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GSW to abdomen

trauma-list@trauma.org trauma-list@trauma.org
Sun, 6 Apr 2003 18:49:11 -0300


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Dear Azonic

Damage control should have been the best option.
- major vascular /GI injuries
- massive blood loss

Priorities: 1st GO FOR BLEEDING than GI SECRETIONS than OTHERS

I know it's very easy to talk about a subject when things have already
happened but that pt would have probably deserved a bogota bag and a =
good
ICU stat instead of several anastomosis mainly because he had iliac =
vessels
injury which generally are tough to manage. The bloody triad =
"coagulation,
acidosis and hypothermia" should be avoided as fast as possible. Ringer =
39C warmed, packing etc. Nice
option to make one bowell anastomosis it's better to avoid several
enterotomies; Colon injuries we usually make end colostomies or stappler =
it
at all so the pt can  quickly go to ICU (whatever is easier).

We usually leave a bogota bag (peritoneostomy) and review laparotomies =
48-72h later. No tension closure and no mesh at first but maybe later at =
the others programed laparotomies (as many
as needed) when the pt would be ok and stable. We have a protocol to  =
close
the abdomen. Peak pressure < 22, Intravesical pressure < 20mmHg (normal
values are negative or zero but pt once operated ivp can be considered
normal as high as 20mmHg with no abdominal compartment signs as =
oliguria,
high peep, peak pressure and oxygen requirements). For those who do not =
have
a transducer to measure ivp the old water collumm (it comes together =
with
PVC kit) works just fine (1mmHg =3D 1,36cmH20).

C Alster, MD

----- Original Message -----
From: "azonic75" <azonic75@yahoo.com>
To: <trauma-list@trauma.org>
Sent: Saturday, April 05, 2003 10:39 PM
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?
>
> __________________________________________________
> Do you Yahoo!?
> Yahoo! Tax Center - File online, calculators, forms, and more
> http://tax.yahoo.com
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/traumalist.html
>


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<BODY>
<DIV><FONT face=3DArial size=3D2>Dear Azonic<BR><BR>Damage control =
should have been=20
the best option.<BR>- major vascular /GI injuries<BR>- massive blood=20
loss<BR></FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Priorities: 1st GO FOR =
<STRONG>BLEEDING</STRONG>=20
than <STRONG>GI SECRETIONS</STRONG> than =
<STRONG>OTHERS</STRONG></FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT><BR><FONT face=3DArial =
size=3D2>I know it's very=20
easy to talk about a subject when things have already<BR>happened but =
that pt=20
would have probably deserved a bogota bag and a good<BR><STRONG>ICU=20
stat</STRONG> instead of several anastomosis mainly because he had iliac =

vessels<BR>injury which generally are tough to manage. The bloody triad=20
"coagulation,<BR>acidosis and hypothermia" should be avoided as fast as=20
possible.&nbsp;Ringer 39C warmed, packing&nbsp;etc.&nbsp;Nice<BR>option =
to make=20
one bowell anastomosis it's better to avoid several<BR>enterotomies; =
Colon=20
injuries we usually make end colostomies or stappler it<BR>at all so the =
pt=20
can&nbsp; quickly go to ICU (whatever is easier).<BR><BR>We usually =
leave a=20
<STRONG>bogota bag</STRONG> (peritoneostomy) and review laparotomies =
48-72h=20
later. No tension closure and no mesh at first but maybe later at the =
others=20
programed laparotomies (as many<BR>as needed) when the pt would be ok =
and=20
stable. We have a protocol to&nbsp; close<BR>the abdomen. Peak pressure =
&lt; 22,=20
Intravesical pressure &lt; 20mmHg (normal<BR>values are negative or zero =
but pt=20
once operated ivp can be considered<BR>normal as high as 20mmHg with no=20
abdominal compartment signs as oliguria,<BR>high peep, peak pressure and =
oxygen=20
requirements). For those who do not have<BR>a transducer to measure ivp =
the old=20
water collumm (it comes together with<BR>PVC kit) works just fine (1mmHg =
=3D=20
1,36cmH20).<BR><BR>C Alster, MD<BR><BR>----- Original Message =
-----<BR>From:=20
"azonic75" &lt;</FONT><A href=3D"mailto:azonic75@yahoo.com"><FONT =
face=3DArial=20
size=3D2>azonic75@yahoo.com</FONT></A><FONT face=3DArial =
size=3D2>&gt;<BR>To:=20
&lt;</FONT><A href=3D"mailto:trauma-list@trauma.org"><FONT face=3DArial=20
size=3D2>trauma-list@trauma.org</FONT></A><FONT face=3DArial =
size=3D2>&gt;<BR>Sent:=20
Saturday, April 05, 2003 10:39 PM<BR>Subject: GSW to =
abdomen<BR><BR><BR>&gt;=20
Would like some feedback/wisdom/criticism regarding a<BR>&gt; recent=20
case....<BR>&gt;<BR>&gt; 26 y/o male presents with multiple GSW, one to=20
the<BR>&gt; left chest mid axillary line 9th ICS, another on the<BR>&gt; =
left=20
just below the costal margin. Combative in ED,<BR>&gt; intubated, left =
chest=20
tube placed with minimal output,<BR>&gt; HR 140, SBP 60. Taken to OR =
where=20
laparotomy reveals<BR>&gt; ~2L blood in belly, 6 SB enterotomies, =
enterotomy=20
in<BR>&gt; transverse colon near the splenic flexture, injury to<BR>&gt; =
distal=20
left iliac vein and artery and diaphragmatic<BR>&gt; =
injury.<BR>&gt;<BR>&gt; We=20
performed a colonic resection with ostomy, resected<BR>&gt; the area of =
SB with=20
the enterotomies (~2 feet) and<BR>&gt; made one anastomosis. Iliac =
injuries were=20
repaired<BR>&gt; after&nbsp; obtaining proximal control at the aorta =
and<BR>&gt;=20
distally with compression<BR>&gt;<BR>&gt; As expected pt became cold, =
acidotic,=20
coagulopathic<BR>&gt; and eventually arrested<BR>&gt;<BR>&gt; What may =
have been=20
done differently? At what point<BR>&gt; would you apply damage control=20
principles? The<BR>&gt; vascular injuries did not appear amenable =
to<BR>&gt;=20
packing....Any thoughts?<BR>&gt;<BR>&gt;=20
__________________________________________________<BR>&gt; Do you=20
Yahoo!?<BR>&gt; Yahoo! Tax Center - File online, calculators, forms, and =

more<BR>&gt; </FONT><A href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/3D"http://tax.yahoo.com"><FONT face=3DArial=20
size=3D2>http://tax.yahoo.com</FONT></A><BR><FONT face=3DArial =
size=3D2>&gt;<BR>&gt;=20
--<BR>&gt; trauma-list : TRAUMA.ORG<BR>&gt; To change your settings or=20
unsubscribe visit:<BR>&gt; </FONT><A=20
href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/3D"http://www.trauma.org/traumalist.html"><FONT face=3DArial=20
size=3D2>http://www.trauma.org/traumalist.html</FONT></A><BR><FONT =
face=3DArial=20
size=3D2>&gt;<BR></FONT></DIV></BODY></HTML>

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