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Thu Jan 5 07:42:44 GMT 2006

Getting a bit out of my league now.

Nothing wrong with leaving the chest open short term. Is he on any catecholamines? Try non catechol inotropes such as levosimendan. If it is purely a mechanical thing then an intraortic balloon pump may help a lot. Not so keen on an RVAD in this context. Bite the bullet and go on to VA ECMO? What is his acid base status at this point? Simple things? Give calcium?

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

>>> KMATTOX at aol.com 01/05/06 01:23pm >>>
Installment # 5

Case to this point.   Middle age male had R to L transaxial  GSW throught the 
chest.   Taken to distant rural hospital and  transfered with purposeful 
hypotension.   To OR because of bliateral  significant blood in chest tube and 
injury to both R and L lower lobes,  posterior left ventricle - grooving of 
heart, no intracavitary penetration,  through and through distal esophageal injury. 
 No abdominal  penetration.   In OR via clamshell incision.  Patient getting  
cold, coagulopathic, and acidotic.     

WHAT IS HAPPENING NOW.  

Room was warmed to make everyone sweat.    All blood and  fluids warmed.  
Bair Hugger on lower body and  abdomen.    

Both lower lobes had a stapled wedge resection as a damage control  tactic.   
Heart sutures attempted, but muscle shreads with such  attempt.    Drain put 
in area of esophagus.     When the uppen and lower leaves of the clamshell 
were pulled together in  anticipation of closing the chest the heart just cannot 
tolerate  it.    The right and left ventricles are both  dilated.   He has 
received 10 units of total blood by now and about  4000 of warmed ringers 
lactate.    

Everyone wants to get out of the OR, and come back another day for the  
esophagus.   All gross bleeding is controlled.    When  the sternal edges are 
brought together, the BP goes to nothing and he tried to  just die.     The 
resident suggests to just go to the ICU  with the whole chest open with he retractor 
in place ???????     Faculty says, Im not sure we can do that.  We will catch 
hell from Mattox  during morning report at 7 AM in the morning.       Resident 
suggests NOW putting him on the pump and or RVAD to unload the Right  
Ventricle.   

Time is passing, and the anesthesiologist is getting fidgetty and says,  stop 
talking and do something or pronounce him.     The EC  nurses and social 
worker state that a very big family has just arrived in the EC  and wants to know 
the status and to talk to the  doctor.       

We are damned if we stay, and damned if we leave because the patient is  
cold, etc. and the heart beats good only when the retractor is in  place.   

OK,   Now commit yourself.   For those who were  supportive of damage 
control, you now have it.   For those who have  not given an opinion, now is the time 
to participate.    

k
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