List Archives

Sat Jan 7 19:12:42 GMT 2006

Tried to send this yesterday but it got rejected.

E

Errington C. Thompson, MD
Trauma/Surgical Critical Care
Author - A Letter to America
www.erringtonthompsonmd.com
Available Now!

Everyone should have an informed opinion.
                                     - Errington C. Thompson, MD

-----Original Message-----
From: Errington Thompson [mailto:errington at erringtonthompson.com] 
Sent: Friday, January 06, 2006 12:04 PM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: # 6 - Mediastinal Traverse

1.    He is very coagulopathic.   We have  available to us the following
clotting studies.   What should we  order???:     PTT, Activated PTT, PT,
INR, Activated  clotting time, platlet count, bleeding time.   Lee White
Clotting time, Fibrinogen levels, specific clotting factor assays, TEG
(regular), TEG (fast), D-Dimer, others.   Just which one or ones will be
helpful in influencing decision making?    HELP

Do the simple stuff first. This is trauma.  unusual trauma but trauma none
the
less. 

2.    What sedation protocol should we use, if any?

This sounds like one of Dr. Mattox's trick questions.  

3.    There is some debate about antibiotic choices and  duration.   The
chief resident has already written for TRIPLE antibiotic coverage, 
including an aminoglycoside, cephalosporin, and  Flagyl.   The ICU resident
wants to add an antifungal drug. 

Why an aminoglycocide?  What is common in your community?  What do you see
in early infections?  That is what you need to cover.  You have the data.  

4.    Is there need for DVT prophylaxis? 

Yes!

5.    Is there need for gastric acid neutralizing?

Yes, I would definitely give H2 blockers.

6.    We have a whole list of imaging, and lab tests available.   Which
would you recommend to be ordered?

7.    We are warming all fluids he is receiving.   We have brought in the
BRAT autotransfusion device in case we need to reinfuse any excess chest
tube drainage.   Is this principle - AUTOTRANSFUSION of chest drainage in
the face of an open esophagus really safe?  We have wrapped him in a Bair
warmer.  His ventalatory system is heated.     Is there any other way we 
should attempt to rewarm him. 

No data that I'm aware for autotransfusion of chest tube blood in the face
of an esophageal injury.  There is data that suggests you can transfuse
contaminated blood from the abdomen.  Yes, blood contaminated with stool!  I
don't do it but there is data to support it. 

If the patient is not warming up you could lavage the chest with warm
saline. 

8.    His temperature is 92, oxygen saturation is 95%, BP 95/60.  P 120.  
base deficit is 20. 

The patient is very hypovolemic.  Needs fluids.  

9.    The nurses are letting 2 family members come in for short periods of
time.   Should they be required to put on gowns, shoe covers, masks, and
caps?

Infection will kill this patient.  I see nothing wrong with making the
family wear everything.  The chest is open.  

I'm sure that there are some hidden Dr. Mattox bombs in these questions. 

E

Errington C. Thompson, MD
Trauma/Surgical Critical Care
Author - A Letter to America
www.erringtonthompsonmd.com
Available Now!

Everyone should have an informed opinion.
                                     - Errington C. Thompson, MD

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Howard C. Berkowitz
Sent: Friday, January 06, 2006 9:20 AM
To: Trauma &amp; Critical Care mailing list
Subject: RE: # 6 - Mediastinal Traverse

