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Case from last night-What to do #2
Haim and Daphna Paran trauma-list@trauma.orgSun, 09 Mar 2003 18:10:02 +0200
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--Boundary_(ID_qK0n0bXP1ajdwM2vTG1t/g) Content-type: text/plain; charset=us-ascii; format=flowed Content-transfer-encoding: 7BIT Guys, there is already a Chest tube in. Augment the picture and you will see it. Still unlike the rt side one cannot see the diaphragm in the left side (Sal is it consistent with "deep sulkus sign?). Since the patiebnt is stable I would go for a CT-angio of the chest and upper abdomen. Haim Paran Ronald Simon wrote: > Oh come on!!!! No chest tube for a significant left hemo. I'll give > you none on the right but not to treat a big hemo because its not > compromising pulmonary physiology on a young kid is taking > non-invasive alittle to far for me. For me its. left chest tube then > CT chest with IV contrast. > Ron Simon > Dir of Trauma > Jacobi Medical Center > Bronx, NY > > meredith mcbride wrote: > >> I would not place chest tubes in the absence of evidence for >> respiratory compromise, significant pneumothorax or hemothorax, but >> would monitor closely for changes and repeat a CXR in the morning. >> >> I believe that chest CT with IV contrast would allow me to screen the >> mediastinum for bleeding, or pneumomediastinum. If I identified >> bleeding, I would proceed with angiography. Pericardial fluid can be >> demonstrated on CT - I would proceed with subxyphoid window for that. >> For air I would do gastrograffin swallow vs. esophagoscopy, and >> bronchoscopy. >> >> I would not add oral contrast unless I was planning on viewing the >> abdomen, which in the absence of any clinical signs of injury and >> a negative FAST, I would not do. >> >> I would have requested an upright PA/LAT CXR, as often occult >> pneumothorax is demonstrated, in which case I would proceed >> with chest tube in the presence of the hemothorax. I also would get a >> better look at the heart borders. >> >> Was an ECG done by chance? Early tamponade might be associated with >> diminished conduction. >> >> At the very least we need admission to telemetry. He is at risk for >> delayed bleeding, and delayed tamponade. >> >> KMATTOX@aol.com wrote: >> >> 1. He was stable, with a pulse oxymetry of 100% saturation with >> O2 via nasal catheter. His BP was now 110/75, his abdomen was >> soft, and he was neurologically intact. He actually wanted to >> get up off the table and go home. The chief resident wanted to >> put in bilateral chest tubes, or at the very least one on the >> left. Remember that this is an institution where I have been >> very critical of CT scans for the ACUTE and IMMEDIATE evaluation >> of ANY chest trauma, so the staff were discussing CT and >> wondering if they could justify it at our morning report. A >> repeat FAST revealed no fluid in the abdomen or the pericardium. >> >> So. I guess the Critical Decision Node at this What to do #2 is: >> >> &nb! sp; 1. Chest tubes, yes or no, if yes right, left or >> bilateral >> 2. CT scan of chest, Yes or no, if yes, what and how to >> enhance, IV contrast? >> oral contrast ? >> >> k >> >> >> ------------------------------------------------------------------------ >> Do you Yahoo!? >> Yahoo! Tax Center >> <http://rd.yahoo.com/finance/mailtagline/*http://taxes.yahoo.com/> - >> forms, calculators, tips, and more > > --Boundary_(ID_qK0n0bXP1ajdwM2vTG1t/g) Content-type: text/html; charset=us-ascii Content-transfer-encoding: 7BIT <html> <head> </head> <body> Guys, there is already a Chest tube in. Augment the picture and you will see it. Still unlike the rt side one cannot see the diaphragm in the left side (Sal is it consistent with "deep sulkus sign?).<br> Since the patiebnt is stable I would go for a CT-angio of the chest and upper abdomen.<br> <br> Haim Paran<br> <br> Ronald Simon wrote:<br> <blockquote type="cite" cite="mid:3E6AE0F0.5020500@nyc.rr.com"> <title></title> Oh come on!!!! No chest tube for a significant left hemo. I'll give you none on the right but not to treat a big hemo because its not compromising pulmonary physiology on a young kid is taking non-invasive alittle to far for me. For me its. left chest tube then CT chest with IV contrast.<br> Ron Simon<br> Dir of Trauma<br> Jacobi Medical Center<br> Bronx, NY<br> <br> meredith mcbride wrote:<br> <blockquote type="cite" cite=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-March/"mid20030309024248.22931.qmail@web21110.mail.yahoo.com"> <p>I would not place chest tubes in the absence of evidence for respiratory compromise, significant pneumothorax or hemothorax, but would monitor closely for changes and repeat a CXR in the morning. </p> <p>I believe that chest CT with IV contrast would allow me to screen the mediastinum for bleeding, or pneumomediastinum. If I identified bleeding, I would proceed with angiography. Pericardial fluid can be demonstrated on CT - I would proceed with subxyphoid window for that. For air I would do gastrograffin swallow vs. esophagoscopy, and bronchoscopy. </p> <p>I would not add oral contrast unless I was planning on viewing the abdomen, which in the absence of any clinical signs of injury and a negative FAST, I would not do. </p> <p>I would have requested an upright PA/LAT CXR, as often occult pneumothorax is demonstrated, in which case I would proceed with chest tube in the presence of the hemothorax. I also would get a better look at the heart borders. </p> <p>Was an ECG done by chance? Early tamponade might be associated with diminished conduction. </p> <p>At the very least we need admission to telemetry. He is at risk for delayed bleeding, and delayed tamponade. </p> <p> <b><i><a class="moz-txt-link-abbreviated" href="mailto:KMATTOX@aol.com"> KMATTOX@aol.com</a> </i></b> wrote: </p> <blockquote style="border-left-width: 2px; border-left-style: solid; border-left-color: rgb(16,16,255); padding-left: 5px; margin-left: 5px; "><font face="arial,helvetica"><font lang="0" face="Arial" size="2" family="SANSSERIF"> 1. He was stable, with a pulse oxymetry of 100% saturation with O2 via nasal catheter. His BP was now 110/75, his abdomen was soft, and he was neurologically intact. He actually wanted to get up off the table and go home. The chief resident wanted to put in bilateral chest tubes, or at the very least one on the left. Remember that this is an institution where I have been very critical of CT scans for the ACUTE and IMMEDIATE evaluation of ANY chest trauma, so the staff were discussing CT and wondering if they could justify it at our morning report. A repeat FAST revealed no fluid in the abdomen or the pericardium. <br> <br> So. I guess the Critical Decision Node at this What to do #2 is:<br> <br> &nb! sp; 1. Chest tubes, yes or no, if yes right, left or bilateral<br> 2. CT scan of chest, Yes or no, if yes, what and how to enhance, IV contrast? <br> oral contrast ? <br> <br> k</font></font></blockquote> <p><br> </p> <hr size="1">Do you Yahoo!?<br> <a href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-March/"http://rd.yahoo.com/finance/mailtagline/*http://taxes.yahoo.com/"> Yahoo! Tax Center</a> - forms, calculators, tips, and more </blockquote> <br> </blockquote> <br> </body> </html> --Boundary_(ID_qK0n0bXP1ajdwM2vTG1t/g)--
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