List Archives

Mon Jan 15 10:02:53 GMT 2007

1. No Clopidogrel.  By the time this patient makes it out of hospital to
such a time when he might restart it his stents will have been fully tested
by the thrombotic/antithrombotic phases of his coagulopathy and they'll
either have remained patent or clotted off.  Clearly this patient is not
happy on Plavix and should not have it again.

2. If this is a subcapsular haematoma I doubt you'll find anything to
embolise on angio, but a CT with IV contrast might help you make this
decision.  More likely though, careful and slow removal of packs with plenty
of soaking to ease them off the liver will be all that is required.  If the
liver has stopped bleeding, leave it alone.  If it's bleeding again then
just repack and come back later.  of course the Clopidogrel will hang around
for 10+ days and so you should cover the pack removal procedure with
platelet therapy.

Karim

On 14/01/07, Ben Reynolds <aneurysm_42 at yahoo.com> wrote:
>
> 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
> >
> >
> > Send trauma-list mailing list submissions to
> >     trauma-list at trauma.org
> >
> > To subscribe or unsubscribe via the World Wide Web,
> > visit
> >
> > http://list.mistral.net/mailman/listinfo/trauma-list
> > or, via email, send a message with subject or body
> > 'help' to
> >     trauma-list-request at trauma.org
> >
> > You can reach the person managing the list at
> >     trauma-list-owner at trauma.org
> >
> > When replying, please edit your Subject line so it
> > is more specific
> > than "Re: Contents of trauma-list digest..."
> > 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 & 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 & 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
> > >--------------------------------------------
> > >My mailbox is spam-free with ChoiceMail, the leader
> > in personal and corporate anti-spam solutions.
> > Download your free copy of ChoiceMail from
> > www.digiportal.com
> > >--
> > >trauma-list : TRAUMA.ORG
> > >To change your settings or unsubscribe visit:
> > >http://www.trauma.org/traumalist.html
> > >
> > >
> > >
> > >
> > >
> > >
> > >--
> > >trauma-list : TRAUMA.ORG
> > >To change your settings or unsubscribe visit:
> > >http://www.trauma.org/traumalist.html
> > >
> > >
> > >
> >
> > --
> >
> > 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
> >
> >
> > "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 & Critical Care mailing list"
> > <trauma-list at trauma.org>
> > Message-ID: <028b01c736e7$24937fa0$0301a8c0 at Jill>
> > Content-Type: text/plain;
> >     charset="iso-8859-1"
> > MIME-Version: 1.0
> > 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 & Critical Care mailing list"
> > <trauma-list at trauma.org>
> > References:
> >
> <86325BB1656A0F4BAC4611A956349E770702A881 at VALIER.me.emh.org>
> > Reply-To: "Trauma & Critical Care mailing list"
> > <trauma-list at trauma.org>
> > Message-ID:
> > <03fb01c73703$3a29b570$0400a8c0 at your8abc512da0>
> > Content-Type: text/plain; format=flowed;
> > charset="iso-8859-1";
> >     reply-type=original
> >
> === message truncated ===
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/traumalist.html
>

List Archives

For your convenience, find the Trauma List Archive Below

Hepatic bleeding