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Sun Jan 14 17:53:28 GMT 2007

Dear All,

A couple of weeks a ago, I presented a case of hepatic bleeding after IABG use. The reason I did was that it involved hepatic bleeding ( although it was not ditectly a trauma case). I am presenting it again to gain advice.

54 yr old male, alcoholic, brought in with cardiac arrest due to massive MI, underwent resuscitation with IABG, and immediate angioplasty and stenting. 6 hours post procedure his BP dropped along with his Hb. Groin exploration of the baloon site was unimpressive. An intraperitoneal drain was left in. Packed cells were given. 4 houre post procedure, his BP dropped again and the drain emptied 3L of fresh blood over6 hours. A CT abdomen showed hemoperitoneum and a suspected liver infarct.

Laprotomy revealed a massive subcapsular hematoma involving both lobes with rupture into the peritoneum. 1.5 L of blood and clots were removed , the perihepatic space was packed with packsand the abdomen closed.I have the following to questions.

1. When should agents like Clopidogrel be started again/
2. After 72 hours, when the packs are removed how should the liver surface be covered and packed adequately?

Zunorain Dodhy MD

----- Original Message ----
From: "trauma-list-request at trauma.org" <trauma-list-request at trauma.org>
To: trauma-list at trauma.org
Sent: Saturday, 13 January, 2007 3:01:51 PM
Subject: trauma-list Digest, Vol 43, Issue 29

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Today's Topics:

   1. Re: BIG MISTAKE TERRY (Sue)
   2. Terry Valentino PLEASE!!! (Jillian Thomas)
   3. Re: death after traumatic asphyxia (Jenny Moncur)
Content-Transfer-Encoding: 7bit
From: Sue <suefire6 at charter.net>
Precedence: list
Subject: Re: BIG MISTAKE TERRY
Cc: 
Date: Fri, 12 Jan 2007 18:48:48 -0800
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>,
    TVALENTINO at swmail.sw.org
References: <FLEMIMADINCLGLENAJLFAEILCLAA.rajesh84 at asianetindia.com>
In-Reply-To: <FLEMIMADINCLGLENAJLFAEILCLAA.rajesh84 at asianetindia.com>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <45A84890.7090800 at charter.net>
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Message: 1
Sorry, I was away from the computer until now.

I have shut him off. 

Sue

Rajesh wrote:

>Please get this man off the list !
>
>Dr.K.R.Rajesh, MS,DipNB,FRCS,FRCS(Orth)
>Consultant Upper Limb Surgeon
>Division of Upper Limb , Arthroscopy & Joint Replacement Surgery.
>Cosmopolitan Hospital
>Trivandrum,Kerala,India.
> 
>Mobile-9447191205
>
>
>-----Original Message-----
>From: trauma-list-bounces at trauma.org
>[mailto:trauma-list-bounces at trauma.org]On Behalf Of Terry Valentino
>Sent: 13 January 2007 07:59
>To: trauma-list at trauma.org
>Subject: RE: BIG MISTAKE TERRY
>
>
>I will be out of the office January 15th - 19th and returning Monday the
>22nd.  If you need assistance during this time, please contact Gerald
>Slaton, Trauma Program Manager at extension 4-9926 or pager 2503.
>
>You may also contact the Trauma Administration Office at extension
>4-8202.  Thank you.
>
>Terry Valentino RN, EMT-P
>Trauma Program Nursing Director
>Scott and White Trauma Center
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-- 

Sue Roundy, M.Ed., EMT-P (ret.)
President, High Sierra Resources
email:  suefire6 at charter.net  
Past President, Nevada Emergency Medical Assoc.
President & Captain (ret.), Dayton (NV) Volunteer Fire Department 

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From: "Jillian Thomas" <jpt at powerup.com.au>
Precedence: list
Subject: Terry Valentino PLEASE!!!
Date: Sat, 13 Jan 2007 17:47:26 +1000
To: <trauma-list at trauma.org>
Reply-To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <028b01c736e7$24937fa0$0301a8c0 at Jill>
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Message: 2
Don't tell me we need to wait until 22nd Jan for Terry Valentino to return to his office to stop his auto-responder!
Jill Thomas
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From: "Jenny Moncur" <jmoncur at netspace.net.au>
Precedence: list
Subject: Re: death after traumatic asphyxia
Date: Sat, 13 Jan 2007 22:08:50 +1100
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
References: <86325BB1656A0F4BAC4611A956349E770702A881 at VALIER.me.emh.org>
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Message: 3
In Victoria, Australia, as a paramedic I am governed by a set of Clinical 
Practice Guidelines.
One of those CPGs relates to circumstances where resuscitation efforts may 
be withheld.

One of those circumstances is "an adult patient (18 yrs or older) whose 
initial cardiac rhythm is asystole (over a minimum 30 sec period), provided 
the time interval between the onset of cardiac arrest, i.e. collapse, and 
arrival of the crew at the patient has exceeded 10 minutes, and there are no 
compelling reasons to continue, such as suspected hypothermia, suspected 
drug overdose,  a child (<18 yrs of age) or family/bystander requests 
continued efforts."

These CPGs are determined by a Medical Standards Committee and CPG advisory 
committee with medical, paramedical and other specialist representatives, 
and represents accepted evidenced based practice. They are reviewed twice 
yearly.

It may be worth looking at these CPG's as evidence of reasonable practice 
that could be expected by other paramedics in the given situation.

I admit that as a paramedic, given the situation and timeframe as described 
by John, I would have done the same and not attempted resuscitation. I think 
there is such a thing as a fate worse than death - PVS.

Regards
Jenny Moncur
IC Paramedic
Oz

----- Original Message ----- 
From: "Bjorn, Pret" <pbjorn at emh.org>
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Sent: Saturday, January 13, 2007 3:45 AM
Subject: RE: death after traumatic asphyxia

I disagree, although I'm wrong a lot.

Literature being equivocal-to-dismal regarding the odds of resuscitation, 
I'm betting you can get any number of expert witnesses to volunteer in the 
defense of the prehospital personnel.  Contemporary
practice -- globally -- was fairly demonstrated in their approach.
Knowing his passions and principles, I bet you could talk Dr. Mattox into 
speaking for the defense.  It'll be the shortest and most decisive civil 
case in EMS history.

Of course this may be answered more quickly another way: what do the local 
protocols have to say on the subject?  Many systems have 
carefully-constructed decision trees for declaration of death in the
field.  If they exist in this case, they probably represent the
proximate standard of care.  And if they were followed, then the medics have 
transferred any responsibility to the system -- which is as it should be.

I think we'll all be very grateful for news when this sorts itself out.

Best of Luck.

Pret
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