At 7:26 AM +0200 1/6/06, Hardcastle Tim, Dr <tch at sun.ac.za> wrote:
>Ken et al.
>
>See my comments after your questions.
>-----Original Message-----
>We have in the past tried and reported on the futility and non-benefit of 
>IABP and CPB in similiar patients.   Their lungs turn to SOLID liver  like
>organs.    ECMO has similiar results.    He  is now in ICU.    One 
>of the members
>of the surgical team  discovered at the end of the case that there was
blood
>penetration from glove  tears in on both right and left gloves, two other
>members of OR team had  blood under one glove.    
>\
>>Good to know - we don't have it as a Level 1 requirement in this country!
>
>1.    He is very coagulopathic.   We have  available to us the following
>clotting studies.   What should we  order???:     PTT, Activated PTT, PT,
INR,
>Activated  clotting time, platlet count, bleeding time.   Lee White
Clotting 
>time, Fibrinogen levels, specific clotting factor assays, TEG (regular),
TEG 
>(fast), D-Dimer, others.   Just which one or ones will be helpful in 
>influencing
>decision making?    HELP
>
>>Do the INR PTT, but ask the lab to adjust the values tothe 
>>patient's body temp. Platelet count may be useful (and TEG - only 
>>if the persons are experienced at interpretation
>
>2.    WHat sedation protocol should we use, if any?
>
>>Here I would paralyse him and use IPPV ventilation, given the open 
>>abdo. I would sedate with either a midazolam with ketamine or 
>>propofol infusion.
>
>3.    THere is some debate about antibiotic choices and  duration.   The
>chief resident has already written for TRIPLE  antibiotic coverage, 
>including an
>aminoglycoside, cephalosporin, and  Flagyl.   The ICU resident wants to add
an
>antifungal drug. 
>
>>There is no evidence to support prophylactic coverage with anyting 
>>more than a 2nd gen cephalosporin and possibly a SINGLE dose of 
>>Metronidazole in Trauma patients. Adding an antifungal just breeds 
>>resistance. Aminoglycosides don't work as the dose is diluted and 
>>the dose required will knock the ears and the kidneys.

I see your point about aminoglycosides. Why limit the metronidazole 
to a single dose, but give it at all? I assume you are using it for 
anaerobic coverage. Since the patient isn't getting po antibiotics, I 
further assume that Cl. difficile prophylaxis isn't a goal.

>
>4.    Is there need for DVT  prophylaxis? 
>
>  >We only have access to unfractionated Heparin - 5000 12hrly SC 
>once clotting.

What about compression stockings or even the inflating-deflating leg 
wraps? Urban legend?

>
>
>5.    Is there need for gastric acid  neutralizing?
>
>>Not with H2 or PPI drugs - would only use sucralphate 1g 6hrly once 
>>the oesophagus is repaired.

Interesting alternative approach.

>
>6.    We have a whole list of imaging, and lab tests  available.   Which
>would you recommend to be ordered?
>
>>CXR to prove your tubes are in right!
>
>7.    We are warming all fluids he is  receiving.   We have brought in the
>BRAT autotransfusion device in  case we need to reinfuse any excess chest
tube
>drainage.   Is this  principle - AUTOTRANSFUSION of chest drainage in the
face
>of an open esophagus  really safe?  We have wrapped him in a Bair warmer.  
>His  ventalatory system is heated.     Is there any other way we 
>should attempt
>to rewarm him. 
>
>>no comment
>
>8.    His temperature is 92, oxygen saturation is 95%,  BP 95/60.  P 120.  
>base deficit is 20. 
>
>>Keep going! 
>
>9.    The nurses are letting 2 family members come in  for short periods of
>time.   Should they be required to put on gowns,  shoe covers, 
>masks, and caps?
>
>>I have not seen evidence to support this other than as urban 
>>legend, certainly this is not standard practise in my country.

It's going to depend what contact they have with the patient. We 
don't have absolutely hard data, but, to me, masks are reasonable, 
and gloves if they will be touching the patient. Caps, shoe covers 
and gowns are far more questionable with respect to nosocomial 
infection.

>
>10.    It is now not yet dawn, and we are discussing  just when we should
>take him back, and what the conditions should  be.   I have asked that the
>primary doctor write a progress note  committing himself to just 
>when the patient
>should go back and under what  conditions he should NOT be taken back.    
>Create a game  plan and plan to stay with the plan.   
>
>>Correct the deficits first and only go back during daylight with 
>>the most experienced team and all the expected facilities in the OR.
>
>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
>Program Manager: Emergency Medicine (U.S.)
>Clinical Head (Director): Diana Princess of Wales Trauma Unit
>Department of Surgery Room 4064
>Tygerberg Hospital / University of Stellenbosch
>PO Box 19063
>Tygerberg 7505
>Western Cape
>South Africa
>
>2 Lorient Close
>Vredekloof, Brackenfell
>7560, Western Cape,
>South Africa
>e-mail: tch at sun.ac.za
>Cell: +27824681615
>Office: +27219389281 or 4911 pager 0302
>Home: +27219813098
>--
>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

List Archives

For your convenience, find the Trauma List Archive Below

FW: # 6 - Mediastinal Traverse