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Wed Jan 4 01:34:50 GMT 2006

Oh boy, Here we go again and the plot thickens.    I am  sorry for drawing 
this case out, but I am giving it to you as it unfolded and as  we saw it.     I 
cannot help it, we did not shoot him, we  just accepted him and learned from 
the experience.  We want to share the  learning experiences with you.  

First a short summary to this point.   Middle age man GSW to R  lateral 
chest, exiting L lateral chest, taken to rural small hospital and taken  to ICU for 
resuscitation.   Two chest tubes put in, good position,  sent to us after 20 
minutes.     No paralysis,    Arrived at BTGH about 75 minutes after injury.   
Not intubated, Now  about 1100 cc of blood in EACH chest bottle, no 
paralysis, acidotic, low BP and  tachycardic.  He got 2 units of blood in transfer..    
Many  excellent suggestions from around the world.    Now to tell what  we 
did not do and what we did do and where we are now.  

We did not do a CT, subxyphoid pericardiotomy, arteriogram, esophagogram,  or 
esophagoscopy.   We did stop in EC for 10 minutes where we did  not draw any 
CBC, clotting studies or liver function tests.   We did  do a T&C for blood.   
We did NOT give rVIIa.    We  DID talk a lot.

Because of the almost 2600 total blood out from both chests by the time we  
got to the OR, 10 minutes after arrival at our hospital, we had made a decision 
 to operate on the chest.    We could not think of any organ  injury that any 
other test would provide any information we could not discover  at 
thoracotomy. So the patient was intubated and positioned for his chest to be  cut.  

Initially one person wanted to consider a bilateral NON-Trans-Sternal  
anterolateral thoracotomy, but lost that discussion as a bilateral transternal  
anterolateral thoracotomy was accomplished.   We deemed that a  mediansternotomy 
was CONTRAINDICATED as evaluation of the posterior mediastinum  and the lateral 
pleural cavities was difficult via a  sternotomy.    So.............Clamshell 
was done because BOTH  pleural cavities had but out a bunch of  blood.      
Opened quite wide via the clamshell  incision.  Anterior pericardium opened.   

Injuries which were discovered:   

1.    Right lateral chest wall
2.    Right lower lobe of lung, bleeding pretty good,  and air leak found
3.   Thru and thru injury to esophagus about 2 inches above  curx
4.    Entry into posterior L Pericardium and a  significant creasing wound to 
the posterior Left ventricle,  No  intracavitary entry
5.    Exit the Left lateral pericardiuim posterior to  phrenic nerve
6.    Left Lower lobe injury, bleeding pretty good and  air leak found
7.    Left lateral chest wall

What was NOT injured:  

1.    No diaphragm injury
2.    No azygous or hemiazygous vein injury
3.    No aortic injury
4.    No Right ventricular injury
5.    No intraabdominal entry or injury

By the time all injuries found, he had lost almost 3000 ml of blood and had  
6 units of bank blood.   BP 85/40, P 140, pH of 6.9, was getting  
coagulopathic, T 92 degrees F, and had base deficite of -24  (still).    So we have a very 
sick patient, cold, acidotic,  coagulopathic, and injury to both lungs, heart 
and  esophagus.      

>From the surgeons on this group, I need to know what you would do and in  
what order?

>From the intensivist on this group, I need to know just when and in what  
condition do you want him to be brought to you.   Should the surgeons  call you 
to the OR to aid in his management?   Maybe the OR should  become an ICU bed?   

Next installment (# 5) in 24 hours (maybe).   Remember that  tomorrow night 
at this time, Texas will be playing USC in the Rose Bowl and I  might get 
distracted.    

k

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