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Mon, 10 Mar 2003 22:00:12 EST

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There has been little discussion of Dr. Mattox case. I wonder why?
Is he setting us up and thus everyone is lurking?
I, for one, am interested in continuing the chase
lead us on, Ken

sal

In a message dated 3/9/2003 6:32:20 AM Eastern Standard Time, 
karim@trauma.org writes:

> Subj: RE: Case from last night-What to do #2 
>  Date: 3/9/2003 6:32:20 AM Eastern Standard Time
>  From: <A HREF="mailto:karim@trauma.org">karim@trauma.org</A>
>  Reply-to: <A HREF="mailto:trauma-list@trauma.org">trauma-list@trauma.org</A>
>  To: <A HREF="mailto:trauma-list@trauma.org">trauma-list@trauma.org</A>
>  Sent from the Internet 
> 
> 
> 
> As I read the chest X-ray he has a left pleural collection, and an abnormal 
> mediastinum with a wide posterior mediastinal shadow and possibly abnormal 
> left heart border. (Ken - if you want to post a larger version of the X-ray 
> to me I can post it on the web site).  My primary concern at this stage is 
> a vascular injury (ie aorta).  I would not trust the FAST to rule in or 
> rule out a cardiac injury given two equivocal scans. 
>  
> The patient is stable-ish (and has become more stable).  So CT is an option 
> currently, but may be ruled out by subsequent haemodynamic deterioration. 
> (But we're not giving any fluids are we!).  If we'renot going to the OR 
> immediately I would place a left chest tube and see what comes out.
>   
> Given the chest X-ray findings we know the bullet has entered the thoracic 
> cavity, so we're not using CT to exclude this.  So CT would be used to 
> identify/exclude vascular injury and identify potential oesophageal injury 
> if the track goes near it or there is mediastinal gas.  I think the 
> decision depends on what sort of scanner you have, where it is in the 
> hospital, and it's ease of access compared to emergent angiography.
>   
> Given our institution's capabilities I would go for a chest (and abdo) CT 
> with IV contrast only, with arterial phase timing of the chest to examine 
> the aorta and pulmonary trunk.  I would not rely on CT to exclude an 
> oesophageal injury if the track came close.
>   
> Karim
>   
>  
> 
> >> -----Original Message-----
>> From: trauma-list-admin@trauma.org [mailto:trauma-list-admin@trauma.org]On 
>> Behalf Of KMATTOX@aol.com
>> Sent: 09 March 2003 01:48
>> To: trauma-list@trauma.org
>> Subject: Re: Case from last night-What to do #2
>> 
>> 
>> 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:
>> 
>>       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 
> 

