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GSW to abdomen

trauma-list@trauma.org trauma-list@trauma.org
Wed, 9 Apr 2003 13:23:43 EDT


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In a message dated 06-Apr-03 05:41:52 Central Daylight Time, 
JVARCELOTTI@mercy.pmhs.org writes:
> 
> 
> >-----Original Message-----
> >From:   azonic75 [SMTP:azonic75@yahoo.com]
> >Sent:   Saturday, April 05, 2003 8:39 PM
> >To:   trauma-list@trauma.org
> >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?
> >
> 
> >> 
>> 
>> Damage control. Stop bleeding, Isolate contaminants (bowel). Quick
>> interposition shunt to iliac artery. Ligature vein. Packing if necessary.
>> Take patient to the ICU . Continue resuscitation, rewarming, correct
>> coagulopathy. Take patient back to the OR and now proceed with the 
>> definite
>> repairs, resections, ostomies.
>> Jorge

Funny, this sounds like the sort of thing that Richard Hooker, MD described 
years ago as "Meatball Surgery"..."Mucosa to mucosa, Muscularis more or less 
to Muscularis, and Serosa to Serosa well enough that it doesn't leak"....in 
that same book, he included a brief description of how to place an improvised 
chest tube in short order...

And his description dated to the Korean Conflict.

ck

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<HTML><FONT FACE=3Darial,helvetica><FONT  SIZE=3D2 FAMILY=3D"SANSSERIF" FACE=
=3D"Arial" LANG=3D"0">In a message dated 06-Apr-03 05:41:52 Central Daylight=
 Time, JVARCELOTTI@mercy.pmhs.org writes:<BR>
<BLOCKQUOTE TYPE=3DCITE style=3D"BORDER-LEFT: #0000ff 2px solid; MARGIN-LEFT=
: 5px; MARGIN-RIGHT: 0px; PADDING-LEFT: 5px"><BR>
<BR>
&gt;-----Original Message-----<BR>
&gt;From:&nbsp;&nbsp; azonic75 [SMTP:azonic75@yahoo.com]<BR>
&gt;Sent:&nbsp;&nbsp; Saturday, April 05, 2003 8:39 PM<BR>
&gt;To:&nbsp;&nbsp; trauma-list@trauma.org<BR>
&gt;Subject:&nbsp;&nbsp; GSW to abdomen<BR>
&gt;<BR>
&gt;Would like some feedback/wisdom/criticism regarding a<BR>
&gt;recent case....<BR>
&gt;<BR>
&gt;26 y/o male presents with multiple GSW, one to the<BR>
&gt;left chest mid axillary line 9th ICS, another on the<BR>
&gt;left just below the costal margin. Combative in ED,<BR>
&gt;intubated, left chest tube placed with minimal output,<BR>
&gt;HR 140, SBP 60. Taken to OR where laparotomy reveals<BR>
&gt;~2L blood in belly, 6 SB enterotomies, enterotomy in<BR>
&gt;transverse colon near the splenic flexture, injury to<BR>
&gt;distal left iliac vein and artery and diaphragmatic<BR>
&gt;injury. <BR>
&gt;<BR>
&gt;We performed a colonic resection with ostomy, resected<BR>
&gt;the area of SB with the enterotomies (~2 feet) and<BR>
&gt;made one anastomosis. Iliac injuries were repaired<BR>
&gt;after&nbsp; obtaining proximal control at the aorta and<BR>
&gt;distally with compression<BR>
&gt;<BR>
&gt;As expected pt became cold, acidotic, coagulopathic<BR>
&gt;and eventually arrested<BR>
&gt;<BR>
&gt;What may have been done differently? At what point<BR>
&gt;would you apply damage control principles? The<BR>
&gt;vascular injuries did not appear amenable to<BR>
&gt;packing....Any thoughts?<BR>
&gt;<BR>
<BR>
<BLOCKQUOTE TYPE=3DCITE style=3D"BORDER-LEFT: #0000ff 2px solid; MARGIN-LEFT=
: 5px; MARGIN-RIGHT: 0px; PADDING-LEFT: 5px"><BR>
<BR>
Damage control. Stop bleeding, Isolate contaminants (bowel). Quick<BR>
interposition shunt to iliac artery. Ligature vein. Packing if necessary.<BR=
>
Take patient to the ICU . Continue resuscitation, rewarming, correct<BR>
coagulopathy. Take patient back to the OR and now proceed with the definite<=
BR>
repairs, resections, ostomies.<BR>
Jorg</BLOCKQUOTE></BLOCKQUOTE>e</FONT><FONT  COLOR=3D"#000000" style=3D"BACK=
GROUND-COLOR: #ffffff" SIZE=3D2 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"=
0"><BR>
<BR>
</FONT><FONT  COLOR=3D"#000000" style=3D"BACKGROUND-COLOR: #ffffff" SIZE=3D2=
 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0">Funny, this sounds like the=20=
sort of thing that Richard Hooker, MD described years ago as "Meatball Surge=
ry"..."Mucosa to mucosa, Muscularis more or less to Muscularis, and Serosa t=
o Serosa well enough that it doesn't leak"....in that same book, he included=
 a brief description of how to place an improvised chest tube in short order=
...<BR>
<BR>
And his description dated to the Korean Conflict.<BR>
<BR>
ck</FONT><FONT  COLOR=3D"#000000" style=3D"BACKGROUND-COLOR: #ffffff" SIZE=
=3D2 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0"><BR>
</FONT></HTML>
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