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Wed, 13 Feb 2002 05:14:42 -0500

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

  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.

  Pelvis plain film and CT both normal.

  What about DPL lab? Leucocytes?Bacteria?Red cells?GI secretions?

  Less than 100,000 rbcs, no fibers or bacteria

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

  Did not think that cardioversion would fix it, causative agent =
(suspected BCI) still there

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

  Do not have routine FAST in my ED and only one doc trained in it.  =
Hijacked a US from OB when arrested later and tamponade suspected.  BP =
had stabilized after DPL so off to CT for definitive studies

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

  Rest of spine was OK

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

  CT of chest (sorry Dr Mattox) showed mediastinal blood but "normal" =
aorta.  Aortogram ordered to confirm.

  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?)

  Again, FAST not routine in my ED, fluke that we did it when tamponade =
suspected.

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

  Have not heard post results yet, alcohol and tox were negative in ED

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

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  face=3DTahoma></FONT></STRONG>&nbsp;</DIV>
  <DIV><BR></DIV>
  <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><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. Really interesting case indeed.</FONT></DIV>
  <DIV><FONT face=3DTahoma></FONT>&nbsp;</DIV>
  <DIV><STRONG><FONT face=3DTahoma>Pelvis plain film and CT both=20
  normal.</FONT></STRONG></DIV>
  <DIV><FONT face=3DTahoma></FONT>&nbsp;</DIV>
  <DIV>
  <DIV>What about DPL lab? Leucocytes?Bacteria?Red cells?GI =
secretions?</DIV>
  <DIV>&nbsp;</DIV>
  <DIV><STRONG><FONT face=3DTahoma>Less than 100,000 rbcs, no fibers or=20
  bacteria</FONT></STRONG></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><STRONG><FONT face=3DTahoma>Did not think that cardioversion =
would fix it,=20
  causative agent (suspected BCI) still there</FONT></STRONG></DIV>
  <DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</DIV>
  <DIV>
  <DIV><FONT face=3DTahoma size=3D2>I'm sorry, but I did not understand =
why the ct=20
  was performed if the pt was hypotensive...Why not FAST =
instead?</FONT></DIV>
  <DIV><FONT face=3DTahoma></FONT>&nbsp;</DIV>
  <DIV><FONT face=3DTahoma><STRONG>Do not have routine FAST in my ED and =
only one=20
  doc trained in it.&nbsp; Hijacked a US from OB when arrested later and =

  tamponade suspected.&nbsp; BP had stabilized after DPL so off to CT =
for=20
  definitive studies</STRONG></FONT></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=20
  a spine fracture diagnosed, there's another 10% chance to find another =

  fracture .</FONT></DIV>
  <DIV><STRONG><FONT face=3DTahoma></FONT></STRONG>&nbsp;</DIV>
  <DIV><STRONG><FONT face=3DTahoma>Rest of spine was =
OK</FONT></STRONG></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 face=3DTahoma></FONT>&nbsp;</DIV>
  <DIV><STRONG><FONT face=3DTahoma>CT of chest (sorry Dr Mattox) showed=20
  mediastinal blood but "normal" aorta.&nbsp; Aortogram ordered to=20
  confirm.</FONT></STRONG></DIV>
  <DIV></FONT><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=20
  again + AFib cardioverted + Laparotomy with a good pulmonary =
anesthesiologist=20
  expert (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><STRONG>Again, FAST not routine in =
my ED, fluke=20
  that we did it when tamponade suspected.</STRONG></FONT></DIV>
  <DIV><STRONG><FONT face=3DTahoma size=3D2></FONT></STRONG>&nbsp;</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><STRONG>Have not heard post results =
yet, alcohol=20
  and tox were negative in ED</STRONG></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></BLOCKQUOTE></BODY></HTML>

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