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<HTML><FONT FACE=3Darial,helvetica><FONT  SIZE=3D2 FAMILY=3D"SANSSERIF" FACE=
=3D"Arial" LANG=3D"0">There has been little discussion of Dr. Mattox case. I=
 wonder why?<BR>
Is he setting us up and thus everyone is lurking?<BR>
I, for one, am interested in continuing the chase<BR>
lead us on, Ken<BR>
<BR>
sal<BR>
<BR>
In a message dated 3/9/2003 6:32:20 AM Eastern Standard Time, karim@trauma.o=
rg writes:<BR>
<BR>
<BLOCKQUOTE TYPE=3DCITE style=3D"BORDER-LEFT: #0000ff 2px solid; MARGIN-LEFT=
: 5px; MARGIN-RIGHT: 0px; PADDING-LEFT: 5px">Subj: <B>RE: Case from last nig=
ht-What to do #2 </B><BR>
 Date: 3/9/2003 6:32:20 AM Eastern Standard Time<BR>
 From: <A HREF=3D"mailto:karim@trauma.org">karim@trauma.org</A><BR>
 Reply-to: <A HREF=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org<=
/A><BR>
 To: <A HREF=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A><BR=
>
 <I>Sent from the Internet </I><BR>
<BR>
<BR>
<BR>
</FONT><FONT  COLOR=3D"#0000ff" style=3D"BACKGROUND-COLOR: #ffffff" SIZE=3D2=
 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0">As I read the chest X-ray he=
 has a left pleural collection, and an abnormal mediastinum with a wide post=
erior mediastinal shadow and possibly abnormal left heart border. (Ken - if=20=
you want to post a larger version of the X-ray to me I can post it on the we=
b site).&nbsp; My primary concern at this stage is a vascular injury (ie aor=
ta).&nbsp; I would not trust the FAST to rule in or rule out a cardiac injur=
y given two equivocal scans. </FONT><FONT  COLOR=3D"#000000" style=3D"BACKGR=
OUND-COLOR: #ffffff" SIZE=3D3 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0"=
><BR>
 <BR>
</FONT><FONT  COLOR=3D"#0000ff" style=3D"BACKGROUND-COLOR: #ffffff" SIZE=3D2=
 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0">The patient is stable-ish (a=
nd has become more stable).&nbsp; So CT is an option currently, but may be r=
uled out by subsequent haemodynamic deterioration. (But we're not giving any=
 fluids are we!).&nbsp; If we'renot going to the OR immediately I would plac=
e a left chest tube and see what comes out.</FONT><FONT  COLOR=3D"#000000" s=
tyle=3D"BACKGROUND-COLOR: #ffffff" SIZE=3D3 FAMILY=3D"SANSSERIF" FACE=3D"Ari=
al" LANG=3D"0"><BR>
&nbsp; <BR>
</FONT><FONT  COLOR=3D"#0000ff" style=3D"BACKGROUND-COLOR: #ffffff" SIZE=3D2=
 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0">Given the chest X-ray findin=
gs we know the bullet has entered the thoracic cavity, so we're not using CT=
 to exclude this.&nbsp; So CT would be used to identify/exclude vascular inj=
ury and identify potential oesophageal injury if the track goes near it or t=
here is mediastinal gas.&nbsp; I think the decision depends on what sort of=20=
scanner you have, where it is in the hospital, and it's ease of access compa=
red to emergent angiography.</FONT><FONT  COLOR=3D"#000000" style=3D"BACKGRO=
UND-COLOR: #ffffff" SIZE=3D3 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0">=
<BR>
&nbsp; <BR>
</FONT><FONT  COLOR=3D"#0000ff" style=3D"BACKGROUND-COLOR: #ffffff" SIZE=3D2=
 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0">Given our institution's capa=
bilities I would go for a chest (and abdo) CT with IV contrast only, with ar=
terial phase timing of the chest to examine the aorta and pulmonary trunk.&n=
bsp; I would not rely on CT to exclude an oesophageal injury if the track ca=
me close.</FONT><FONT  COLOR=3D"#000000" style=3D"BACKGROUND-COLOR: #ffffff"=
 SIZE=3D3 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0"><BR>
&nbsp; <BR>
</FONT><FONT  COLOR=3D"#0000ff" style=3D"BACKGROUND-COLOR: #ffffff" SIZE=3D2=
 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0">Karim</FONT><FONT  COLOR=3D"=
#000000" style=3D"BACKGROUND-COLOR: #ffffff" SIZE=3D3 FAMILY=3D"SANSSERIF" F=
ACE=3D"Arial" LANG=3D"0"><BR>
&nbsp; <BR>
 <BR>
</FONT><FONT  COLOR=3D"#000000" style=3D"BACKGROUND-COLOR: #ffffff" SIZE=3D2=
 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0"><BR>
<BLOCKQUOTE TYPE=3DCITE style=3D"BORDER-LEFT: #0000ff 2px solid; MARGIN-LEFT=
: 5px; MARGIN-RIGHT: 0px; PADDING-LEFT: 5px"></FONT><FONT  COLOR=3D"#000000"=
 style=3D"BACKGROUND-COLOR: #ffffff" SIZE=3D2 FAMILY=3D"SANSSERIF" FACE=3D"T=
ahoma" LANG=3D"0">-----Original Message-----<BR>
<B>From:</B> trauma-list-admin@trauma.org [mailto:trauma-list-admin@trauma.o=
rg]<B>On Behalf Of </B>KMATTOX@aol.com<BR>
<B>Sent:</B> 09 March 2003 01:48<BR>
<B>To:</B> trauma-list@trauma.org<BR>
<B>Subject:</B> Re: Case from last night-What to do #2<BR>
<BR>
</FONT><FONT  COLOR=3D"#000000" style=3D"BACKGROUND-COLOR: #ffffff" SIZE=3D3=
 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0"><BR>
</FONT><FONT  COLOR=3D"#000000" style=3D"BACKGROUND-COLOR: #ffffff" SIZE=3D2=
 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0">1.&nbsp; He was stable, with=
 a pulse oxymetry of 100% saturation with O2 via nasal catheter.&nbsp;&nbsp;=
 His BP was now 110/75, his abdomen was soft, and he was neurologically inta=
ct.&nbsp;&nbsp; He actually wanted to get up off the table and go home.&nbsp=
;&nbsp; The chief resident wanted to put in bilateral chest tubes, or at the=
 very least one on the left.&nbsp;&nbsp;&nbsp; Remember that this is an inst=
itution where I have been very critical of CT scans for the ACUTE and IMMEDI=
ATE evaluation of ANY chest trauma, so the staff were discussing CT and wond=
ering if they could justify it at our morning report.&nbsp;&nbsp; A repeat F=
AST revealed no fluid in the abdomen or the pericardium.&nbsp;&nbsp; <BR>
<BR>
So.&nbsp; I guess the Critical Decision Node at this What to do #2 is:<BR>
<BR>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 1.&nbsp;&nbsp; Chest tubes, yes or no, if yes=
 right, left or bilateral<BR>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 2.&nbsp;&nbsp; CT scan of chest, Yes or no, i=
f yes, what and how to enhance, IV contrast? <BR>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbs=
p;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; oral contrast ?&nbsp;&nbsp; <BR>
<BR>
k</FONT><FONT  COLOR=3D"#000000" style=3D"BACKGROUND-COLOR: #ffffff" SIZE=
=3D3 FAMILY=3D"SANSSERIF" FACE=3D"arial" LANG=3D"0"> </BLOCKQUOTE><BR>
</BLOCKQUOTE></FONT><FONT  COLOR=3D"#000000" style=3D"BACKGROUND-COLOR: #fff=
fff" SIZE=3D2 FAMILY=3D"SANSSERIF" FACE=3D"Arial" LANG=3D"0"><BR>
<BR>
</FONT></HTML>
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Case from last night-What to do #2