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Wed, 20 Feb 2002 21:16:47 -0300

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Dear Avi:

In the first case I agree with you. In spite of his rapid declining =
condition we should have operated him on. The problem is that our active
Service was meanwhile having 1 liver transplant and the 3 other OR (book =
to trauma) were with other gunshotwound victims. Besides, we only had =
Leucocytosis previously... Would you operate his hemogram, I mean, that =
pt?

1st Patient: 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.

About the second... well her clinical picture was so dramatic I think a =
laparotomy would have further deteriorated her quickly...U/S did not =
showed any significant collections. Besides, let me remind you her CT =
was operated, I mean, We operated her on based on CT findings. If no CT =
was done no one would have operate her! And as Zsolt Balogh has pointed =
out what I described was the two-hit theory of MOF in severely injured =
patients!

What I'm asking is what if we had not performed pancreatectomy plus =
splenectomy? Would that make a difference? What if we could use some =
sort of intra-op exam like ulta-sound or intra-op cholangiography so we =
could determine if there was for real a laceration of the wirsung's =
duct? And what about that Dr. Rick Fry's pt : why he/she could stay =
alive and did not die? Non operative management of pancreatic injury?  =
Luck I guess.=20

When I was back to my first year resident I still remember my 2nd year =
colleague: "When you're an intern, no matter
how much you try to kill our patient (new drugs, treatments or even =
negligence) they just do not die!". What if our today's standard =
treatment for
SIRS/SEPSIS is just the other side of the coin?

What's still missing?

2nd Patient: 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.

C Alster, MD

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<DIV><FONT face=3DArial>Dear Avi:</FONT></DIV>
<DIV><FONT face=3DArial></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial>In the first case I agree with you. In spite =
of&nbsp;his=20
rapid declining condition we should have operated him on. The problem is =
that=20
our active</FONT></DIV>
<DIV><FONT face=3DArial>Service was meanwhile having 1 liver transplant =
and the 3=20
other OR (book to trauma) were with other gunshotwound victims. Besides, =
we only=20
had </FONT><FONT face=3DArial>Leucocytosis previously... Would you =
operate his=20
hemogram, I mean, that pt?</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV>
<DIV><FONT face=3DArial size=3D1>1st Patient: 26 Y/O white latin male =
was victim of=20
a gunshot wound in the RUQ exiting&nbsp;on the back (lumbar&nbsp;level). =

</FONT></DIV>
<DIV><FONT face=3DArial size=3D1>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=3D1>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=3D1>We ordered a CT but 12h later he had to =
be admitted=20
to ICU because of ARDS. His oxymetry saturation reached 30% at best with =

FiO2=3D100%. He died in 4 hours.</FONT></DIV></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial>About the second... well her clinical picture =
was so=20
dramatic I think a laparotomy would have further deteriorated her =
quickly...U/S=20
did not showed any significant </FONT><FONT face=3DArial>collections. =
</FONT><FONT=20
face=3DArial>Besides, let me remind you her CT was operated, I mean, We =
operated=20
her on based on CT findings. If no&nbsp;CT was done no one would have =
operate=20
her! And as Zsolt Balogh has pointed out what I described was the =
two-hit theory=20
of MOF&nbsp;in severely injured patients!</FONT></DIV>
<DIV><FONT face=3DArial></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial>What I'm asking is what if we had not =
</FONT><FONT=20
face=3DArial>performed pancreatectomy plus splenectomy? Would that make =
a=20
difference? What if we could use some sort of intra-op exam like =
ulta-sound or=20
intra-op cholangiography&nbsp;so we could&nbsp;determine if there was=20
<STRONG>for real</STRONG> </FONT><FONT face=3DArial>a&nbsp;laceration of =
the=20
wirsung's duct? And what about that Dr. Rick Fry's pt&nbsp;: why he/she =
could=20
stay alive and did not die? Non operative management of pancreatic =
injury?&nbsp;=20
Luck I guess. </FONT></DIV>
<DIV><FONT face=3DArial>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>
<DIV><FONT face=3DArial size=3D3>When I was back to my first year =
resident I still=20
remember my 2nd year colleague: "When you're an intern, no =
matter</FONT></DIV>
<DIV><FONT face=3DArial size=3D3>how much&nbsp;you try to kill our =
patient (new=20
drugs, treatments or even negligence) they just do not die!". What if =
our=20
today's standard treatment for</FONT></DIV>
<DIV><FONT size=3D3>SIRS/SEPSIS is just the other side of the=20
coin?</FONT></DIV></FONT></DIV></FONT>
<DIV><FONT face=3DArial></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial>What's still missing?</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>
<DIV><FONT face=3DArial size=3D1>2nd Patient: 19Y/O white latin female =
was also=20
victim of a gunshot wound on the back exiting at epigastric level. She =
got a=20
ride from her boyfriend who was driving a&nbsp;motorcycle&nbsp;when 2 =
other guys=20
in a car 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 arm.=20
There was a trauma to the tail of the =
pancreas.</FONT></DIV></FONT></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>C Alster, MD</FONT></DIV></BODY></HTML>

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PANCREATIC TRAUMA - What are we missing?