Next GSW case...

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Hi,

here are my suggestions:

1) YES!
2)fentanyl, etomidate
3)Visibility intraoral? If bad do not manipulate - establish surgical 
airway, otherwise give it ONE try
4)Pressure dressing leave it for now and come back later (OR)
5)Accept the blood pressure for the moment like it is.
6) If there is no other obvious reason for the pt. being restless, try 
sedation with fentanyl
7)see 6

Suggestion:  c-spine protection if not done by now, try to get a lateral 
x-ray of the c-spine, if there is still time re-evaluate the pt.. get him to 
the OR and explore his wound. I would not go on with further diagnosis as 
long as he is in critical condition.

just my 2cents...

Farid

Gen. surgeon
BG Trauma centre Duisburg
Duisburg / Germany

----- Original Message ----- 
From: "Ross Hofmeyr" <wildmedic at gmail.com>
To: <trauma-list at trauma.org>
Sent: Friday, August 31, 2007 6:33 AM
Subject: Next GSW case...


> This one just in.  Your management?
>
> 40-something male hijacking victim brought in off the street by
> companions with transaxial GSW to the neck.  Entry at left mandible
> with ramus fracture; exit just anterior to right external auditory
> meatus.  On arrival in our resus unit the patient is making gurgling
> attempts at respiration and has rapid weak radial pulse.  GCS 6 with
> equal reacuve pupils; restless; moving all limbs.
>
> 1) Do you immobilise c-spine?
>
> We commenced with RSI...
>
> 2) What drugs?
> 3) Endotracheal or surgical airway?
>
> ...and established bilateral large IV's.  Initial BP was 71/33, HR
> 130.  Rapid infusion of Ringer's Lactate (1500ml) brought BP to 96
> systolic but spurting arterial bleeding from the exit wound.
>
> 4) Oversew, foley's tamponade, pack or just a pressure dressing?
> 5) What BP should we target? Permissive hypotension or normotension?
>
> Patient continues to be restless.
>
> 6)Sedation?
> 7) Analgesia?
>
> The patient was stabilised to the point at which doom was not
> immediately impending.  A plain chest film confirmed our tube
> placement and demonstrated aspiration (presumed blood).  Orogastric
> tube in situ; urinary catheter drained 300ml.  No other injuries on
> survey.
>
> What's the next step?
> What imaging are you wanting?
> What interventions do you plan?
>
> I'll let you know what we did when some reponses come in.
>
> Ross.
>
> -- 
> _____________________
> Ross Hofmeyr
> MBChB (Stell) ATLS ACLS
> wildmedic at gmail.com
> ross at wildmedix.com
> www.wildmedix.com
> --
> trauma-list : TRAUMA.ORG
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