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Fri, 15 Feb 2002 22:12:35 -0500

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I agree with that. I thought there was no such thing as non-op mgmt of=20
pancreas injury. Though I still don't think that it caused the sudden=20
pulmonary decompensation in these 2 patients.
Ron Simon
Dir of Trauma
Jacobi  Medical Center
Bronx, NY

avir@bgumail.bgu.ac.il wrote:

>Dear Alster,=20
>
>What you are missing, in both cases, is an exploratory lap.=20
>You need to have your hands in the abdomen.=20
>
>You trust the CT too much, and doing the CT is not a therapeutic measure=
. I=20
>would explore the first case now, and would have explored the 2nd case e=
arly in=20
>her course.=20
>
>Avi=20
>=20
>
>
>>From: " alster" <alster@usp.br>
>>Date: 2002/02/12 =E2 AM 04:05:41 GMT+05:30
>>To: <trauma-list@trauma.org>
>>Subject: PANCREATIC TRAUMA - What are we missing?
>>
>>--- Start Notice from the BGU CC --------------------
>>
>>The file named email-body that was attached was scanned and no virus wa=
s found
>>The file named email-body that was attached was scanned and no virus wa=
s found
>>The file named masimone.jpg that was attached was scanned and no virus =
was=20
>>
>found
>
>>The file named masimone2.jpg that was attached was scanned and no virus=
 was=20
>>
>found
>
>>--- End Notice from the BGU CC ---------------------
>>
>>Hello List!=20
>>Where do we go from here?
>>
>>26 Y/O white latin male was victim of a gunshot wound in the RUQ exitin=
g on=20
>>
>the back (lumbar level).=20
>
>>Trauma to the pancreas (Grade III - caudal pancreatectomy performed), S=
tomach=20
>>
>(Grade II - sutured), Spleen (nothing done -Grade I), Diaphragm (sutured=
) and=20
>mesentery (sutured). Pancreatic fistula (400ml/day from day 5 till 10th =
Post Op=20
>day). U/S showed no collections elsewhere. No fever.
>
>>Suddenly, at the 12th POp day he was in abdominal pain with no relief t=
o=20
>>
>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 A=
RDS.=20
>>
>His oxymetry saturation reached 30% at best with FiO2=3D100%. He died in=
 4=20
>hours.
>
>>19Y/O white latin female was also victim of a gunshot wound on the back=
=20
>>
>exiting at epigastric level. She got a ride from her boyfriend who was d=
riving=20
>a motorcycle when 2 other guys in a car tried to rob him. As soon as he=20
>accelerated, trying to run away, his girlfriend was shot on the back and=
 he=20
>suffered only scratches in his right arm. There was a trauma to the tail=
 of the=20
>pancreas as showed bellow:
>
>> =20
>>
>>That trauma was only diagnosed by CT and because amylase levels reached=
 549.=20
>>
>Besides that, pt was doing fine. Still in noradrenalin but going down wi=
th=20
>0,15mcg/Kg/min.
>
>>Based on CT findings and because there was no ERCP available during wee=
kends=20
>>
>she was taken to the OR and a distal pancreatectomy plus spenectomy was
>
>>performed. No intraop cholangiography was done. She did well till the 1=
0th=20
>>
>POp day when both lungs got WHITE and she developed ARDS. Amylase levels=
=20
>diminished to normal levels. Then, hepatic and renal insufficiency. Her =
pulse=20
>oxymetry at best was 40% with FiO2=3D100% (last Friday) getting better w=
hen TGI=20
>was instituted (80% at best). Our hemofiltration machine was broken. Sev=
eral=20
>U/S was done showing no collection besides 18ml around the pancreas. As =
she was=20
>unstable no post op ct was done. She had no fever. Nothing.She died at t=
he 23=20
>Post Op day (Saturday).=20
>
>>What are we missing?
>>
>>CAlster, MD
>>
>>
>>
>>
>>
>>
>> ----------------------------------------------------------------------=
--
>>
>> Hello List!
>>
>> Where do we go from here?
>>
>> =20
>>
>> 26 Y/O white latin male was victim of a gunshot wound in the RUQ=20
>> exiting on the back (lumbar level).
