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Fri Apr 21 17:43:26 BST 2006

I agree, but all that is necessary to send the patient home is no hard signs--all else is irrelevant and superfluous for an uncomplicated penetrating wound in proximity to a major extremity vessel.  There is no basis for using noninvasives to make this decision other than other people saying you should, or that they do, and there is reason that these can lead you astray into dangerous territory, as we explain in that paper.  I am sorry for misunderstanding what you meant
ERF

-----Original Message-----
From: Roy Danks <roydanks at hotmail.com>
To: Trauma &amp; Critical Care mailing list <trauma-list at trauma.org>
Sent: Fri, 21 Apr 2006 11:12:58 -0500
Subject: RE: Re: Penetrating extremity trauma

I have read the paper and I didn't intentionally misrepresent the literature.  
The question that started this thread is:  what do I have to do to be sure I'm 
not missing a vascular 
injury in a penetrating ext. trauma pt? (Paraphrased)

Do you, then, agree that as long as the ABI, if you want to use this parameter, 
is > 0.8 and no hard signs, all is good, send the patient home?

I appreciate your experience, but disagree with the prior posting that >0.8 
indicates no arterial injury.  If it's 0.85 and <0.95 is considered abnormal 
then 
how do you go about further work up?

I understand that location means a lot too.  But I don't think your paper or any 
other paper I've read on the subject throws a blanket over the assessment issue.
In fact, my first post says what you said:  physical exam is the most important.  
But I would hope that even the most experienced trauma surgeon wouldn't get 
tunnel-
vision to the point that a lateral thigh wound without hard signs can simply be 
discharged.  And I'm not saying that it needs to be imaged.  But we aren't 
teaching the 
residents anything by saying "here is our paper that shows that lateral thigh 
SWs don't cause vascular injury".  I know that's an overstatement of your paper.

And I'm not an expert.  I'm not sure anyone is an "expert" though some of you 
out there certainly have more experience than I and I more than some others.  
ERF has lots of 
experience (I heard you speak at the Univ. of Iowa a couple of yrs ago).  That's 
helpful to you, in your institution.  We all have different support available, 
even those of us
at Level I centers.

What would you tell a general surgeon at a Level II or lower center to do?  
Assuming low volume of penetrating ext trauma?  Send to you?  If so, I hate to 
hear that when
a reasonable general surgeon can figure these things out.  Punting everything to 
the Level I centers is the answer...so, what's yours, ERF?

RD
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Penetrating extremity trauma