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Tue Feb 13 15:59:26 GMT 2007

NOPE!  I would not operate on her.  What did you do?

>>> "Errington Thompson" <errington at erringtonthompson.com> 2/12/2007 6:18 PM >>>
Does this paper change anyone's mind?

Livingston DH,  Lavery RF,  Passannante MR,  Skurnick JH,  Baker S,  

  Fabian TC,  Fry DE,  Malangoni MA  

Free fluid on abdominal computed tomography without solid organ

  injury after blunt abdominal injury does not mandate celiotomy.

In: Am J Surg (2001 Jul) 182(1):6-9

ISSN: 0002-9610

BACKGROUND: Mandatory celiotomy has been proposed for all patients with
unexplained free fluid on abdominal computed tomography (CT) scanning after
blunt abdominal injury. This recommendation has been based upon
retrospective data and concerns over the potential morbidity from the late
diagnosis of blunt intestinal injury. This study examined the rate of
intestinal injury in patients with free fluid on abdominal CT after blunt
abdominal trauma. METHODS: This study was a multicenter prospective series
of all patients with blunt abdominal trauma admitted to four level I trauma
centers over 22 months. Data were collected concurrently at the time of
patient enrollment and included demographics, injury severity score,
findings on CT scan, and presence or absence of blunt intestinal injury.
This database was specifically queried for those patients who had free fluid
without solid organ injury. RESULTS: In all, 2,299 patients were evaluated.
Free fluid was present in 265. Of these, 90 patients had isolated free fluid
with only 7 having a blunt intestinal injury. Conversely, 91% of patients
with free fluid did not. All patients with free fluid were observed for a
mean of 8 days (95% confidence interval 6.1 to 10.4, range 1 to 131). There
were no missed injuries. CONCLUSIONS: Free fluid on abdominal CT scan does
not mandate celiotomy. Serial observation with the possible use of other
adjunctive tests is recommended.

So, is anyone aware of any data that suggests that back fractures have a
higher incidence of bowel injuries?

Errington C. Thompson, MD, FACS, FCCM

Trauma/Surgical Critical Care

Mission Hospital

Asheville, NC

Author - A Letter to America

www.whereistheoutrage.net <http://www.erringtonthompsonmd.com/> 

Everyone deserves to make an informed decision

                                - Errington Thompson, MD

  _____  

From: rwolfer at aol.com [mailto:rwolfer at aol.com] 
Sent: Monday, February 12, 2007 3:43 PM
To: trauma-l at lists.aast.org 
Subject: Re: Old lady in MVC

I have seen this before, in all types of patients, teens, old, adult and
kids.  You really need to be worried about bowel injury esp with seat belt
sign.  I would have  a very low threshold for exploration.  I have seen
hemodynamically stable pts with complete bowel transections.  An elderly pt
may not "take the hit" of delayed exploration very well.

Rebecca Wolfer, MD, FACS, FCCP
Associate Professor, Marshall University School of Medicine
Dept of Surgery
Director Thoracic Surgery
Director, Surgical Critical Care Cabell Huntington Hospital
Director, Trauma Cabell Huntington Hospital

-----Original Message-----
From: jkcumming at yahoo.com 
To: trauma-l at lists.aast.org 
Sent: Mon, 12 Feb 2007 2:12 PM
Subject: Re: FW: Old lady in MVC

In the absence of solid organ injury, I would be concerned about the free
fluid in the abdomen. Hollow viscus injury would have to be considered. The
mesenteric hematoma could represent a bucket handle tear and associated
bowel compromise.  In this case, I would low threshold for exploration.

John K. Cumming, M.D.

Errington Thompson <errington at erringtonthompson.com 
<javascript:parent.ComposeTo(> > wrote:

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 <http://www.whereistheoutrage.net/> 

Everyone deserves to make an informed decision
                                - Errington Thompson, MD

-----Original Message-----
From: trauma-list-bounces at trauma.org <javascript:parent.ComposeTo(>
[mailto:trauma-list-bounces at trauma.org <javascript:parent.ComposeTo(> ]
On Behalf Of Bjorn, Pret
Sent: Monday, February 12, 2007 8:06 AM
To: Trauma & 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 <javascript:parent.ComposeTo(> 
[mailto:trauma-list-bounces at trauma.org <javascript:parent.ComposeTo(> ] On
Behalf Of candymsnjd at aol.com <javascript:parent.ComposeTo(> 
Sent: Friday, February 09, 2007 7:04 PM
To: trauma-list at trauma.org <javascript:parent.ComposeTo(> 
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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Old lady in MVC