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Sun Dec 24 04:58:03 GMT 2006

Dear all 

Thanks for the replies and discussion.

To further define issues - Here in South Africa we know that our severe head
injured patients do not survive. There is no concept (in the provincial
sector) of Trache, PEG and long term skilled nursing facility. This is our
tragic reality. Regarding the patient I presented - he had brain injuries
that according to the neurosurgeon had a dismal prognosis. I do not know
exactly what the findings were.

I think that those who work in places where severe heads can do well would
be more aggressive with treatment of the patient.

The point that Tim makes about hypoperfusion contributing towards the low
GCS is vital - maybe if you stop the abdominal bleeding, the patient will
perk up a bit.

The definition of brain dead I use here is not the same as for organ
procurement. We see patients who come in who have been intubated without
drugs, have fixed and dilated pupils, are not breathing and have no
brainstem reflexes. No formal apnoea testing etc... From what I have seen,
there is a strong reluctance to operate on these patients for intraabdominal
bleeding in our setting, because these patients simply do not recover from
their head injuries.

Thanks all for giving me some more food for thought

Dean

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of William Bromberg
Sent: Saturday, December 23, 2006 5:37 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Brain dead and bleeding

Exactly.

It depends on what the CT showed i.e. how "unsurvivable" is unsurvivable.
For example if the CT showed b/l carotid  occlusions with massive but not
complete ischemia - the patient is dead and just doesn't know it (not quite
brain dead by criteria but will become so when the swelling starts). It
would be ludicrous to operate on the patients spleen in this situation for
anything but organ salvage. Another example would be transcranial
high-caliber GSW and one to the belly. 

If the head injury is truly unsurvivalve then the only reason to operate is
for organs. Of course there are few CHI's that can be categorically
determined to be non-survivable and I can't say that this case had one
without more info.

William J. Bromberg
Savannah Surgical Group
912 350-7412

>>> "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za> 12/22/06 12:02 AM
>>>
Dean

As a fellow SA dr. I would not operate if the CT head showed non-survivable
injury in the context of a patient stable enough to have gone to scanner
first. The critique may have been that the surgeon should first do the
laparotomy - i.e. address a,b & C, then sort out the head (CT later); this
would certainly hold water if the patient was UNstable. Then the
justification is simply that the potential for hypoperfusion as the
contributor to the low GCS is excluded. 

Your term "brain dead" here needs qualification - have you done all the
tests yet? Or is he just a GCS 3 from scene - I've seen these WAKE-UP!

Regards
Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
M.Med (Emergency Medicine) Executive Committee member
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Division of Surgery (General) Room 4064
Department of Surgical Sciences
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za 
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

-----Original Message-----
From: trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Dean Lutrin
Sent: Thursday, December 21, 2006 7:12 PM
To: 'Trauma & Critical Care mailing list'
Subject: Brain dead and bleeding

Dear list

A quick question. What are your feelings on operating on a patient who comes
into your ER brain dead with intraabdominal bleeding? Do you treat the
abdomen on its own merits assuming that some of the low GCS may be
attributable to hypovolaemia etc...

I am of course assuming that the patient has been intubated without drugs,
there is no drug history etc etc...

We debated this a bit today where one of the surgeons did not operate on a
case because the CT brain showed unsurvivable injuries and was roundly
criticised.

Is this a matter of opinion or are there good answers?

Thanks 

Dean Lutrin
JHB, SA

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