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GSW to abdomen

caesar ursic trauma-list@trauma.org
Sun, 6 Apr 2003 08:34:07 -0700 (PDT)

>From what you describe there were immediate
indications to go into damage control mode as soon as
you finished initially exploring the abdomen:  initial
class IV hemorrhagic shock on presentation with
massive blood loss associated with combined major
vascular and gastrointestinal injuries.  The
intestinal repairs should not have been performed, but
rather just stapled or quickly sewn closed so as  to
stop further enteric contamination.  Creation of
stomas and intestinal anastomoses should have waited
until the definitive repair stage (at a second
laparotomy) once the shock, coagulopathy and acidosis
had been corrected in the ICU.  

Question for you: how well did the anesthesiologists
keep you appraised of the patient's declining
physiologic reserve (i.e. temperature, pH, fluid
requirements, etc.) as you were operating?  Did you
notice diffuse oozing indicative of coagulopathy?

Question for the group:  how many of you would
eventually bring divert the colon at the final
laparotomy when colonic injuries were initially
temporized by rapid stapling/oversewing?  Or would you
simply re-establish colonic continuity despite the
injury being days old?  Would it matter whether or not
primary fascila reapproximation was achieved versus
interposition mesh was required to close the abdomen?

C.M. Ursic, M.D.
Dept. of Surgery
UCSF-East Bay
Oakland, California

--- azonic75 <azonic75@yahoo.com> wrote:
> Would like some feedback/wisdom/criticism regarding
> a
> recent case....
> 26 y/o male presents with multiple GSW, one to the
> left chest mid axillary line 9th ICS, another on the
> left just below the costal margin. Combative in ED,
> intubated, left chest tube placed with minimal
> output,
> HR 140, SBP 60. Taken to OR where laparotomy reveals
> ~2L blood in belly, 6 SB enterotomies, enterotomy in
> transverse colon near the splenic flexture, injury
> to
> distal left iliac vein and artery and diaphragmatic
> injury. 
> We performed a colonic resection with ostomy,
> resected
> the area of SB with the enterotomies (~2 feet) and
> made one anastomosis. Iliac injuries were repaired
> after  obtaining proximal control at the aorta and
> distally with compression
> As expected pt became cold, acidotic, coagulopathic
> and eventually arrested
> What may have been done differently? At what point
> would you apply damage control principles? The
> vascular injuries did not appear amenable to
> packing....Any thoughts?
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