NEJM images in clinical medicine

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Hi Paul,

It's difficult to answer the questions specifically.
This was, I guess a very shocked trauma patient after
MVA (I think in excess of 200km per hr). The A&E
things had been dealt with very quickly, ie:
intubation, bilateral chest tubes (1L blood came out
the right side over an hour, nil from left) and iv
access and fluids / blood. 

The patient remained hypotensive (I think the highest
the blood pressure went was about 85 systolic).
Although one must assume spinal cord / unstable spinal
injury in all these patients, it's the potential
on-going blood loss that must be dealt with ASAP if
things are to improve...hence the decision to go to
the OR stat! Statistically that's where the money will
be. I think to waste time thinking and pouring fluids
in will be detrimental 9 times out of 10, if the
bleeding is in the abdo.

Anyway, there was a very distended abdo. at this
point, and despite the fact that there was a OG tube
in situ, this was all due to a very distended stomach.

The pulse rate was always between 100-120 bpm and
there was no evidence of priapism (too early??).

If I were to see a case like this again, I would still
err on the side of urgent surgery (+/- damage
control). Most other things can wait, and if they
can't it's unlikely to be salvagable anyway.

The only thing that got to me later was wondering if
we'd have stopped if we had a plain film of C-spine
earlier. I too generally agree that that can wait (esp
in light of the recent paper by Gale et al in J Trauma
Nov 2005), but once in a while it may be so severe as
to stop further treatment?

Regards,

Morgan


--- Paul.Harrison at sth.nhs.uk wrote:

> Morgan,
> 
> THankyou for sharing this incident. A few other
> pieces of information would have significantly
> informed the presentation and understanding of
> whether this was an unfortunate miss or one that
> could have been suspected at an earlier point in
> time:
> 
> 1) Were the team  dealing with other apparent
> 'masking' injuries in addition to the evident HI/TBI
> that may have led to assumed blood loss of critical
> significance.
> 2) Was potential internal trauma/bleeding assumed in
> view of other evidence (e.g. object impact
> history/evidence) apart from 'hypotensive with no
> other source of visible blood loss'. Was the trend
> line of the pulse and BP monitored prior to decision
> to go to OR. Was any imaging attempted prior.
> 3)Did the primary survey look for other indicators
> of SCI specifically, bradycardia or priapism
> 
> 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]On Behalf Of
> Karim Brohi
> Sent: 27 January 2006 12:34
> To: 'Trauma & Critical Care mailing list'
> Subject: NEJM images in clinical medicine
> 
> 
> Morgan,
> 
> Congratulations on your 'Image in Clinical Medicine'
> in this weeks NEJM on cervical spine injury. 
> Interesting Australian
> modification of the Glasgow Coma Scale !!
> 
> Karim
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of
> morgan mcmonagle
> Sent: 27 January 2006 11:58
> To: Trauma &amp, Critical Care mailing list
> Subject: Re: Zevon and Whale in London- lesson to
> learn?
> 
> 
> On a point of information, Warren Zevon died of a
> mesothelioma!
> 
> Morgan
> 
> 
> --- Charlene M Morris <cvmmorris at gmail.com> wrote:
> 
> > Still it saddens me that a denizen of the deep has
> > perished and humans
> > theoretically run the earth.
> > 
> > And remember: Warren Zevon died of lung ca-- after
> > smoking 2ppd for most of
> > his short, albeit influential life.
> > 
> > C M Morris
> > 
> > 
> > On 1/25/06, Howard C. Berkowitz <hcb at gettcomm.com>
> > wrote:
> > >
> > > At 1:34 AM -0500 1/25/06, Krin135 at aol.com wrote:
> > > >
> > > >In a message dated 25-Jan-06 00:30:24 Central
> > Standard Time,
> > > >ben.addleman at gmail.com writes:
> > > >
> > > >I've got  a picture of myself with an
> elephant's
> > ETT. It's about the same
> > > >diameter as  my arm!
> > > >
> > > >
> > > >
> > > >and I can just imagine what a ProboscoTracheal
> > Tube would look like for
> > > a
> > > >Pachyderm...
> > > >
> > > >ck
> > > >
> > > >Charles S. Krin, DO  FAAFP
> > >
> > > NG tube for a giraffe?  Actually, I have had to
> do
> > a bit of
> > > engineering in giraffe country, where the lines
> on
> > telephone poles
> > > must be at least 16 feet, 6 inches tall, or
> > giraffes will attempt to
> > > eat them.
> > >
> > > Retrieving odd lengths of wire from a giraffes
> > esophagus should
> > > be...interesting.
> > >
> > > As an even more random comments, giraffes should
> > get priority from
> > > opthalmologists. They have some of the most
> > beautiful eyes, with
> > > incredibly long lashes, I have ever seen.
> > > --
> > > trauma-list : TRAUMA.ORG
> > > To change your settings or unsubscribe visit: 
> > > http://www.trauma.org/traumalist.html
> > >
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit: 
> > http://www.trauma.org/traumalist.html
> > 
> 
> --
> trauma-list : TRAUMA.ORG
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> --
> trauma-list : TRAUMA.ORG
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