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Tue Jan 10 05:15:03 GMT 2006

Ken

All I ask is what was the degree of ease / difficulty in closing the abdo after the placement of the feeding and gastrostomy tube; if the bowel was oedematous should the abdo have been left open at this point.

Does the autopsy maybe show a clot in the heart or the shock-wave aortic intimal flap as a sourse of SMA embolisation? - No way to predict and very little chance to prevent given his other surgical risks. I don't think you could have done much differently on this one!

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

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of KMATTOX at aol.com
Sent: Tuesday, January 10, 2006 12:22 AM
To: ccm-l at ccm-l.org; trauma-list at trauma.org
Subject: # 10 Severe Sepsis, ACS, (was transverse)

Case to this point.   Mediastinal traverse GSW transfered great  distance, 
found to have injury to both lungs, back of heart and esophagus, had  staged 
approach resulting in stapled lower lobectomies, nothing to graze wound  to 
heart, and a T tube into esophageal injury, repair of one wall, and many  drains.   
  Had feeding jejunostomy and drainage into  stomach and proximal esophagus.  
 Developed pseudomonas and  acenidobacter (sp) sepsis and pneumonia.     Not 
really  putting out much via T tube or chest tubes.   NOW..........we are  
about 6-7 days post injury.  

1.    We have given only leukocyte depleted  blood.  Only thing available. 
2.    Family knows how very very very sick he is
3.    Have had him reviewed for any one of many  different research protocols 
for sepsis, ARDS, cytokine storm, etc.    He was too sick to put into any of 
them.   
4.    Infectious disease consultants have assisted with  antibiotic choices.  

5.    LFT - ALL off the wall abnormal
6.    Urine output down to almost nothing.    Increasing expiratory pressures 
on ventilator,   Blood sugars continue  to be low and hard to control .   pO2 
is 60.   

Patient arrested and after 30 minutes we got him back but probably broke  the 
sternal wire sutures in the process.   He is sick sick sick.  

It is obvious that he has what looks like an abdominal compartment  syndrome. 
   Too sick to move to OR.    

WE make a decision to open abdomen in the ICU and sew on a Bogota  bag.    
One side of bag sewn in place prior to skin  incision.   Appropriate sedation 
given.    

SURPRISE- well not really.   He does have a compartment syndrome,  but the 
gut is ALL DEAD.   And the liver looks  blanched.    Renal output does not 
really come back after Bogota  Bag sewn in place, although femoral pulses are 
intact.    

Decision made to do nothing further as all of small bowel is DEAD.   BLACK.   

In about 8 hours he DIES.     Autopsy is  pending.   

Now I need for everyone who has made comment in the past to give me their  
reflections and any new person can comment if they wish.      We really thought 
we would turn him around on the third day, but we did  not.      I would also 
be happy to know what anyone  might think that we would find different, if 
anything on the  autopsy.    

k

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# 10 Severe Sepsis, ACS, (was transverse)