List Archives

Thu Nov 8 13:16:19 GMT 2007

Karl

Absolutely - it is considered obsolete: by me, by the SA Trauma Society, by IATSIC/ISS (see the DSTC manual) and by EAST (personal communication with Raj Gupta and Bill Schwab)

Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
M.Med (Emergency Medicine) Executive Committee member
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Division of Surgery (General) Room 4064
Department of Surgical Sciences
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Orlebar-Edwards,
Karl
Sent: Thursday, November 08, 2007 2:22 PM
To: Trauma &amp; Critical Care mailing list
Subject: The obsolete Trapdoor?

"The trapdoor incision has so much morbidity associated with it that
it is considered obsolete"

The trapdoor is now obsolete?
Dr Hardcastle, Is the trapdoor no longer common practice?

Regards
KP

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Hardcastle, Tim,
Dr <tch at sun.ac.za>
Sent: 08 November 2007 11:42
To: Trauma &amp; Critical Care mailing list
Subject: RE: trauma-list Digest, Vol 52, Issue 31

Naveed & Khumar

The best access to both SCA and the (L) chest is actually the median
sternotomy. The trapdoor incision has so much morbidity accociated
with it that it is considered obsolete.

I seldom if even divide the clavicle as this too leads to severe
morbidity. The left chest can be easily inspected through the
sternotomy. Only a posterior intercostal bleeder may be more difficult
to access, the lung can be tractotomised through the sternal access.

Regards
Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU) ATLS
instructor and DSTC Cape Town Course Director Intern program
Coordinator: Surgery M.Med (Emergency Medicine) Executive Committee
member Clinical Head (Director): Diana Princess of Wales Trauma Unit
Division of Surgery (General) Room 4064 Department of Surgical
Sciences Tygerberg Hospital / University of Stellenbosch PO Box 19063
Tygerberg 7505 Western Cape South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Ahmed, Naveed
Sent: Wednesday, November 07, 2007 6:28 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: trauma-list Digest, Vol 52, Issue 31

Dear Dr Huseynova,
A left thoracotomy initially with proximal control of subclavian
vessels, than left clavicle incision/excision to access proximal and
distal ends of injured vessels for possible repair/ ligation. If
proximal part of the damaged vessel is hard to access, we than proceed
to partial sternotomy to complete the trap door, Is how we usually
handle this. I will love to have some input from the group.
Naveed Ahmed MD FACS
Pictures attached after consent of the patient.(Injury at the junction
of L subclavian vein and L IJ, brachiochephalic/left IJ and subclavian
veins ligated.)

-----Original Message-----
From: khumar huseynova [mailto:khumarhuse at yahoo.ca] 
Sent: Saturday, November 03, 2007 6:03 PM
To: trauma-list at trauma.org
Subject: Re: trauma-list Digest, Vol 52, Issue 31

Pt with  GSW to the L chest with 1 hole in the L supraclavicular area
and another in the 8-9th ICS. Hemodynamically unstable. What incision
would you use to access both the subclavians and the L chest? We;ve
debated between trapdoor and clamshell. What's yoru experience?

  Thanks
  Khumar Huseynova

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Today's Topics:

1. RE: [ccm-l] RE: Pelvic fracture (Stephen Luk) 2. Sending Power
Point Presentations (Charlene M Morris) 3. RE: Pelvic fracture (Olav
R?ise) 4. Pelvic fracture - operative findings (Saboor Khan) 5. RE:
Pelvic fracture - operative findings (Lorick Fox, MPAS, PA-C) 6. RE:
Pelvic fracture - operative findings (Olav R?ise) 7. RE: Pelvic
fracture (Hardcastle, Tim, Dr ) 8. RE: Pelvic fracture - operative
findings (Hardcastle, Tim, Dr ) 9. RE: Pelvic fracture - operative
findings (Sanjay Gupta MD)

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

Message: 1
Date: Sun, 28 Oct 2007 08:48:41 -0400
From: "Stephen Luk" 
Subject: RE: [ccm-l] RE: Pelvic fracture
To: , "Dr Brahma Balakrishnan"
, "'Trauma & Critical Care mailing list'"

Cc: ccm-l at ccm-l.org
Message-ID: <47244CE5.F618.0087.0 at harthosp.org>
Content-Type: text/plain; charset=UTF-8

try this link - browse through the selections, the pelvic packing
lecture is on the bottom of the left hand column

http://www.panamtrauma.org/Lectures/Lectures.htm 

Stephen S. Luk, MD, FACS, FCCP
Assistant Professor of Surgery
Associate Director of Trauma
Medical Director, ATOM Course
Hartford Hospital
EMS/Trauma Program
80 Seymour Street
Hartford, CT 06102-5037
(860) 545-3766
sluk at harthosp.org 

>>> Dr Brahma Balakrishnan 10/27/2007 1:23 PM >>>
Dear Stephen,
Nothing happens when I click on the link.

