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Thu Jan 5 00:18:02 GMT 2006

Please explain the 6 mcg/min dopamine (DelGuercio effect)!!!!

In the 21st century the only place for dopamine is in Dr Mattox's medical museum. I have a vast file of literature to support that statement - for good summaries see either:

Debaveye YA and van den Berghe GH, Is there still a place for dopamine in the modern intensive care unit?, Anesth Analg, 2004, 98:461-468 or

Holmes CL and Walley KR, Bad medicine: low dose dopamine in the ICU, Chest, 2003, 123:1266-1275

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

>>> John_R_Hall at Wellmont.org 01/05/06 02:38am >>>
Glad we see almost only blunt...

1)  Surgical:  Agree with clamshell.  Would oversew (or staple) lung;  Would staple across esophagus just above and below injury;  Leave pericardium open, drain both chests. Close.  Would call intensivist to OR to help, Would give fibro and rFVIIa and plts.  Would give 2 gram Mefoxin, repeat 4 hours.  Warm saline

2)  ICU.  Would warm.  Bicarb, 6 mics/kg Dopamine  (DelGuercio effect),  resus to BP 90s, polyheme if available, FFP as colloid for BP, restrict salt water as much as possible.

3)  Call Priest

________________________________

From: trauma-list-bounces at trauma.org on behalf of KMATTOX at aol.com 
Sent: Tue 1/3/2006 8:34 PM
To: trauma-list at trauma.org; ccm-l at ccm-l.org; SURGINET at listserv.utoronto.ca 
Subject: Mediastinal Traverse - #4

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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Mediastinal Traverse - #4