>>
>> Trauma to the pancreas (Grade III - caudal pancreatectomy performed),=20
>> Stomach (Grade II - sutured), Spleen (nothing done -Grade I),=20
>> Diaphragm (sutured) and mesentery (sutured). Pancreatic fistula=20
>> (400ml/day from day 5 till 10th Post Op day). U/S showed no=20
>> collections elsewhere. No fever.
>>
>> Suddenly, at the 12th POp day he was in abdominal pain with no relief=20
>> 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=20
>> ARDS. His oxymetry saturation reached 30% at best with FiO2=3D100%. He=
=20
>> died in 4 hours.
>>
>> =20
>>
>> 19Y/O white latin female was also victim of a gunshot wound on the=20
>> back exiting at epigastric level. She got a ride from her boyfriend=20
>> who was driving a motorcycle when 2 other guys in a car tried to rob=20
>> him. As soon as he accelerated, trying to run away, his girlfriend=20
>> was shot on the back and he suffered only scratches in his right arm.=20
>> There was a trauma to the tail of the pancreas as showed bellow:
>>
>> [Will you operated on this pt based on CT findings?]   [What about=20
>> this one?]
>> =20
>>
>> That trauma was only diagnosed by CT and because amylase levels=20
>> reached 549. Besides that, pt was doing fine. Still in noradrenalin=20
>> but going down with 0,15mcg/Kg/min.
>>
>> 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=20
>> spenectomy was
>>
>> performed. No intraop cholangiography was done. She did well till the=20
>> 10th POp day when both lungs got WHITE and she developed ARDS.=20
>> Amylase levels diminished to normal levels. Then, hepatic and renal=20
>> insufficiency. Her pulse oxymetry at best was 40% with FiO2=3D100%=20
>> (last Friday) getting better when TGI was instituted (80% at best).=20
>> Our hemofiltration machine was broken. Several U/S was done showing=20
>> no collection besides 18ml around the pancreas. As she was unstable=20
>> no post op ct was done. She had no fever. Nothing.She died at the 23=20
>> Post Op day (Saturday).
>>
>> =20
>>
>> What are we missing?
>>
>> =20
>>
>> CAlster, MD
>>
>> =20
>>
>> =20
>>
>> =20
>>
>>
>> ----------------------------------------------------------------------=
--
>>
>> <cid:part3.01080000.00060100@netscape.com>
>>
>>
>> ----------------------------------------------------------------------=
--
>>
>> <cid:part4.05030804.08070008@netscape.com>
>>

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<html>
<head>
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<body>
I agree with that. I thought there was no such thing as non-op mgmt of pa=
ncreas
injury. Though I still don't think that it caused the sudden pulmonary de=
compensation
in these 2 patients.<br>
Ron Simon<br>
Dir of Trauma<br>
Jacobi =A0Medical Center<br>
Bronx, NY<br>
<br>
<a class=3D"moz-txt-link-abbreviated" href=3D"mailto:avir@bgumail.bgu.ac.=
il">avir@bgumail.bgu.ac.il</a> wrote:<br>
<blockquote type=3D"cite" cite=3D"mid:20020214073500.FWUM128678.doarim@%5=
B132.72.137.74%5D">
  <pre wrap=3D"">Dear Alster, <br><br>What you are missing, in both cases=
, is an exploratory lap. <br>You need to have your hands in the abdomen. =
<br><br>You trust the CT too much, and doing the CT is not a therapeutic =
measure. I <br>would explore the first case now, and would have explored =
the 2nd case early in <br>her course. <br><br>Avi <br> <br><br><br></pre>
  <blockquote type=3D"cite">
    <pre wrap=3D"">From: " alster" <a class=3D"moz-txt-link-rfc2396E" hre=
f=3D"mailto:alster@usp.br">&lt;alster@usp.br&gt;</a><br>Date: 2002/02/12 =
=E2 AM 04:05:41 GMT+05:30<br>To: <a class=3D"moz-txt-link-rfc2396E" href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002/3D=
"mailto:trauma-list@trauma.org">&lt;trauma-list@trauma.org&gt;</a><br>Sub=
ject: PANCREATIC TRAUMA - What are we missing?<br><br>--- Start Notice fr=
om the BGU CC --------------------<br><br>The file named email-body that =
was attached was scanned and no viirus was found<br>The file named email-=
body that was attached was scanned and no virus was found<br>The file nam=
ed masimone.jpg that was attached was scanned and no virus was <br></pre>
    </blockquote>
    <pre wrap=3D""><!---->found<br></pre>
    <blockquote type=3D"cite">
      <pre wrap=3D"">The file named masimone2.jpg that was attached was s=
canned and no virus was <br></pre>