Regards Dr B

Dr. Brahma Balakrishnan
Clinical Director
Wijaya International Medical Center
Malaysia

-----Original Message-----
From: ccm-l-bounces at ccm-l.org [mailto:ccm-l-bounces at ccm-l.org] On
Behalf Of Stephen Luk
Sent: Saturday, October 27, 2007 11:19 PM
To: Olav RÃ¸ise; 'Trauma & Critical Care mailing list'
Cc: ccm-l at ccm-l.org
Subject: [ccm-l] RE: Pelvic fracture

A presentation by Dr. Moore from the Panamerican Trauma Society
meeting on Pelvic Packing. 

http://www.panamtrauma.org/Lectures/Pelvic%20Retroperitoneal%20Packing
%20Rel

ated%20to%20Hemorrhage%20by%20Fractures/player.html

Stephen S. Luk, MD, FACS, FCCP
Assistant Professor of Surgery
Associate Director of Trauma
Medical Director, ATOM Course
Hartford Hospital
EMS/Trauma Program
80 Seymour Street
Hartford, CT 06102-5037
(860) 545-3766
sluk at harthosp.org 

>>> Olav RÃ¸ise 10/27/2007 10:26 AM >>>
I agree with Ken Mattox. I introduced extrapelvic packing in Oslo in
1994
and it has been part of our pelvic bleeding protocol ever since.

So as the patient is haemodynamically unstable this would be the
option in this case. First the fracture should be stabilized with the
binder or sheet around the trochanter region and kept in place during
the surgical procedure of damage control. 

For the urethral injury I would not have put the catheter in before
the urethra was cleared by an urethra-graphy. It is known that
catheter can put a partial rupture into a total disruption. I would
not focus on the urethra before the pelvic bleed is under controll. 

With regard to the possible rectal injury we are doing a
rectal/sigmoidoscopy to exclude injury. We have seen false negative
contrast exam. of the rectum. This has of low priority and should not
be done before control of the bleed. Eventually a sigmoidotomy shoul
be done - keeping in mind the later reconstruction of the pelvis - and
talk to the pelvic surgeon to avoid incision conflict for later
reconstruction of the pelvis 

With kind regards,

Olav

Olav RÃ¸ise

Division of Neuroscience and Muscoloskeletal Medicine, Ullevaal
University Hospital, Oslo

Cellular phone;+4790895062
E-mail;olro at uus.no or; olav.roise at medisin.uio.no 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of KMATTOX at aol.com
Sent: 27. oktober 2007 15:44
To: trauma-list at trauma.org
Cc: ccm-l at ccm-l.org
Subject: Re: Pelvic fracture

In a message dated 10/27/2007 5:39:42 A.M. Central Daylight Time,
hpb.surgery at gmail.com writes:

1. Pelvic fracture + suspected ongoing retro peritoneal venous bleed,

what
surgical strategy would you employ?
2. If a rectal tear is suspected, without any perioneal trauma, how
would you de-function, loop colostomy? Or end colostomy and mucous
fistula?
Would you
try and establish the site of perforation - on-table flexible
sigmoidoscopy etc.?

I agree with Bjorn regarding the excessive fluid administration. 

The patient appears to be hemodynamically stable. If unstable, then
one of several tactics to impede ongoing blood loss is indicated. I
have never been totally satisfied with arterial embolization for
control of venous bleeding. I also have not been satisfied with
external fixation to reduce blood loss. The orthopedic community is
mixed in its suppor t of external 

fixation. The new extra peritoneal packing as reported from Europe and
from a couple of centers in the United States bears watching. I might
have

considered such a procedure in this patient. It is a temporizing
("damage
control")
tactic. 

