

  -----Original Message-----
  From: trauma-list-admin@trauma.org [mailto:trauma-list-admin@trauma.org]On
Behalf Of Clive Leach
  Sent: 07 January 2002 11:40
  To: trauma-list@trauma.org
  Subject: Head injury

  Can someone please tell me why hyperventilating head injury is "out" .
  We are still told to do it..
  Many thanks and Happy New Year,  Clive

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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<HTML><HEAD>
<META http-equiv=3DContent-Type content=3D"text/html; =
charset=3Diso-8859-1">
<META content=3D"MSHTML 6.00.2600.0" name=3DGENERATOR>
<STYLE></STYLE>
</HEAD>
<BODY bgColor=3D#ffffff>
<DIV><SPAN class=3D999194722-08012002><FONT color=3D#0000ff=20
size=3D2>Clive</FONT></SPAN></DIV>
<DIV><SPAN class=3D999194722-08012002><FONT color=3D#0000ff=20
size=3D2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=3D999194722-08012002><FONT color=3D#0000ff =
size=3D2>Hyperventilation=20
leads to vasoconstriction - which leads to a reduction in perfusion and =
cerebral=20
ischaemia.&nbsp; </FONT></SPAN></DIV>
<DIV><SPAN class=3D999194722-08012002><FONT color=3D#0000ff=20
size=3D2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=3D999194722-08012002><FONT color=3D#0000ff size=3D2>You =
can have a=20
'play' with this on the website's neurotrauma physiology simulator=20
at:</FONT></SPAN></DIV>
<DIV><SPAN class=3D999194722-08012002><FONT color=3D#0000ff=20
size=3D2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=3D999194722-08012002><FONT color=3D#0000ff size=3D2><A=20
href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002/3Dhttp://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002/"http://www.trauma.org/resus/neuromoulage/index.html">http://www.t=
rauma.org/resus/neuromoulage/index.html</A></FONT></SPAN></DIV>
<DIV><SPAN class=3D999194722-08012002><FONT color=3D#0000ff=20
size=3D2></FONT></SPAN>&nbsp;</DIV>
<DIV><SPAN class=3D999194722-08012002><FONT color=3D#0000ff=20
size=3D2>Karim</FONT></SPAN></DIV>
<DIV><SPAN class=3D999194722-08012002><FONT color=3D#0000ff=20
size=3D2></FONT></SPAN>&nbsp;</DIV>
<BLOCKQUOTE dir=3Dltr style=3D"MARGIN-RIGHT: 0px">
  <DIV class=3DOutlookMessageHeader dir=3Dltr align=3Dleft><FONT =
face=3DTahoma=20
  size=3D2>-----Original Message-----<BR><B>From:</B> =
trauma-list-admin@trauma.org=20
  [mailto:trauma-list-admin@trauma.org]<B>On Behalf Of </B>Clive=20
  Leach<BR><B>Sent:</B> 07 January 2002 11:40<BR><B>To:</B>=20
  trauma-list@trauma.org<BR><B>Subject:</B> Head =
injury<BR><BR></FONT></DIV>
  <DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
  <DIV><FONT face=3DArial size=3D2>Can someone please tell me why =
hyperventilating=20
  head injury is "out" .</FONT></DIV>
  <DIV><FONT face=3DArial size=3D2>We are still told to do it.. =
</FONT></DIV>
  <DIV><FONT face=3DArial size=3D2>Many thanks and Happy New Year,&nbsp; =

  Clive</FONT></DIV></BLOCKQUOTE></BODY></HTML>

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--__--__--

Message: 9
From: DocRickFry@aol.com
Date: Tue, 8 Jan 2002 18:23:21 EST
Subject: Re: penetrating trauma definition
To: trauma-list@trauma.org
Reply-To: trauma-list@trauma.org

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In a message dated 1/8/2002 4:31:58 PM Eastern Standard Time, 
CurtisK@sesahs.nsw.GOV.AU writes:

> We're compiling a regional trauma data dictionary, and have conflicting
> views on the definition of penetrating trauma.  Obviously a gsw or
stabbing
> is likely to be penetrating, what about falling through a glass window and
> getting a laceration?  What about a chainsaw injury?  
> 
> 

