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Mon Feb 12 18:03:13 GMT 2007

E,
Clearly the concern is for a hollow viscus injury.  My guess is that the mesenteric hematoma is the source of her abdominal fluid, and that as long as she remains completely asymptomatic, I would not operate on her.  However, I would do q 4h serial exams myself, and would recheck her lactate and WBS q 6h times 2 or 3.  The other alternative would be to do a DPL and see what that shows.  But, and I will say it again, I would just watch her as long as she remains completely stable and asymptomatic; I would move to surgery at the slightest indication to the contrary.

Just my 2 cents!
Let us know....
Ron

>>> "Errington Thompson" <errington at erringtonthompson.com> 2/12/2007 12:45 PM >>>
I have a few questions on a case that I took care of recently. 

92 yo female was a restrained passenger in a MVC.  She was taken to an
outside hospital.  They got a chest x-ray and an x-ray of her knee.  She was
diagnosed with a patella fracture and was discharged.  The patient became
hypotensive when she got up to leave.  The patient was transferred to our
hospital.  She arrived approximately 3 hours after her injury.  She became
hypotensive again as she rolled into the ER.  The patient had gotten less
than 500 cc of fluid prior to arrival.  The patient was bolus with 2 L of
normal saline.

On physical examination, the patient had a positive "seatbelt sign" which
was located above the umbilicus.  The patient's abdomen was completely
nontender above and below this sign.  The patient was awake and alert.  She
was conversant.

CT scan of the abdomen revealed a modest amount of free fluid with no
abdominal injuries.  Fluid could be seen around the liver, between the bowel
and in the pelvis.  There was a large mesenteric hematoma with no active
extravasation.  The patient was also noted to have an L3 compression
fracture.

Question: this patient is currently hemodynamically stable by whatever
criteria you would like to use.  Should this patient go to the operating
room or should this patient be observed?  (It is now almost 5 hours from the
patient's motor vehicle crash.)

Errington

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

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] 
On Behalf Of Bjorn, Pret
Sent: Monday, February 12, 2007 8:06 AM
To: Trauma &amp; Critical Care mailing list
Subject: Steroids in SCI (was RE: (no subject))

I see that everyone is rightly reluctant to pick at this scab.  Either
we all thought it was put to rest, or we find it too tiresome to bother
with.  Probably quite a lot of both.

"...why does this issue keep rearing its ugly head..."

PASG's.  The Trendelenburg position.  Atropine and asystole.
Hyperventilation and brain injury.  Iraq and 9/11.  

Ignorance inspires, perpetuates, and vigorously defends myth.  See also
ANECDOTE in the glossary.

"...what evidence is there to give MP in acute SCI..."

There is of course more evidence NOT to give it.  But in vivo, evidence
and ignorance are evenly matched.

"...is it considered efficacious..."

No.  But then, that's only considering the evidence.

Pret Bjorn, RN
Bangor, ME USA

-----Original Message-----
From: trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org] On Behalf Of candymsnjd at aol.com 
Sent: Friday, February 09, 2007 7:04 PM
To: trauma-list at trauma.org 
Subject: (no subject)

help why does this issue keep rearing its ugly head...what evidence is
there to give MP in acute SCI?  Is it considered efficacious....
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