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Sun Jan 14 20:13:13 GMT 2007

1.  Is the liver cirrhotic?  Does he have significant
liver dysfunction at baseline?  How is his PT/INR when
he's not bleeding to death?  I don't know for a fact
but I'm going to guess he won't thrombose his stents
in the face of ongoing coagulopathy and hepatic
synthetic dysfunction.  The risk benefit analysis
clearly would suggest that administering antiplatelets
to this patient with the problems as described
immediately would likely be fatal.  If the
cardiologists protest MAYBE a baby aspirin.  Given the
severity of the liver injury and whatever other
bleeding diathesis is going on if his stents were to
acutely occlude he would need rescue angioplasty. 
It's simply a matter of triaging competing and
confounding priorities.

2.  Prior to going back to the OR one should CONSIDER
hepatic angio with embolization if at all feasible to
decrease the risk of ongoing bleeding once the packs
are removed.

Ben Reynolds, PA-C
Pittsburgh, PA

--- zunorain dodhy <zunoraind at yahoo.com> wrote:

> 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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>    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>
> Content-Type: text/plain; charset=ISO-8859-1;
> format=flowed
> MIME-Version: 1.0
> 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 
> 
> 
> All email checked by Norton Anti-Virus
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> 
> "I am the master of my house and what my wife says
> shall be done."
> Frank Thornton Olmstead
> Content-Transfer-Encoding: quoted-printable
> 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
> Content-Transfer-Encoding: 7bit
> 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>
> Reply-To: "Trauma &amp; Critical Care mailing list"
> <trauma-list at trauma.org>
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> 
=== message truncated ===

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