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PANCREATIC TRAUMA - What are we missing?

MARK FORREST trauma-list@trauma.org
Tue, 12 Feb 2002 20:08:29 -0000 

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Dear Alster,
Any more information for the non-surgical members.=20
Very interested in the amount and type of fluid given during =
resuscitation and inevitable SIRS period after surgery.

Surprised that deteriorations were so rapid as although surgical =
conditions can develop rapidly, the ARDS picture is far more likely to =
have been developing over several days.

Any ABGs, CRPs, lactates prior to deterioration?

Mark F=20
ITU Cons,UK
  ----- Original Message -----=20
  From: alster=20
  To: trauma-list@trauma.org=20
  Sent: Monday, February 11, 2002 10:35 PM
  Subject: PANCREATIC TRAUMA - What are we missing?


  Hello List!=20
  Where do we go from here?

  26 Y/O white latin male was victim of a gunshot wound in the RUQ =
exiting on the back (lumbar level).=20
  Trauma to the pancreas (Grade III - caudal pancreatectomy performed), =
Stomach (Grade II - sutured), Spleen (nothing done -Grade I), Diaphragm =
(sutured) and mesentery (sutured). Pancreatic fistula (400ml/day from =
day 5 till 10th Post Op day). U/S showed no collections elsewhere. No =
fever.
  Suddenly, at the 12th POp day he was in abdominal pain with no relief =
to analgesics. Plus there was a leucocytosis 15.000 (B=3D7% S=3D70%).
  We ordered a CT but 12h later he had to be admitted to ICU because of =
ARDS. His oxymetry saturation reached 30% at best with FiO2=3D100%. He =
died in 4 hours.

  19Y/O white latin female was also victim of a gunshot wound on the =
back exiting at epigastric level. She got a ride from her boyfriend who =
was driving a motorcycle when 2 other guys in a car tried to rob him. As =
soon as he accelerated, trying to run away, his girlfriend was shot on =
the back and he suffered only scratches in his right arm. There was a =
trauma to the tail of the pancreas as showed bellow:
   =20

  That trauma was only diagnosed by CT and because amylase levels =
reached 549. Besides that, pt was doing fine. Still in noradrenalin but =
going down with 0,15mcg/Kg/min.
  Based on CT findings and because there was no ERCP available during =
weekends she was taken to the OR and a distal pancreatectomy plus =
spenectomy was
  performed. No intraop cholangiography was done. She did well till the =
10th POp day when both lungs got WHITE and she developed ARDS. Amylase =
levels diminished to normal levels. Then, hepatic and renal =
insufficiency. Her pulse oxymetry at best was 40% with FiO2=3D100% (last =
Friday) getting better when TGI was instituted (80% at best). Our =
hemofiltration machine was broken. Several U/S was done showing no =
collection besides 18ml around the pancreas. As she was unstable no post =
op ct was done. She had no fever. Nothing.She died at the 23 Post Op day =
(Saturday).=20

  What are we missing?