      </blockquote>
      <pre wrap=3D""><!---->found<br></pre>
      <blockquote type=3D"cite">
        <pre wrap=3D"">--- End Notice from the BGU CC -------------------=
--<br><br>Hello List! <br>Where do we go from here?<br><br>26 Y/O white l=
atiin male was victim of a gunshot wound in the RUQ exiting on <br></pre>
        </blockquote>
        <pre wrap=3D""><!---->the back (lumbar level). <br></pre>
        <blockquote type=3D"cite">
          <pre wrap=3D"">Trauma to the pancreas (Grade III - caudal pancr=
eatectomy performed), Stomach <br></pre>
          </blockquote>
          <pre wrap=3D""><!---->(Grade II - sutured), Spleen (nothing don=
e -Grade I), Diaphragm (sutured) and <br>mesentery (sutured). Pancreatic =
fistulaa (400ml/day from day 5 till 10th Post Op <br>day). U/S showed no =
collections elsewhere. No fever.<br></pre>
          <blockquote type=3D"cite">
            <pre wrap=3D"">Suddenly, at the 12th POp day he was in abdomi=
nal pain with no relief to <br></pre>
            </blockquote>
            <pre wrap=3D""><!---->analgesics. Plus there was a leucocytos=
is 15.000 (B=3D7% S=3D70%).<br></pre>
            <blockquote type=3D"cite">
              <pre wrap=3D"">We ordered a CT but 12h later he had to be a=
dmitted to ICU because of ARDS. <br></pre>
              </blockquote>
              <pre wrap=3D""><!---->His oxymetry saturation reached 30% a=
t best with FiO2=3D100%. He died in 4 <br>hours.<br></pre>
              <blockquote type=3D"cite">
                <pre wrap=3D"">19Y/O white latin female was also victim o=
f a gunshot wound on the back <br></pre>
                </blockquote>
                <pre wrap=3D""><!---->exiting at epigastric level. She go=
t a ride from her boyfriend who was driving <br>a motorcycle when 2 other=
 guys in a caar tried to rob him. As soon as he <br>accelerated, trying t=
o run away, his girlfriend was shot on the back and he <br>suffered only =
scratches in his right arm. There was a trauma to the tail of the <br>pan=
creas as showed bellow:<br></pre>
                <blockquote type=3D"cite">
                  <pre wrap=3D"">  <br><br>That trauma was only diagnosed=
 by CT and because amylase levels reached 549. <br></pre>
                  </blockquote>
                  <pre wrap=3D""><!---->Besides that, pt was doing fine. =
Still in noradrenalin but going down with <br>0,15mcg/Kg/min.<br></pre>
                  <blockquote type=3D"cite">
                    <pre wrap=3D"">Based on CT findings and because there=
 was no ERCP available during weekends <br></pre>
                    </blockquote>
                    <pre wrap=3D""><!---->she was taken to the OR and a d=
istal pancreatectomy plus spenectomy was<br></pre>
                    <blockquote type=3D"cite">
                      <pre wrap=3D"">performed. No intraop cholangiograph=
y was done. She did well till the 10th <br></pre>
                      </blockquote>
                      <pre wrap=3D""><!---->POp day when both lungs got W=
HITE and she developed ARDS. Amylase levels <br>diminished to normal leve=
ls. Then, hepatic aand renal insufficiency. Her pulse <br>oxymetry at bes=
t was 40% with FiO2=3D100% (last Friday) getting better when TGI <br>was =
instituted (80% at best). Our hemofiltration machine was broken. Several =
<br>U/S was done showing no collection besides 18ml around the pancreas. =
As she was <br>unstable no post op ct was done. She had no fever. Nothing=
.She died at the 23 <br>Post Op day (Saturday). <br></pre>
                      <blockquote type=3D"cite">
                        <pre wrap=3D"">What are we missing?<br><br>CAlste=
r, MD<br><br><br><br><br><br></pre>
                        <br>
                        <hr width=3D"90%" size=3D"4"><br>
                        <meta content=3D"MSHTML 6.00.2600.0" name=3D"GENE=
RATOR">
                        <style></style>
                        <div><font face=3D"Arial" size=3D"2">Hello List! =
</font></div>
                        <div><font face=3D"Arial" size=3D"2">Where do we =
go from
here?</font></div>
                        <div>=A0</div>
                        <div><font face=3D"Arial" size=3D"2">26 Y/O white=
 latin
male was victim of a gunshot  wound in the RUQ exiting=A0on the back (lum=
bar=A0level).