Of course these are penetrating!  What would you call them?
I guess this seems awfully simple but here goes for a definition--
Any wound causing a break in the skin.  Certainly there are injuries 
involving varying levels of combined blunt and penetrating trauma--for 
instance we had a male arrive who had a two-by-four board fall from a height

and one of the corners hit him in the neck--it caused a large 10 cm gash
into 
Zone 1.  Of course this is a penetrating injury,  tho also having a blunt 
component that should be considered in assessing the potential injuries.
ERF

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<HTML><FONT FACE=arial,helvetica><FONT  COLOR="#0000ff" SIZE=2
FAMILY="SCRIPT" FACE="Comic Sans MS" LANG="0"><B>In a message dated 1/8/2002
4:31:58 PM Eastern Standard Time, CurtisK@sesahs.nsw.GOV.AU writes:<BR>
<BR>
</FONT><FONT  COLOR="#000000" style="BACKGROUND-COLOR: #ffffff" SIZE=2
FAMILY="SANSSERIF" FACE="Arial" LANG="0"></B><BR>
<BLOCKQUOTE TYPE=CITE style="BORDER-LEFT: #0000ff 2px solid; MARGIN-LEFT:
5px; MARGIN-RIGHT: 0px; PADDING-LEFT: 5px">We're compiling a regional trauma
data dictionary, and have conflicting<BR>
views on the definition of penetrating trauma.&nbsp; Obviously a gsw or
stabbing<BR>
is likely to be penetrating, what about falling through a glass window
and<BR>
getting a laceration?&nbsp; What about a chainsaw injury?&nbsp; <BR>
<BR>
</BLOCKQUOTE><BR>
</FONT><FONT  COLOR="#0000ff" style="BACKGROUND-COLOR: #ffffff" SIZE=2
FAMILY="SCRIPT" FACE="Comic Sans MS" LANG="0"><B><BR>
Of course these are penetrating!&nbsp; What would you call them?<BR>
I guess this seems awfully simple but here goes for a definition--<BR>
Any wound causing a break in the skin.&nbsp; Certainly there are injuries
involving varying levels of combined blunt and penetrating trauma--for
instance we had a male arrive who had a two-by-four board fall from a height
and one of the corners hit him in the neck--it caused a large 10 cm gash
into Zone 1.&nbsp; Of course this is a penetrating injury,&nbsp; tho also
having a blunt component that should be considered in assessing the
potential injuries.<BR>
ERF</B></FONT></HTML>

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Message: 10
From: DocRickFry@aol.com
Date: Tue, 8 Jan 2002 18:25:59 EST
Subject: Re: penetrating trauma definition
To: trauma-list@trauma.org
Reply-To: trauma-list@trauma.org

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In a message dated 1/8/2002 4:41:36 PM Eastern Standard Time, 
Greg.Benton@wdbh.hume.org.au writes:

> Trauma Caused by force distributed over a small area of the body surface
> causing an object or projectile to enter a body cavity"
> 

N0--entering a body cavity is certainly too restrictive--a plate glass
window 
shattering and lacerating the volar elbow down thru the brachial artery is 
clearly a penetrating injury--as is a GSW or strab in same area--yet not 
violating any body cavity.   By your definition, a laceration of the scalp 
would not be a penetrating injury--which of course it is.
ERF

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<HTML><FONT FACE=arial,helvetica><FONT  COLOR="#0000ff" SIZE=2
FAMILY="SCRIPT" FACE="Comic Sans MS" LANG="0"><B>In a message dated 1/8/2002
4:41:36 PM Eastern Standard Time, Greg.Benton@wdbh.hume.org.au writes:<BR>
<BR>
</FONT><FONT  COLOR="#000000" style="BACKGROUND-COLOR: #ffffff" SIZE=2
FAMILY="SANSSERIF" FACE="Arial" LANG="0"></B><BR>
<BLOCKQUOTE TYPE=CITE style="BORDER-LEFT: #0000ff 2px solid; MARGIN-LEFT:
5px; MARGIN-RIGHT: 0px; PADDING-LEFT: 5px">Trauma Caused by force
distributed over a small area of the body surface<BR>
causing an object or projectile to enter a body cavity"<BR>
</BLOCKQUOTE><BR>
</FONT><FONT  COLOR="#0000ff" style="BACKGROUND-COLOR: #ffffff" SIZE=2
FAMILY="SCRIPT" FACE="Comic Sans MS" LANG="0"><B><BR>
N0--entering a body cavity is certainly too restrictive--a plate glass
window shattering and lacerating the volar elbow down thru the brachial
artery is clearly a penetrating injury--as is a GSW or strab in same
area--yet not violating any body cavity.&nbsp;&nbsp; By your definition, a
laceration of the scalp would not be a penetrating injury--which of course
it is.<BR>
ERF</B></FONT></HTML>

