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Wed Nov 1 12:36:34 GMT 2006

Tim's caveats are important. If your surgeon and institution can and are
willing to deal with the patient's bleeding acutely they should by all
means. However, if there is much hemming and hawing.... Go to the place
where they are able and willing to deal with the injury immediately. I mean
no offense whatsoever but it is almost hard for me to believe that if your
personnel and institution are not used to doing this, that you'll be able to
do it promptly.

I tend to lean toward using the system if you have a good working system in
place. And the sicker the patient is, the more they need a good system
rather than an ad hoc response to their injury. 

Just my contrarian point of view.

BTW later you might want to review how the patient was triaged to your
hospital instead of the trauma center.

Rob Smith, MD 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Hardcastle, Tim, Dr <tch at sun.ac.za>
Sent: Wednesday, November 01, 2006 5:12 AM
To: Trauma &amp; Critical Care mailing list
Subject: RE: penetrating posterior torax injury

Richard

The treatment of bleeding is stop the bleeding! This patient is likely to
exanguinate over the next 40 mins, even with permissive hypotension. He
needs the tinture of surgical steel.

If your surgeon CAN do a thoracotomy he should - stop the obvious bleeding
(oversew / staple off intercostals or lung, or clamp lung hilum), treat any
tamponade and THEN transport to the Trauma Center for definitive care; this
is DAMAGE CONTROL for the chest.

regards
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 M.Med (Emergency Medicine) Executive
Committee member Clinical Head (Director): Diana Princess of Wales Trauma
Unit Division of Surgery (General) Room 4064 Department of Surgical Sciences
Tygerberg Hospital / University of Stellenbosch PO Box 19063 Tygerberg 7505
Western Cape South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Richard van der Kleyn
Sent: Wednesday, November 01, 2006 12:00 PM
To: trauma-list at trauma.org
Subject: penetrating posterior torax injury

Dear list,
would like your coments on a recent case as i am planning to review the case
for lessons learned:

39 year old female, penetrating injury from a knife right posterior torax
level 6/7 rib. Found on the streat, brought in to our small hospital by the
ambulance (personal not qualified for bringing in infusions- unfortunatly
the medicalized ambulance was occupied with an MI), pacient entered our ED
following signs: A- clear B/ sat 80%, dimished breath sounds right hand side
C/ pulse 130 RR 80/30 (class 3 shock). D glasgow 9 (hipoperfusion). 
RxTorax: hematotorax right hand side, pneumotorax right hand side with shift
of of the mediastinum tio the left.
Pacient was intubated while the surgeon placed a chest tube right hand side
which produced 1,500-2000 ml blood and air.
Libral fluid infusion first o negative then type specific without respons (4
concentrats and 2 L saline)- tensions remain same.

At this moment ther is a medicalized ambulance waiting to bring the pacient
to the nearest trauma center (35-40 minutes). Ours is a small hospital, 1
surgeon who happened to be new but with some experiance in toractomy, last
toracotomy performed about 8 years ago

question: toractomy or transport to traumacenter   (easy answer for people
who deal with these cases everyday)

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penetrating posterior torax injury