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Thu Aug 25 02:27:12 BST 2005

Apnoeic at scene, GCS 3, fixed dilated pupils, CT severe brain oedema ........

Why not just leave the haematoma alone, see what transpires with her head injury and let the forensic pathologist work out the haematoma at autopsy? If it turns out that in fact her brain injury is not so severe as it sounds is it really a problem waiting for a few days and just watching the chest X ray?

Cheers, Ian

Ian Seppelt FANZCA FJFICM
Staff Specialist in Intensive Care Medicine
The Nepean Hospital, 
PO Box 63, Penrith NSW 2751
Clinical Lecturer, University of Sydney

>>> YoramKl at clalit.org.il 08/24/05 11:25pm >>>
A week ago we had a young woman, unrestrained passenger that was injured in an MVC. She was apneic on the scene, hypotensive, GCS=3 with fixed dilated pupils. She was intubated by the paramedic and was brought to our ED. She had a positive FAST, and a widened mediastinum in the CXR. She was taken to the OR where a splenectomy was done (less than a 500cc of blood in the abdomen). After the operation we took her to the CT scanner. She had severe brain edema with minimal SAH. In the angio-CT of the chest we found a large posterior extra-pleural hematoma (see sample images). Despite normally looking aorta we continued to a formal angiography. The aorta and its branches, including the intercostal arteries were intact. At this point the patient is coagulopathic a hemodynamic compromised. 

1. What can be the source of this hematoma?
2. Would you do a thoracotomy? 
Best regards

Yoram Klein 

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extra-pleural hematoma