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--__--__--

Message: 11
Date: Tue, 08 Jan 2002 19:05:22 -0500
From: Ronald Simon <Traumamd@nyc.rr.com>
To: aast list <trauma-l@lists.aast.org>, CCM list <ccm-l@list.pitt.edu>,
   "trauma.org" <trauma-list@trauma.org>
Subject: Venting subcutaneous emphysema
Reply-To: trauma-list@trauma.org

I have a case i'd like your opinion on. Sorry for the multi listing but 
this problem crosses specialties.

A 48 yo woman victim of MVC. Has multiple rib fx, pulm contusions, R 
pneumothorax for which a chest tube was placed. Patient now several days 
out chest tube still has small airleak, lung is up on chest xray. She 
has over the last few days developed significant subcut emphysema of her 
chest and face. My collegue wants to place a mediastinal "vent" (small 
incision above the manubrium to allow the air to escape). This does not 
make sense to me but in trying to be open minded i'm wondering if this 
is a described treatment. As far as i'm concerned as long as the chest 
tube is controlling the leak, the SQ air is unsightly and has no adverse 
effects unlike making a connection between the mediastinum and the 
outside world.
Thanks for your input
Ron Simon, MD
Jacobi Medical Center
Bronx, NY

--__--__--

Message: 12
From: "MARK FORREST" <atacc.doc@virgin.net>
To: <trauma-list@trauma.org>
Subject: Re: Venting subcutaneous emphysema
Date: Wed, 9 Jan 2002 00:50:05 -0000
Reply-To: trauma-list@trauma.org

Dear Ron,
We recently had a patient with a similar problem bilaterally. As you
suggest, whilst the lung was up and ventilation was effective, we simply
ignored the 'unsightly' surgical emphysema, as it causes few other problems.

Unfortunately, the emphysema eventually got so severe that there was a risk
of superficial skin breakdown and a severe reduction in chest wall
compliance, starting to effect ventilation. After some thought we inserted
two of our largest surgical drains into the subcutaneous tissues over the
anterior chest wall. The drains were intially connected to vacu-drains, but
they were so effective in removing the air that they filled very quickly. In
the end we connected the patient to low grade suction  (2-3 mmHg) through a
non-return valve.
Within 12 hours the emphysema had reduced by ~75%. The drains reamined
effective for over 4 days, until we were able to reduce veniltation
pressures and reduce the pleural leak.
Other patients that I have seen with very severe surgical emphysema after
tracheostomy problems, have been managed with no drains, without ill effect.
I have also seen one patient with marked swelling from severe surgical
emphysema, very effectively 'squashed' back to normal size in a hyperbaric
chamber (2-3 ATA) within ~3 hours. (Incidental benefit when treated for
another condition)
Hope that this helps
Good luck
Mark F
ITU Cons,UK
----- Original Message -----
From: "Ronald Simon" <Traumamd@nyc.rr.com>
To: "aast list" <trauma-l@lists.aast.org>; "CCM list" <ccm-l@list.pitt.edu>;
"trauma.org" <trauma-list@trauma.org>
Sent: Wednesday, January 09, 2002 12:05 AM
Subject: Venting subcutaneous emphysema

> I have a case i'd like your opinion on. Sorry for the multi listing but
> this problem crosses specialties.
>
> A 48 yo woman victim of MVC. Has multiple rib fx, pulm contusions, R
> pneumothorax for which a chest tube was placed. Patient now several days
> out chest tube still has small airleak, lung is up on chest xray. She
> has over the last few days developed significant subcut emphysema of her
> chest and face. My collegue wants to place a mediastinal "vent" (small
> incision above the manubrium to allow the air to escape). This does not
> make sense to me but in trying to be open minded i'm wondering if this
> is a described treatment. As far as i'm concerned as long as the chest
> tube is controlling the leak, the SQ air is unsightly and has no adverse
> effects unlike making a connection between the mediastinum and the
> outside world.
> Thanks for your input
> Ron Simon, MD
> Jacobi Medical Center
> Bronx, NY
>
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/traumalist.html
>

--__--__--

Message: 13
From: "Enrique y Maritza Montbrun" <montbrun@internet.ve>
To: <trauma-list@trauma.org>
Subject: Re: penetrating trauma definition
Date: Tue, 8 Jan 2002 21:20:40 -0400
Organization: FUNDATRAUMA
Reply-To: trauma-list@trauma.org

This is a multi-part message in MIME format.

