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Tue, 11 Mar 2003 06:38:02 EST

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I wonder if the #3 post made it through to all list servers.   Let me repeat=
=20
what that #3 stated. =20
In this case, there may be more than one "correct" course of action, but eac=
h=20
action will lead to a different course of action, which may or may not be=20
correct.=A0=20

Bilateral chest tubes were inserted.=A0 First on the left which yielded abou=
t=20
400 ml of blood and a persistent small air leak.=A0 A chest tube was inserte=
d=20
into the right which then yielded a 300 ml of blood and a small persistent=20
air leak.=A0=A0 A repeat FAST was interpreted as NO HEMOTHORAX and maybe, ju=
st=20
maybe a very small=A0 amount of blood in the abdomen.=A0 BP 120/80 at this t=
ime.=A0=20
P 100, SO2 was 99.=A0=A0 RR 18.=A0=A0 Like many of you a decision was made t=
o do a=20
chest and abdominal CT scan.=A0 In this hospital, the radiology department w=
ill=20
not do a trauma abdominal CT with IV contrast unless there has also been ora=
l=20
contrast given.=A0 Therefore, he was readied for the CT and given a bunch of=
=20
oral contrast to drink, I think it was a liter.=A0=A0 And as most of you kno=
w=20
there is a requisite time to wait till the orally administered contrast gets=
=20
into the gut.=A0=A0 His urinary output was good the whole time and he had=20
restricted IV administration (as most of you should have already surmised as=
=20
he was at BTGH)=A0=A0=20

While waiting for CT to take the patient, he slowly dropped his pressure to=20
85/50, P 110, RR 22, and SO2 of 98.=A0=A0=A0 The nurse reported to the resid=
ent=20
that the RIGHT chest tube collection device now contained 1200 ml of blood=20
and that the LEFT had not changed since the original insertion.=A0=A0 I have=
=20
attached the original and subsequent Chest X-Rays and the Chest Tube=20
collection device as ATTACHMENTS (a zip file) so that each of you can enhanc=
e=20
anyway you wish.=A0=A0 For the really astute among you there was a very subt=
le=20
sign on the original chest x-ray which is now more pronounced that aids in=20
the ultimate diagnosis and decision making.=A0=A0=20

Almost as soon as the low BP was noted (taken by an automatic device, not a=20
direct cuff with a nurse attached) a cuff pressure was taken which was=20
110/80.

Remember, critical decision nodes, once the decision is made, might tie your=
=20
hands to stay on that route of thinking and therapy.=A0=20

You must understand that there was considerable discussion among the trauma=20
surgeon, the residents, the thoracic resident, the thoracic staff, the=20
radiology staff as to what was the "standard" next step, all the way from=20
going stat to the OR, to getting additional studies.=A0=A0=A0=20

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<HTML><FONT FACE=3Darial,helvetica><FONT  SIZE=3D2 FAMILY=3D"SANSSERIF" FACE=
=3D"Arial" LANG=3D"0">I wonder if the #3 post made it through to all list se=
rvers.&nbsp;&nbsp; Let me repeat what that #3 stated.&nbsp; <BR>
In this case, there may be more than one "correct" course of action, but eac=
h action will lead to a different course of action, which may or may not be=20=
correct.=A0 <BR>
<BR>
Bilateral chest tubes were inserted.=A0 First on the left which yielded abou=
t 400 ml of blood and a persistent small air leak.=A0 A chest tube was inser=
ted into the right which then yielded a 300 ml of blood and a small persiste=
nt air leak.=A0=A0 A repeat FAST was interpreted as NO HEMOTHORAX and maybe,=
 just maybe a very small=A0 amount of blood in the abdomen.=A0 BP 120/80 at=20=
this time.=A0 P 100, SO2 was 99.=A0=A0 RR 18.=A0=A0 Like many of you a decis=
ion was made to do a chest and abdominal CT scan.=A0 In this hospital, the r=
adiology department will not do a trauma abdominal CT with IV contrast unles=
s there has also been oral contrast given.=A0 Therefore, he was readied for=20=
the CT and given a bunch of oral contrast to drink, I think it was a liter.=
=A0=A0 And as most of you know there is a requisite time to wait till the or=
ally administered contrast gets into the gut.=A0=A0 His urinary output was g=
ood the whole time and he had restricted IV administration (as most of you s=
hould have already surmised as he was at BTGH)=A0=A0 <BR>
<BR>
While waiting for CT to take the patient, he slowly dropped his pressure to=20=
85/50, P 110, RR 22, and SO2 of 98.=A0=A0=A0 The nurse reported to the resid=
ent that the RIGHT chest tube collection device now contained 1200 ml of blo=
od and that the LEFT had not changed since the original insertion.=A0=A0 I h=
ave attached the original and subsequent Chest X-Rays and the Chest Tube col=
lection device as ATTACHMENTS (a zip file) so that each of you can enhance a=
nyway you wish.=A0=A0 For the really astute among you there was a very subtl=
e sign on the original chest x-ray which is now more pronounced that aids in=
 the ultimate diagnosis and decision making.=A0=A0 <BR>
<BR>
Almost as soon as the low BP was noted (taken by an automatic device, not a=20=
direct cuff with a nurse attached) a cuff pressure was taken which was 110/8=
0.<BR>
<BR>
Remember, critical decision nodes, once the decision is made, might tie your=
 hands to stay on that route of thinking and therapy.=A0 <BR>
<BR>
You must understand that there was considerable discussion among the trauma=20=
surgeon, the residents, the thoracic resident, the thoracic staff, the radio=
logy staff as to what was the "standard" next step, all the way from going s=
tat to the OR, to getting additional studies.=A0=A0=A0 <BR>
<BR>
</FONT></HTML>
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Case from last night-What to do #3 repeat