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GSW to abdomen

MARK FORREST trauma-list@trauma.org
Sun, 6 Apr 2003 20:10:05 +0100


Sad that this young man didn't make it despite your efforts. It would be
nice to have a little more information regarding times (pre-hosp,  to ER),
resus targets (eg conscious level, BP, pulses etc). How cold was he on
arrival in hospital?
I was surprised that you describe the bowel injuries and treatment before
the vascular injuries which presumably took priority?
The 'old chestnuts' must be asked....how much fluid, what type and how was
it warmed. How quickly was haemorrhage control obtained?
Was there any chest injury?
Plan: shortest time to OR, permissive hypotension, active warming, surgical
haemosatsis (?aortic x-clamp if necessary), +/-packing, ?Factor VIIa
(discuss?), bowel defunctioning (end stomas), peritoneal washout, ICU,
further resus (incl blood if Hb <7-8g/dl, clotting factors etc), rewarming
and full monitoring during reperfusion/resuscitation. Return to theatre
24-36hrs later for review +/-more definitive surgery.
Tell us more about what happened
Regards
Mark F
UK

----- Original Message -----
From: "azonic75" <azonic75@yahoo.com>
To: <trauma-list@trauma.org>
Sent: Sunday, April 06, 2003 2:39 AM
Subject: GSW to abdomen


> 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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