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I agree with ERF. It is too restrictive.  Consider the option that is a =
trauma caused by an object or projectile to enter a compartment of the =
body. Another option is consider if it  lay across a fascial layer.=20
Enrique Montbrun=20
  ----- Original Message -----=20
  From: DocRickFry@aol.com=20
  To: trauma-list@trauma.org=20
  Sent: Tuesday, January 08, 2002 7:25 PM
  Subject: Re: penetrating trauma definition

  In a message dated 1/8/2002 4:41:36 PM Eastern Standard Time, =
Greg.Benton@wdbh.hume.org.au writes:

    Trauma Caused by force distributed over a small area of the body =
surface
    causing an object or projectile to enter a body cavity"

  N0--entering a body cavity is certainly too restrictive--a plate glass =
window shattering and lacerating the volar elbow down thru the brachial =
artery is clearly a penetrating injury--as is a GSW or strab in same =
area--yet not violating any body cavity.   By your definition, a =
laceration of the scalp would not be a penetrating injury--which of =
course it is.
  ERF=20

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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<HTML><HEAD>
<META http-equiv=3DContent-Type content=3D"text/html; =
charset=3Diso-8859-1">
<META content=3D"MSHTML 6.00.2712.300" name=3DGENERATOR>
<STYLE></STYLE>
</HEAD>
<BODY bgColor=3D#ffffff>
<DIV><FONT face=3DArial size=3D2>I agree with ERF. It is too =
restrictive.&nbsp;=20
Consider the option that is a trauma caused by an object or projectile =
to enter=20
a compartment of the body. Another option is consider if it&nbsp; lay =
across a=20
fascial layer. </FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Enrique Montbrun</FONT>&nbsp;</DIV>
<BLOCKQUOTE=20
style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
  <DIV style=3D"FONT: 10pt arial">----- Original Message ----- </DIV>
  <DIV=20
  style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
  <A title=3DDocRickFry@aol.com=20
  href=3D"mailto:DocRickFry@aol.com">DocRickFry@aol.com</A> </DIV>
  <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A =
title=3Dtrauma-list@trauma.org=20
  href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =
</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Tuesday, January 08, 2002 =
7:25=20
  PM</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> Re: penetrating trauma =

  definition</DIV>
  <DIV><BR></DIV><FONT face=3Darial,helvetica><FONT lang=3D0 =
face=3D"Comic Sans MS"=20
  color=3D#0000ff size=3D2 FAMILY=3D"SCRIPT"><B>In a message dated =
1/8/2002 4:41:36 PM=20
  Eastern Standard Time, <A=20
  =
href=3D"mailto:Greg.Benton@wdbh.hume.org.au">Greg.Benton@wdbh.hume.org.au=
</A>=20
  writes:<BR><BR></FONT><FONT lang=3D0 style=3D"BACKGROUND-COLOR: =
#ffffff"=20
  face=3DArial color=3D#000000 size=3D2 FAMILY=3D"SANSSERIF"></B><BR>
  <BLOCKQUOTE=20
  style=3D"PADDING-LEFT: 5px; MARGIN-LEFT: 5px; BORDER-LEFT: #0000ff 2px =
solid; MARGIN-RIGHT: 0px"=20
  TYPE=3D"CITE">Trauma Caused by force distributed over a small area of =
the body=20
    surface<BR>causing an object or projectile to enter a body=20
  cavity"<BR></BLOCKQUOTE><BR></FONT><FONT lang=3D0=20
  style=3D"BACKGROUND-COLOR: #ffffff" face=3D"Comic Sans MS" =
color=3D#0000ff size=3D2=20
  FAMILY=3D"SCRIPT"><B><BR>N0--entering a body cavity is certainly too=20
  restrictive--a plate glass window shattering and lacerating the volar =
elbow=20
  down thru the brachial artery is clearly a penetrating injury--as is a =
GSW or=20
  strab in same area--yet not violating any body cavity.&nbsp;&nbsp; By =
your=20
  definition, a laceration of the scalp would not be a penetrating =
injury--which=20
  of course it is.<BR>ERF</B></FONT> </FONT></BLOCKQUOTE></BODY></HTML>