With the case as you describe, I would consider going to OR for an
examination under anesthesia, looking mainly at the rectum. For this
one does not need to do a flexible sigmoidoscopy, as it is only the
rectum which is of concern. This can be done with a straight short
scope. Even a full thickness injury might be missed, but your CT
description is suggestive of a rectal injury. I would strongly
consider a LOOP colostomy, but to be sure that the distal stoma is
totally defunctionalized, unless the patient is obese and the
mesentery is foreshortened and to do a loop would create vascular
compromise to the exteriorized segment. If the patient's pelvis was
operatively repaired, and he did not become febrile, I would study the
distal rectum via the loop colostomy and if NO LEAK, I would consider
closing this colostomy at the first hospitalization. 

k

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

Message: 2
Date: Sun, 28 Oct 2007 08:57:06 -0400
From: "Charlene M Morris" 
Subject: Sending Power Point Presentations
To: "Trauma &, Critical Care mailing list" 
Message-ID:

Content-Type: text/plain; charset=ISO-8859-1

for sending ppp, use www.yousendit.com. It is still free for the basic
and
TERRIFIC for alrge files.

Charlene Morris

On 10/28/07, Charles Brault wrote:
>
> I find that
> Goop powerpoint presentation
> Are normaly bad reference document
>
> The poerpoint when well used is but a frame
> That does not hold much without IT's presenter
>
> ... or take on an all other form (god or bad)
>
>
> Charles
>
> ----- Original Message ----
> From: "Bjorn, Pret" 

> To: "Trauma & Critical Care mailing list" 
> Sent: Friday, October 26, 2007 9:14:06 PM
> Subject: RE: Pedi Pointers and Pertinent Propaganda
>
> Just to show I tried: my slides apparently got confiscated at the
border
> (at least, I never saw this on the other end). Still available
> off-List, I think; but again: low expectations are advised.
>
> Pret
>
> -----Original Message-----
> From: Bjorn, Pret
> Sent: Wednesday, October 24, 2007 12:44 PM
> To: 'Trauma & Critical Care mailing list'
> Cc: 'Andrew J Bowman'
> Subject: RE: Pedi Pointers and Pertinent Propaganda
>
>
> Sorry Andrew and everybody. Bangor can be a busy place, and I really
> intended to annotate these (there's of course a lot of scripting
that
> wouldn't be intuitive from the slides); but that's not gonna happen
any
> time soon.
>
> Please forgive the colloquiality, and be patient with the format:
> PowerPoints don't tend to travel well over the internet. The fonts
and
> bullets and layouts will probably not translate cleanly.
>
> And above all, know that these were very short presentations for a
local
> audience, not by any means definitive or comprehensive. But if
there's
> a slide or two that you can use, have at it.
>
> 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 Andrew J Bowman
> Sent: Sunday, October 14, 2007 5:20 PM
> To: Trauma & Critical Care mailing list
> Subject: Re: Pedi Pointers and Pertinent Propaganda
>
>
> Pret,
>
> How did your presentation go?
>
> Andrew Bowman
>
> ----- Original Message -----
> From: "Bjorn, Pret" 

>
>
>
> I'm speaking to a group of nurse anesthetists this weekend who want
to
> know cool stuff about pediatric trauma. I've got a couple of canned
> lectures on my hard drive, but they (and surely I) could use some
> freshening up.
>
> Pret Bjorn, RN
> Bangor, ME USA
>
> --
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>

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

Message: 3
Date: Sun, 28 Oct 2007 15:12:45 +0100
From: Olav R?ise 
Subject: RE: Pelvic fracture
To: "'Trauma & Critical Care mailing list'"

Message-ID: <002201c8196c$9c998bd0$63faf081 at uio.no>
Content-Type: text/plain; charset="iso-8859-1"

Technically this is a very simple method. We have described it in a
recent
issue of Journal of Trauma(1).The Denver group presented their results
in
the same issue. 

We are doing the procedure in the ER. We have embolization as the main
method for controlling bleeding for pelvic bleeding. However, our
angio
suite is located far from ER and for patients in shock embolization is
no
option as such patients will die during transfer - even though we have
intervention services on call 24hrs/365. So packing is for patients
that
otherwise would exanguinate. 

