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Sun Aug 12 16:29:10 BST 2007

Ok, I'll play.

With the information given I'll make several
assumptions:

1.  In the absence of any evidence of head injury
(noting that it is unclear to me whether the injury to
the lip is upper or lower or whether he has stigmata
of a penetrating wound to the head) or profound
hypoxia, the blown pupil may represent a CNS injury as
stated previously by Ken, most likely by an embolic
stroke to the brain from, I would surmise an injury to
the transverse aortic arch or one of the great
vessels.  

More unlikely it may represent some weird sympathetic
chain injury not Horner's.  

It would be helpful to know whether this gentleman has
a pulse in his left hand, whether the blood pressures
in both upper extremities are unequal, or whether a
bruit over the base of his left carotid is present.

2.  Unless the chest xray was provacative for a left
hemothorax, I would not place a second chest tube
unless I was really concerned that there should have
been more output with the intital placement as would
be evidenced by an impressive chest xray or
hemodynamic instability.  My feeling is that the low
initial chest tube output is diagnostic for contained
mediastinal injury, given the stated location of the
injury and it's presumed trajectory.

3.  Given that this in all likelihood represents a
contained upper mediastinal injury, any further
imaging (whether aortography or CT scanning) may prove
to be CONFOUNDING and MISLEADING when in fact the
definitive DIAGNOSTIC and THERAPEUTIC intervention is
mediastinal exploration.  

That said, I believe that one could choose antecedent
aortography and not be wrong predicated on the
patient's hemodynamic stability and with the
understanding that performing it does NOT negate the
need for surgical exploration.

My approach would be median sternotomy with left neck
extension, keeping in mind that this may require a
trap door on the left.

Ben Reynolds, PA-C
Pittsburgh, PA

--- KMATTOX at aol.com wrote:

> TO THE MEMBERS OF THIS LIST SERVER
>  
> Sal Sclafani has whetted our appetites with a
> complex  case.    From the 
> literature there are MULTIPLE RIGHT ways to 
> evaluate and treat this patient.    
> Multiple imaging, endoscopic,  and lab challenges
> exist and all of them have 
> appeared in the literature.  
>  
> MULTIPLE incisions, positions, and techniques have
> been  described.    This 
> is the kind of case that seasoned CARDIAC and 
> VASCULAR surgeons are more 
> confused than most of the TRAUMA surgeons, but they 
> will not admit it.      
>  
> I strongly encourage each of you to READ the CASE
> and COMMIT yourself to a  
> workup and follow Sal as he dribbles out clues as
> they unfold.     TO MAXIMALLY 
> benefit you must commit yourself and give an
> opinion.   I  will promise that 
> both Sal and I will fully respect your  views.   
> Just to show that there are 
> glitches,   TWO  of the things that I stated in my
> post are completely 
> opposite to things I have  writtened in the past.   
>  
> JOIN this fun discussion.      
>  
> k
> 
> 
> 
> ************************************** Get a sneak
> peek of the all-new AOL at 
> http://discover.aol.com/memed/aolcom30tour
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UPPER MEDIASTINUM Trans thoracic INJURY.