List Archives

Tue Feb 13 16:05:04 GMT 2007

E,
Did you operate solely because of the presence of fluid on the CT?  AS
far as the confusion and all of the other "issues", sounds like she
should be allowed to mobilize her fluids, get some sleep, and normalize
her routine as best as you can not that she is gonna have the need for
narcotics for pain control, and minimize fluids/diurese by allowing her
kidneys to work normally, as they were doing prior to her crash (at
least I am assuming that is the case).  I guess I am saying that at this
point this lady would benefit from a healthy dose of "therapeutic
Nihilism".......
R

>>> "Errington Thompson" <errington at erringtonthompson.com> 2/12/2007
6:57 PM >>>
The EAST guidelines really don't address fluid see on CT.  Here what I
found
on EAST. 

Routine use of CT for the evaluation of BAT was not initially viewed
with
overwhelming enthusiasm. CT requires a cooperative, hemodynamically
stable
patient. In addition, the patient must be transported out of the
trauma
resuscitation area to the radiographic suite. Specialized technicians
and
the availability of a radiologist for interpretation were also viewed
as
factors which limited the utility of CT for trauma patients. CT
scanners are
now available in most trauma centers and, with the advent of helical
scanners, scan time has been significantly reduced. As a result, CT
has
become an accepted part of the traumatologist*s armamentarium.

The accuracy of CT in hemodynamically stable blunt trauma patients has
been
well established. Sensitivity between 92% and 97.6% and specificity as
high
as 98.7% has been reported in patients subjected to emergency CT.38, 39
Most
authors recommend admission and observation following a negative CT
scan.40,
41 In a recent study of 2774 patients, the authors concluded that the
negative predictive value (99.63%) of CT was sufficiently high to
permit
safe discharge of BAT patients following a negative CT scan.42

CT is notoriously inadequate for the diagnosis of mesenteric injuries
and
may also miss hollow visceral injuries. In patients at risk for
mesenteric
or hollow visceral injury, DPL is generally felt to be a more
appropriate
test.37, 43 A negative CT scan in such a patient cannot reliably
exclude
intra-abdominal injuries.

CT has the unique ability to detect clinically unsuspected injuries. In
a
series of 444 patients in whom CT was performed to evaluate renal
injuries,
525 concomitant abdominal and/or retroperitoneal injuries were
diagnosed.
Another advantage of CT scanning over other diagnostic modalities is
its
ability to evaluate the retroperitoneal structures.40 Kane performed CT
in
44 hemodynamically stable blunt trauma patients following DPL. In 16
patients, CT revealed significant intra-abdominal or retroperitoneal
injuries not diagnosed by DPL. Moreover, the findings on CT resulted in
a
modification to the original treatment plan in 58% of the patients

-----------------
Onward thru the fog.  

The patient was taken to the OR for an exploratory lap.  Blood was
found in
the abdomen.  No bowel was seen.  Mesenteric hematoma was also seen.  

Post-operatively the patient's urine output fell off on several
occasions.
She responded to fluid boluses.  She was awake and alert.  She did
complain
of abdominal pain.  Over the next 2 days the patient was 8 liters
positive.
She was looking very swollen.  Her urine output was adequate.  Her plt
count
was in the 40,000 range and her Blood count had dropped from 9 to 6. 
An
Echocardiogram revealed right ventricular hypertrophy.  A central line
was
placed and the patient had a CVP of 32.  Lasix was given and some
afterload
reducers.  The patient's plt count came up nicely.  She did receive 2
units
of PRBC's.  

On post op day #6 the patient is out of the unit on the trauma floor. 
The
patient's daughter and grand-daughter complain that the patient is
confused.
Really, for the first time in the patient's hospital stay she is
confused.
T
he patient had 6 mg of morphine in the previous 24 hours and 15 mg of
hydrocodone.  The patient is on diliazem and lasix.  Her BP has been
around
130 - 140's over 70's.  The patient is on telemetry and she has had
occasion
PVC's 1 - 2 per minute since admission.  So now what?  How do you work
up
confusion in 92 yo?  Does every 92 yo with confusion get a CT of the
head?

E

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: juandutch at hotmail.com [mailto:juandutch at hotmail.com] 
Sent: Monday, February 12, 2007 5:01 PM
To: trauma-l at lists.aast.org 
Subject: Re: FW: Old lady in MVC

Only level III evidence. (EAST guidelines)
Juan
Sent via BlackBerry from Cingular Wireless  

-----Original Message-----
From: "Errington Thompson" <errington at erringtonthompson.com>
Date: Mon, 12 Feb 2007 15:48:16 
To:<trauma-l at lists.aast.org>
Subject: RE: FW: Old lady in MVC

Any data to support this feeling.

Errington C. Thompson, MD, FACS, FCCM

Trauma/Critical Care

Author - A Letter to America

www.whereistheoutrage.net 

I can only show you the door...

                                               Morpheus (The Matrix)

----------------

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

Probably should explore.

The risk of mortality for missed injury in this case would be very high
and
probably outweigh the risk of a negative laparotomy in this patient who
was
otherwise hardy enough that they tried to get her to walk and go home. 
With
the mesenteric hematoma and L3 fracture she's going to be stuck in the
hospital with an ileus anyway so no matter which way you go there will
still
be all the risks of keeping a 92 year old hospitalized.

If the patient is known to have a hostile abdomen, so that an
exploration
would involve hours of dissection then I might rethink this and just
observe.

 Errington Thompson <errington at erringtonthompson.com> 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 

 Everyone deserves to make an informed decision
                                 - Errin
gton 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 & 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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FW: Old lady in MVC