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Mon Dec 31 18:13:46 GMT 2007

I think you are being paranoid. Any injury to the liver with a venous 
injury big enough to force air into is not going to be in a patient who 
is stable enough to be scoped.
ron simon

Sam Picone wrote:
> Isn't there the very real possibility with this injury of forcing air into
> the biliary tree or (more importantly) into the system venous system with
> the positive pressure required from the scope. What pressure do you scope
> these people with...can you see evrything. have you ever had an air
> embolis...or am I just being paranoid?
>
> Sam Picone MD FACS
> Wisconsin USA
>
> On Dec 30, 2007 1:32 PM, Ben Reynolds <aneurysm_42 at yahoo.com> wrote:
>
>   
>> On the whole, I think Errington's approach was the safest.
>>
>> The impetus for nonoperative management of penetrating (specifically
>> civilian FIREARM) abdominal trauma comes primarily out of LA and Baltimore
>> (overwhelmingly the former).  Their results, I think are mixed and do NOT
>> provide a strong enough foundation to defend a reproducible and sustainable
>> "standard of care" in all institutions.  Way too many questions are left
>> unanswered and no papers from other centers have come out duplicating their
>> results (THAT I KNOW OF).  Probably because few other places see as much
>> penetrating trauma as they do in order to accomplish nonoperative management
>> successfully.
>>
>> A laparotomy is a DIAGNOSTIC test with as near to a 100% sensitivity and
>> specificity as one can get and is THERAPEUTIC if you make a diagnosis that
>> requires intervention.  In general one shouldn't fall into believing that a
>> penetrating wound to the right upper quadrant would ONLY involve liver.  CT
>> cannot accurately diagnose a penetrating injury to the bile ducts, the
>> gallbladder or the colon (among other structures).
>>
>> I think that it's important to keep in mind that the morbidity of a
>> diagnostic (nontherapeutic) laparotomy can PALE in comparison to the
>> mortality associated with missed injury (hollow viscus, biliary, vascular).
>>
>> Ben Reynolds, PA-C
>> Pittsburgh, PA
>>
>> ----- Original Message ----
>> From: Errington Thompson <errington at erringtonthompson.com>
>> To: "Louis Brusco Jr., M.D." <lb86 at columbia.edu>
>> Cc: Critical Care List <ccm-l at ccm-l.org>
>> Sent: Sunday, December 30, 2007 11:26:27 AM
>> Subject: RE: [ccm-l] FW: GSW to liver
>>
>> There is a growing body of literature that says that CT'ing these patients
>> are safe.  I believe that a good CT scan is only as good as the
>> radiologists
>> reading the scan.  I fear missing bowel injuries in patients I know will
>> have fluid on their CT scans.
>>
>> Of course, I could laparoscope the patient.  That is something that I
>> considered at the time.  The patient probably could have benefitted from
>> being scoped.  I'm still on the fence on this one.
>>
>> Serial exams - Eddie Cornwell and the guys at LA County looked at this.
>> You
>> need a specialized unit to this protocol.  Breaking the protocol has
>> significant consequences to the patient - prolonged ICU/hospital
>> stay/infectious complications.  Great study.
>>
>> Errington C. Thompson, MD, FACS, FCCM
>> Trauma/Surgical Critical Care
>> Author - Letter to America
>> Asheville, NC
>>
>> -----Original Message-----
>> From: Louis Brusco Jr., M.D. [mailto:lb86 at columbia.edu]
>> Sent: Sunday, December 30, 2007 10:54 AM
>> To: errington at erringtonthompson.com
>> Cc: 'Critical Care List'
>> Subject: Re: [ccm-l] FW: GSW to liver
>>
>> E
>>
>> Isn't this one where the literature is little help?  If you look at the
>> literature - the patient should go to OR or get a DPL - but sometimes
>> they look SO SO good - and you go in and find nothing that you had to do
>> anything about - with modern, good SICU care - why not admit them and
>> wait it out?  The down side - he bleeds out and you get him to the OR
>> too late - if that happens one out of 1000 - is that too much of a risk
>> for you?  I am sure Ken M will have an opinion here that I am
>> interesting in hearing.  When I get these patients in the ICU - and I
>> hear the absolutes (take GSW to Abd to OR - take Zone X neck stab wound
>> to OR) I wonder if modern imaging and ICU care has yet changed that...
>>
>> Lou
>>
>> --
>> Louis Brusco Jr., M.D., F.C.C.M.
>> Associate Medical Director
>> St. Luke's-Roosevelt Hospital Center
>> NYC
>>
>> Co-Director, Surgical Intensive Care Unit
>> Director, Critical Care Anesthesiology
>> Medical Director, Post-Anesthesia Care Unit
>>
>>
>>
>>
>> Errington Thompson wrote:
>>     
>>> I have a couple of questions on a recent case.  30 yo male was too drunk
>>>       
>> to
>>     
>>> have a gun but had one nonetheless.  He shot himself in the right upper
>>> quadrant.  He was stable, awake and talking in the ER.  Entrance wound
>>> easily seen just under the ribs and just lateral to the mid-clavicular
>>>       
>> line.
>>     
>>> The bullet was palpable just under the skin at about the 12th rib.   No
>>>       
>> SOB.
>>     
>>> 1) CT or not CT scan.  IF you do scan the patient and see a thru and
>>>       
>> thru
>>     
>>> wound the liver, can you just watch him?
>>>
>>> I take the patient to the OR.  He indeed has a thru and thru GSW to the
>>> liver.  The wounds are not really bleeding.  There is no bile oozing
>>>       
>> from
>>     
>>> either wound.
>>>
>>> 2) Drain or no drain?
>>>
>>> The patient develops an ileus and bile peritonitis.  He is
>>>       
>> percutaneously
>>     
>>> drained.  On day 5 with his drain output still over 300 cc per day the
>>> character of the drainage changes to a dark green.  CT scan revealed an
>>> abscess posterior to the liver.  Percutaneous drainage was performed.
>>> Enterococcus in the fluid.  Antibiotics were started.  Antiobiotics
>>>       
>> stopped
>>     
>>> after 7 days.
>>>
>>> Thoughts?
>>>
>>> Errington C. Thompson, MD, FACS, FCCM
>>> Trauma/Surgical Critical Care
>>> Mission Hospital
>>> Asheville, NC
>>> Author - A Letter to America
>>> www.whereistheoutrage.net
>>>
>>>
>>> Everyone deserves to make an informed decision
>>>                                - Errington Thompson, MD
>>>
>>>
>>> _______________________________________________
>>> ccm-l mailing list
>>> ccm-l at ccm-l.org
>>> http://ccm-l.org/mailman/listinfo/ccm-l
>>>
>>>
>>>       
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>>     
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>   
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begin:vcard
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n:;Ronald Simon, MD
org:Bellevue Hospital Center
adr;dom:;;550 First Avenue NBV-15S5;New York;NY;10016
title:Director of Trauma and Surgical Critical Care
tel;work:212-263-5751
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[ccm-l] FW: GSW to liver