                        </font></div>
                        <div><font face=3D"Arial" size=3D"2">Trauma to th=
e pancreas
(Grade III - caudal  pancreatectomy performed), Stomach (Grade II - sutur=
ed),
Spleen (nothing done  -Grade I), Diaphragm (sutured) and mesentery (sutur=
ed).
Pancreatic fistula  (400ml/day from day 5 till 10th Post Op day). U/S sho=
wed
no collections  elsewhere. No fever.</font></div>
                        <div><font face=3D"Arial" size=3D"2">Suddenly, at=
 the
12th POp day he was in abdominal  pain=A0with no relief to analgesics. Pl=
us
there was a leucocytosis 15.000  (B=3D7% S=3D70%).</font></div>
                        <div><font face=3D"Arial" size=3D"2">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.</fo=
nt></div>
                        <div>=A0</div>
                        <div><font face=3D"Arial" size=3D"2">19Y/O white =
latin
female was also victim of a  gunshot wound on the back exiting at epigast=
ric
level. She got a ride from her  boyfriend who was driving a=A0motorcycle=A0=
when
2 other guys in a car  tried to rob him. As soon as he accelerated, tryin=
g
to run away, his girlfriend  was shot on the back and he suffered only sc=
ratches
in his right arm. There was  a trauma to the tail of the pancreas as show=
ed
bellow:</font></div>
                        <img alt=3D"Will you operated on this pt based on=
 CT findings?" hspace=3D"0" src=3D"cid:004601c1b34c$6fd6f790$0100007f@lap=
" border=3D"0" moz-do-not-send=3D"true">
=A0<img alt=3D"What about this one?" hspace=3D"0" src=3D"cid:004701c1b34c=
$6fe01f50$0100007f@lap" border=3D"0" moz-do-not-send=3D"true">
                        <div>=A0</div>
                        <div>That trauma was only diagnosed by CT and bec=
ause
amylase levels reached  549.=A0Besides that,=A0pt was doing fine. Still i=
n noradrenalin
 but=A0going down=A0with 0,15mcg/Kg/min.</div>
                        <div>Based on CT findings and because there was n=
o
ERCP available during  weekends she was taken to the OR and a distal panc=
reatectomy
plus spenectomy  was</div>
                        <div>performed. No intraop cholangiography was do=
ne.
She did well till the 10th  POp day when=A0both lungs got WHITE and she d=
eveloped
ARDS. Amylase levels  diminished=A0to normal levels. Then, hepatic and re=
nal
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 1=
8ml
around the pancreas. As she was  unstable no post op ct was done.=A0She h=
ad
no fever.=A0Nothing.She died at  the 23 Post Op day (Saturday). </div>
                        <div>=A0</div>
                        <div>What are we missing?</div>
                        <div>=A0</div>
                        <div>CAlster, MD</div>
                        <div>=A0</div>
                        <div>=A0</div>
                        <div>=A0</div>
                        <br>
                        <hr width=3D"90%" size=3D"4"><br>
                        <center><img src=3D"cid:part3.01080000.00060100@n=
etscape.com">
                        </center>
                        <p><br>
                        </p>
                        <hr width=3D"90%" size=3D"4"><br>
                        <center><img src=3D"cid:part4.05030804.08070008@n=
etscape.com">
                        </center>
                        </blockquote>
                        </blockquote>
                        <br>
                        </body>
                        </html>

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