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Message: 14
From: KMATTOX@aol.com
Date: Tue, 8 Jan 2002 21:35:39 EST
Subject: Re: Venting subcutaneous emphysema
To: Traumamd@nyc.rr.com, trauma-l@lists.aast.org, ccm-l@list.pitt.edu,
        trauma-list@trauma.org
Reply-To: trauma-list@trauma.org

NO, never, as described venting of this patients subcutaneous emphysema is 
NOT indicated.  It is probably contraindicated.    Send your colleague back 
to medical school to take a course in physiology. 

k

--__--__--

Message: 15
From: KMATTOX@aol.com
Date: Tue, 8 Jan 2002 21:43:23 EST
Subject: Re: Venting subcutaneous emphysema
To: trauma-list@trauma.org, atacc.doc@virgin.net
Reply-To: trauma-list@trauma.org

To suggest hyperbaric treatment in this case is continuing the dumb
responses 
I have been witnessing in suggestions on this case.    Please call a
thoracic 
surgeon to take over the care of this patient.  

HYPERBARIC oxygen has NO PLACE in the treatment of this condition

k

--__--__--

Message: 16
From: KMATTOX@aol.com
Date: Tue, 8 Jan 2002 21:45:13 EST
Subject: Re: Venting subcutaneous emphysema
To: SeppelI@wahs.nsw.gov.au
CC: ccm-l@list.pitt.edu, trauma-l@lists.aast.org, Traumamd@nyc.rr.com,
        trauma-list@trauma.org
Reply-To: trauma-list@trauma.org

Finally, Dr. Seppell, a sane mind.   Congratulations, and you are not even a

surgeon.   Come work with us.  I do have an opening in three areas:   EC,  
Trauma Service, and ICU.    

k

--__--__--

Message: 17
From: KMATTOX@aol.com
Date: Tue, 8 Jan 2002 21:46:18 EST
Subject: Re: Venting subcutaneous emphysema
To: mmazer@charter.net, Traumamd@nyc.rr.com, trauma-l@lists.aast.org,
        ccm-l@list.pitt.edu, trauma-list@trauma.org
Reply-To: trauma-list@trauma.org

PLEASE, please, Dr. Mazer, do not suggest a CT,   For many reasons, CT is a 
bad idea in this case.  

k

--__--__--

Message: 18
From: KMATTOX@aol.com
Date: Tue, 8 Jan 2002 21:47:32 EST
Subject: Re: Venting subcutaneous emphysema
To: chris_anstey@health.qld.gov.au, ccm-l@list.pitt.edu,
        trauma-l@lists.aast.org, Traumamd@nyc.rr.com, trauma-list@trauma.org
Reply-To: trauma-list@trauma.org

To Chris Anstey, another sound sane mind.  Congratulations,   COme work with

us in Houston at Baylor College of Medicine and Ben Taub General Hospital

k

--__--__--

Message: 19
From: Nappio@aol.com
Date: Tue, 8 Jan 2002 23:07:52 EST
Subject: Re: bile fistula
To: trauma-list@trauma.org
Reply-To: trauma-list@trauma.org

I would begin with upper GI and small bowel follow thru to confirm your not 
dealing with an occult duodenal lesion. If negative, I would recomend ERCP 
and Stent placement if a bile duct leak is identified or not as it may help 
decompress the biliary tree in the face of a parenchymal leak (albeit 
anectdotal). In either case, npo, parenteral nutrition, ngt decompression 
accompanied with Octreotide 100ug Sub Q q8(somatostatin analog) has given us

excellent results for non-op management of fistulas as well as duodenal 
ulcer. It usually takes 48-72 hrs to see initial results.
dave nap

--__--__--

Message: 20
Date: Tue, 08 Jan 2002 23:14:40 -0500
From: Ronald Simon <Traumamd@nyc.rr.com>
To: trauma-list@trauma.org
Subject: Re: Venting subcutaneous emphysema
Reply-To: trauma-list@trauma.org

--------------070200080406040402000908
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>
>
>Please call a thoracic 
>surgeon to take over the care of this patient.  
>

