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Tue, 12 Feb 2002 17:29:00 -0300

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Hello Andrew!
A few more questions to your interesting case:

18 year old male, driver of pick up, no restraints, lost control, rolled =
over with ejection of driver.

Sounds like the mechanism of trauma that remind us of Pelvic fracture. =
Hypotension with no other sign of bleeding besides chest (300ml).
Any crepitus? I know Pelvis x-ray was ok but was the pt wearing PASG? I =
saw a case report few years ago, describing an open book pelvic fracture =
(previously not diagnosed)when PASG was deflated. Really interesting =
case indeed.

DPL done, no gross blood, barely pink on return of fluid.  BP now coming =
up with blood, fluids and levophed at 4mcg/min.  Monitor now a-fib at =
140-150 (previously healthy teenager)
=20
If that's a pelvic fracture case DPL is almost always positive...What =
about DPL lab? Leucocytes?Bacteria?Red cells?GI secretions?

Why a new onset A Fib was not cardioverted since the pt was unstable?

ACLS causes of AFib: sick sinus sy? Hypoxia(probably)? increased atrial =
pressure (tamponade?)=20

Off to CT, head OK, abdomen OK ( no liver/spleen, + free fluid but had =
just had DPL)

I'm sorry, but I did not understand why the ct was performed if the pt =
was hypotensive...Why not FAST instead?

 Chest with massive bilateral pulmo contusions and 20% right hemo/pneumo =
and T6 fx with frags in canal

Have you had all spine work up done? Once there is a spine fracture =
diagnosed, there's another 10% chance to find another fracture .

Besides, cardiac contusion is another possibility but it's not a must  =
cardiac tamponade and then arrhythmias.

Waiting for aortogram, patient suddenly bradycardic at 40, no pulses or =
BP, lungs without change, ETT in place, abdomen still flat, no increase =
blood out of chest tube.

Was there a mediastinum enlargement? A fib and the mechanism of trauma =
were the only indications for the aortogram? Two firs ribs fractured?

Pulses return, back to a-fib 120-140, BP 80.  Off to aortogram, normal =
aortogram.

Well, once again I'm sorry, I know it's easy to talk since I was not =
there but how about the sequence FAST + 1h later FAST again + AFib =
cardioverted + Laparotomy with a good pulmonary anesthesiologist expert =
(how sure are you there's no abdominal source?)

Finally and most important, what did the autopsy result show?

C Alster, MD
University of Sao Paulo Medical School, Br

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<DIV><FONT face=3DArial size=3D2>Hello Andrew!</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>A few more questions to your =
interesting=20
case:</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>
<DIV><STRONG><FONT face=3DTahoma size=3D2>18 year old male, driver of =
pick up, no=20
restraints, lost control, rolled over with ejection of=20
driver.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma></FONT></STRONG>&nbsp;</DIV>
<DIV><FONT face=3DTahoma>Sounds like the mechanism of trauma that remind =
us of=20
Pelvic fracture. Hypotension with no other sign of bleeding besides =
chest=20
(300ml).</FONT></DIV>
<DIV><FONT face=3DTahoma>Any crepitus? I know Pelvis x-ray was ok but =
was the pt=20
wearing PASG? I saw a case report&nbsp;few years ago,&nbsp;describing an =
open=20
book pelvic fracture&nbsp;(previously not diagnosed)when&nbsp;PASG was =
deflated.=20
Really interesting case indeed.</FONT></DIV>
<DIV><FONT face=3DTahoma></FONT>&nbsp;</DIV>
<DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>DPL done, no gross blood, =
barely pink on=20
return of fluid.&nbsp; BP now coming up with blood, fluids and levophed =
at=20
4mcg/min.&nbsp; Monitor now a-fib at 140-150 (previously healthy=20
teenager)</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>&nbsp;</FONT></STRONG></DIV>
<DIV>If that's a pelvic fracture case DPL is almost always =
positive...What about=20
DPL lab? Leucocytes?Bacteria?Red cells?GI secretions?</DIV>
<DIV>&nbsp;</DIV>
<DIV>Why a new onset A Fib was not cardioverted since the pt&nbsp;was=20
unstable?</DIV>
<DIV>&nbsp;</DIV>
<DIV>ACLS causes of AFib: sick sinus sy? Hypoxia(probably)? increased =
atrial=20
pressure (tamponade?) </DIV>
<DIV>&nbsp;</DIV>
<DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Off to CT, head OK, abdomen OK =
( no=20
liver/spleen, + free fluid but had just&nbsp;had =
DPL)</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><FONT face=3DTahoma size=3D2>I'm sorry, but I did not understand =
why the ct was=20
performed if the pt was hypotensive...Why not FAST instead?</FONT></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>&nbsp;Chest with massive =
bilateral pulmo=20
contusions and 20% right hemo/pneumo&nbsp;and T6 fx with frags in=20
canal</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma></FONT></STRONG>&nbsp;</DIV>
<DIV><FONT face=3DTahoma>Have you&nbsp;had all spine work up done? Once =
there is a=20
spine fracture diagnosed, there's another 10% chance to find another =
fracture=20
.</FONT></DIV>
<DIV><FONT face=3DTahoma></FONT>&nbsp;</DIV>
<DIV><FONT face=3DTahoma>Besides, cardiac contusion is another =
possibility but=20
it's not a must&nbsp; cardiac tamponade&nbsp;and=20
then&nbsp;arrhythmias.</FONT></DIV>
<DIV><FONT face=3DTahoma></FONT>&nbsp;</DIV>
<DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Waiting for aortogram, patient =
suddenly=20
bradycardic at 40, no pulses or BP, lungs without change, ETT in place, =
abdomen=20
still flat, no increase blood out of chest =
tube.</FONT></STRONG></DIV></DIV>
<DIV><FONT face=3DTahoma></FONT>&nbsp;</DIV>
<DIV><FONT face=3DTahoma>Was there a mediastinum&nbsp;enlargement? A fib =
and the=20
mechanism of trauma were the only indications for the aortogram? Two =
firs ribs=20
fractured?</FONT></DIV>
<DIV></FONT><STRONG><FONT face=3DTahoma =
size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2>Pulses return, back to a-fib =
120-140, BP=20
80.&nbsp; Off to aortogram, normal aortogram.</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><FONT face=3DTahoma size=3D2>Well, once again I'm sorry, I know =
it's easy to=20
talk since I was not there but how about the sequence FAST + 1h later =
FAST again=20
+ AFib cardioverted + Laparotomy with a good pulmonary anesthesiologist =
expert=20
(how sure are you there's no abdominal source?)</FONT></DIV>
<DIV><FONT face=3DTahoma size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DTahoma size=3D2>Finally and most important, what did =
the autopsy=20
result show?</FONT></DIV>
<DIV><FONT face=3DTahoma size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DTahoma size=3D2>C Alster, MD</FONT></DIV>
<DIV><FONT face=3DTahoma size=3D2>University of Sao Paulo Medical =
School,=20
Br</FONT></DIV></DIV></DIV></DIV></BODY></HTML>

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