  CAlster, MD




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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 5.50.4207.2601" name=3DGENERATOR>
<STYLE></STYLE>
</HEAD>
<BODY bgColor=3D#ffffff>
<DIV><FONT face=3DArial size=3D2>Dear Alster,</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Any more information for the =
non-surgical members.=20
</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Very interested in the amount and type =
of fluid=20
given during resuscitation and inevitable SIRS period after=20
surgery.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Surprised that deteriorations were so =
rapid as=20
although surgical conditions can develop rapidly, the ARDS picture is =
far more=20
likely to have been developing over several days.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Any ABGs, CRPs, lactates prior to=20
deterioration?</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Mark F </FONT></DIV>
<DIV><FONT face=3DArial size=3D2>ITU Cons,UK</FONT></DIV>
<BLOCKQUOTE dir=3Dltr=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=3Dalster@usp.br href=3D"mailto:alster@usp.br">alster</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> Monday, February 11, 2002 =
10:35=20
  PM</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> PANCREATIC TRAUMA - =
What are we=20
  missing?</DIV>
  <DIV><FONT face=3DArial size=3D2></FONT><BR></DIV>
  <DIV><FONT face=3DArial size=3D2>Hello List! </FONT></DIV>
  <DIV><FONT face=3DArial size=3D2>Where do we go from =
here?</FONT></DIV>
  <DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
  <DIV><FONT face=3DArial size=3D2>26 Y/O white latin male was victim of =
a gunshot=20
  wound in the RUQ exiting&nbsp;on the back (lumbar&nbsp;level). =
</FONT></DIV>
  <DIV><FONT face=3DArial size=3D2>Trauma to the pancreas (Grade III - =
caudal=20
  pancreatectomy performed), Stomach (Grade II - sutured), Spleen =
(nothing done=20
  -Grade I), Diaphragm (sutured) and mesentery (sutured). Pancreatic =
fistula=20
  (400ml/day from day 5 till 10th Post Op day). U/S showed no =
collections=20
  elsewhere. No fever.</FONT></DIV>
  <DIV><FONT face=3DArial size=3D2>Suddenly, at the 12th POp day he was =
in abdominal=20
  pain&nbsp;with no relief to analgesics. Plus there was a leucocytosis =
15.000=20
  (B=3D7% S=3D70%).</FONT></DIV>
  <DIV><FONT face=3DArial size=3D2>We ordered a CT but 12h later he had =
to be=20
  admitted to ICU because of ARDS. His oxymetry saturation reached 30% =
at best=20
  with FiO2=3D100%. He died in 4 hours.</FONT></DIV>
  <DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
  <DIV><FONT face=3DArial size=3D2>19Y/O white latin female was also =
victim of a=20
  gunshot wound on the back exiting at epigastric level. She got a ride =
from her=20
  boyfriend who was driving a&nbsp;motorcycle&nbsp;when 2 other guys in =
a car=20
  tried to rob him. As soon as he accelerated, trying to run away, his=20
  girlfriend was shot on the back and he suffered only scratches in his =
right=20
  arm. There was a trauma to the tail of the pancreas as showed=20
  bellow:</FONT></DIV><IMG=20
  alt=3D"Will you operated on this pt based on CT findings?" hspace=3D0=20
  src=3D"cid:002701c1b401$09f06140$0100007f@oemcomputer" =
border=3D0>&nbsp;<IMG=20
  alt=3D"What about this one?" hspace=3D0=20
  src=3D"cid:002801c1b401$09f06140$0100007f@oemcomputer" border=3D0>=20
  <DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
  <DIV>That trauma was only diagnosed by CT and because amylase levels =
reached=20
  549.&nbsp;Besides that,&nbsp;pt was doing fine. Still in noradrenalin=20
  but&nbsp;going down&nbsp;with 0,15mcg/Kg/min.</DIV>
  <DIV>Based on CT findings and because there was no ERCP available =
during=20
  weekends she was taken to the OR and a distal pancreatectomy plus =
spenectomy=20
  was</DIV>
  <DIV>performed. No intraop cholangiography was done. She did well till =
the=20
  10th POp day when&nbsp;both lungs got WHITE and she developed ARDS. =
Amylase=20
  levels diminished&nbsp;to normal levels. Then, hepatic and renal=20
  insufficiency. Her pulse oxymetry at best was 40% with FiO2=3D100% =
(last Friday)=20
  getting better when TGI was instituted (80% at best). Our =
hemofiltration=20
  machine was broken. Several U/S was done showing no collection besides =
18ml=20
  around the pancreas. As she was unstable no post op ct was =
done.&nbsp;She had=20
  no fever.&nbsp;Nothing.She died at the 23 Post Op day (Saturday). =
</DIV>
  <DIV>&nbsp;</DIV>
  <DIV>What are we missing?</DIV>
  <DIV>&nbsp;</DIV>
  <DIV>CAlster, MD</DIV>
  <DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
  <DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
  <DIV><FONT face=3DArial =
size=3D2></FONT>&nbsp;</DIV></BLOCKQUOTE></BODY></HTML>

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