Interestingly enough is the person who wanted to to the venting WAS a 
thoracic surgeon!!!!!!!!
Ron

KMATTOX@aol.com wrote:

>To suggest hyperbaric treatment in this case is continuing the dumb
responses 
>I have been witnessing in suggestions on this case.    Please call a
thoracic 
>surgeon to take over the care of this patient.  
>
>HYPERBARIC oxygen has NO PLACE in the treatment of this condition
>
>k
>
>--
>trauma-list : TRAUMA.ORG
>To change your settings or unsubscribe visit:
>http://www.trauma.org/traumalist.html
>

--------------070200080406040402000908
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<html>
<head>
</head>
<body>
<blockquote type="cite">
  <pre wrap=""><b>Please call a thoracic <br>surgeon to take over the care
of this patient.  </b></pre>
  </blockquote>
  <br>
Interestingly enough is the person who wanted to to the venting WAS a
thoracic
surgeon!!!!!!!!<br>
Ron<br>
  <br>
<a class="moz-txt-link-abbreviated"
href="mailto:KMATTOX@aol.com">KMATTOX@aol.com</a> wrote:<br>
  <blockquote type="cite" cite="mid:186.18423f2.296d084b@aol.com">
    <pre wrap="">To suggest hyperbaric treatment in this case is continuing
the dumb responses <br>I have been witnessing in suggestions on this case.
<b>Please call a thoracic <br>surgeon to take over the care of this patient.
</b><br><br>HYPERBARIC oxygen has NO PLACE in the treatment of this
condition<br><br>k<br><br>--<br>trauma-list : TRAUMA.ORG<br>To change your
settings or unsubscribe visit:<br><a class="moz-txt-link-freetext"
href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002/"http://www.trauma.org/traumalist.html">http://www.trauma.org/traumalis
t.html</a><br><br></pre>
    </blockquote>
    <br>
    </body>
    </html>

--------------070200080406040402000908--

--__--__--

Message: 21
From: Nappio@aol.com
Date: Tue, 8 Jan 2002 23:29:16 EST
Subject: Re: Venting subcutaneous emphysema
To: trauma-list@trauma.org
Reply-To: trauma-list@trauma.org

On a few occaisions we have had persistant air leaks with lung up on CXR, 
subcutaneous emphysema that were shown to have had a large occult anterior 
pneumo. they responded well to a second chest tube.
dave nap

--__--__--

Message: 22
From: "J.C. Goslings" <j.c.goslings@amc.uva.nl>
To: <trauma-list@trauma.org>
Subject: Re: bile fistula
Date: Wed, 9 Jan 2002 08:25:23 +0100
Reply-To: trauma-list@trauma.org

We would suggest ERCP. In case of intrahepatic duct lesion stent placement;
extrahepatic lesion stent or PTC drainage and reconstruction after +/- 6
weeks. Cholecystectomy if the gallbladder is injured.

J.C. Goslings
O.R.C. Busch
Trauma Unit and HPB Unit, Dept. Surgery
Acad. Med. Centre Amsterdam.

----- Original Message -----
From: "Honorio Ma. Jr. Pangilinan" <junpangilinan@yahoo.com>
To: <trauma-list@trauma.org>
Sent: Tuesday, January 08, 2002 7:17 AM
Subject: bile fistula

> I have a 22 year old male patient who was referred to
> our facility after sustaining 2 GSWs to the back. He
> was initially admitted to a remote provincial hospital
> where he reportedly underwent laparotomy for repair of
> multiple intestinal perforations. He was subsequently
> transferred to our facility 33 hours post-injury.
>
> On admission he was stable, normotensive, afebrile. He
> had 2 GSWs at the back, one at level L1 left mid
> scapular line, and another at level T10 right
> posterior axillary line. Anteriorly he had a sutured
> midline laparotomy incision and there was a GSW of
> exit in the epigastrium, just to the right of the
> midline from which was oozing brownish fluid (bile).
> The abdomen was flat, soft, with slight tenderness on
> palpation around the incision, otherwise, everything
> was unremarkable. 2 days later, he was still afebrile,
> the abdomen was soft and non-tender, and he was
> hungry. The output from the GSW of exit was 700 cc.
> Suspecting a biliary-cutaneous fistula a soft Fr 10
> rubber catheter was inserted into the cutaneous
> opening and a fistulogram was done. This revealed
> opacification of the gall bladder and intra hepatic
> ducts. There was no spillage of contrast into the
> peritoneal cavity. Patient is now on his 5th day in
> our hospital, he is feeding, has passed flatus and
> stools, and remained afebrile. No abdominal
> complaints, no jaundice. Fistula output is 750 to 900
> cc bile per day. We plan to operate on him to try to
> locate the source of the bile leak.
>
> Is there room for non-operative management in this
> case? Any opinion from the list will be appreciated.
>
> Dr. Jun Pangilinan
> Baguio General Hospital
> Baguio City, Philippines
>
> __________________________________________________
> Do You Yahoo!?
> Send FREE video emails in Yahoo! Mail!
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>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/traumalist.html
>

--__--__--

Message: 23
Date: Wed, 09 Jan 2002 20:43:26 +1300
From: Ian Civil <icivil@xtra.co.nz>
To: trauma-list@trauma.org
Subject: Re: penetrating trauma definition
Reply-To: trauma-list@trauma.org

Dear Kate,

This can be difficult at times e.g when there is an RTC and the patient is
cut by the glass from the windscreen. Is this (in TRISS terms) blunt trauma
or penetrating trauma?

We determine whether the predominant mechanism was blunt or penetrating and
class the injury based on that. Glass windows and chainsaws are definitely
penetrating but the scenario described above we class as blunt.

I will be interested to see what others say.

Ian Civil

Kate Curtis wrote:

> Hi all
>
> We're compiling a regional trauma data dictionary, and have conflicting
> views on the definition of penetrating trauma.  Obviously a gsw or
stabbing
> is likely to be penetrating, what about falling through a glass window and
> getting a laceration?  What about a chainsaw injury?
>
> Can anyone provide their concise definition from their data dicitonary?
>
> Many thanks
>
> Kate
>
> Kate Curtis
> Trauma Coordinator
> St George Hospital
> Gray St, Kogarah
> NSW, 2217
> ph:   (02) 9350 3499 or (02) 3950 1111 page 019
> fax:   (02) 9350 3974
> email: curtisk@sesahs.nsw.gov.au
>
>
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--__--__--

Message: 24
From: Thomas Anthony Horan <thoran@bsb.sarah.br>
To: "'trauma-list@trauma.org'" <trauma-list@trauma.org>
Subject: RE: Venting subcutaneous emphysema
Date: Wed, 9 Jan 2002 09:33:03 -0300 
Reply-To: trauma-list@trauma.org

Dear Dr Mattox:
I presume this response was directed to some one on another list or to Dr
Ansty privately, perhaps this type of cross posting could be avoided or the
original referenced and appended, Otherwise such comments needlessly clutter
the mail box.
Thank you 
Tom Horan 

> ----------
> De: 	KMATTOX@aol.com[SMTP:KMATTOX@aol.com]
> Responder: 	trauma-list@trauma.org
> Enviada: 	Quarta-feira, 9 de Janeiro de 2002 00:47
> Para: 	chris_anstey@health.qld.gov.au; ccm-l@list.pitt.edu;
> trauma-l@lists.aast.org; Traumamd@nyc.rr.com; trauma-list@trauma.org
> Assunto: 	Re: Venting subcutaneous emphysema
> 
> To Chris Anstey, another sound sane mind.  Congratulations,   COme work
> with 
> us in Houston at Baylor College of Medicine and Ben Taub General Hospital
> 
> k
> 
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/traumalist.html
> 

--__--__--

Message: 25
From: Holmes John <Jholmes@mater.org.au>
To: Dick Burrows <burrows2@telkomsa.net>
Cc: "'ccm-l@list.pitt.edu'" <ccm-l@list.pitt.edu>, 
	"'trauma-list@trauma.org'" <trauma-list@trauma.org>
Subject: RE: Pneumothoracies and CT scans - a long time worry for me
Date: Wed, 9 Jan 2002 19:01:00 +1000 
Reply-To: trauma-list@trauma.org

...............Quite simply pneumothoraces are all too often discovered
serendipitously................

Serendipity  =  finding something by accident that leads to a pleasant or
happy outcome.

Probably not quite what you mean when talking about pneumo's     :)

John

J Holmes
Mater Hospitals, Brisbane

 ----------

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Venting subcutaneous emphysema