Pelvic packing is done with the sheet or pelvic binder placed around
the
trochanter regions and the extremities internally rotated. A short
midline
incision from the symphysis to 4- 5 cm below the umbilicus is made.
The
haemotoma makes the surgical dissection easy as the bleed is
extraperitoneal. The bladder is held cranially and then you just go
laterally along the pelvic brim under the external illac vessels and
the
psoas muscle. The pelvic bleeding is controlled by a minimum of 3-4
large
swabs on each side in the interspace between the bony pelvic ring and
the
peritoneum, starting from caudal and posterior at the ileosacral joint
and
advancing anteriorily to the symphysis. The swabs are directed toward
branches of the internal iliac artery and the pelvic venous plexus
situated
in the retroperitoneal space. Usually access to the site of bleeding
is
simple as haematoma has already dissected the retroperitoneal space.
To
obtain maximum compression the contra-lateral side is packed in the
same
manner. In unstable pelvic fractures (vertical shear and major open
book
injuries - C and B1) the muscles and ligaments of the pelvic floor may
be
torn. This increases the volume of the true pelvis and more swabs may
be
needed. After completing pelvic packing the linea alba is closed with
continuous sutures in order to achieve additional tamponading effect.
No
wound drains are left. 

The swabs are left for 48 hours. Usually definitive internal fixation
can be
performed at the time of swab removal. However, if the patients starts
to
rebleed at the time of swab removal the EPP is repeated and swabs left
for
another 48 hours. 

This procedure is done by the resident on call. We have established a
systematic training for the trauma team leaders at the lab of
pathology. The
residents are not allowed to serve as a team leader without knowing
the
procedure. 

The procedure is very simple and can easily be learned by any surgeon.
You
will be able to do this in just few minutes. 

Reference;

1. Totterman A, Madsen JE, Skaga NO, Roise O. Extraperitoneal pelvic
packing: a salvage procedure to control massive traumatic pelvic
hemorrhage.
J Trauma. 2007 Apr;62(4):843-52. 

Olav

Olav Røise
Chairman, MD, Ph.D

Division of Neuroscience and Muscoloskeletal Medicine, Ullevaal
University
Hospital

Cellular phone;+4790895062
E-mail;olro at uus.no or; olav.roise at medisin.uio.no 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of Robert F. Smith
Sent: 28. oktober 2007 12:37
To: 'Trauma & Critical Care mailing list'
Subject: RE: Pelvic fracture

Doesn't work for me either even if I cut and paste. 

How does one technically do this? Do you worry about violating
expanding

hematoma?

Rob Smith

-----Original Message-----

From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]

On Behalf Of Richard Wigle MD FACS

Sent: Saturday, October 27, 2007 10:19 PM

To: Trauma &, Critical Care mailing list

Subject: RE: Pelvic fracture

Having had the opportunity to hear Dr Moore speak on this

topic I would very much like to have access to this

presentation. This link- and the previous link- are,

however not working for me despite my trying all the usual

tricks to milk reticent data from web sites. Any other

suggestions?

R Wigle

--- Stephen Luk wrote:

> A presentation by Dr. Moore from the Panamerican Trauma

> Society meeting

> on Pelvic Packing. 

> 

> 

http://www.panamtrauma.org/Lectures/Pelvic%20Retroperitoneal%20Packing
%20Rel

ated%20to%20Hemorrhage%20by%20Fractures/player.html

> 

> 

> 

> 

> Stephen S. Luk, MD, FACS, FCCP

> Assistant Professor of Surgery

> Associate Director of Trauma

> Medical Director, ATOM Course

> Hartford Hospital

> EMS/Trauma Program

> 80 Seymour Street

> Hartford, CT 06102-5037

> (860) 545-3766

> sluk at harthosp.org 

> 

> 

> >>> Olav Røise 10/27/2007

> 10:26 AM >>>

> I agree with Ken Mattox. I introduced extrapelvic packing

> in Oslo in

> 1994

> and it has been part of our pelvic bleeding protocol ever

> since.

> 

> So as the patient is haemodynamically unstable this would

> be the option

> in

> this case. First the fracture should be stabilized with

> the binder or

> sheet

> around the trochanter region and kept in place during the

> surgical

> procedure

> of damage control. 

> 

> For the urethral injury I would not have put the catheter

> in before

> the

> urethra was cleared by an urethra-graphy. It is known

> that catheter

> can put

> a partial rupture into a total disruption. I would not

> focus on the

> urethra

> before the pelvic bleed is under controll. 

> 

> With regard to the possible rectal injury we are doing a

> rectal/sigmoidoscopy to exclude injury. We have seen

> false negative

> contrast

> exam. of the rectum. This has of low priority and should

> not be done

> before

> control of the bleed. Eventually a sigmoidotomy shoul be

> done - keeping

> in

> mind the later reconstruction of the pelvis - and talk to

> the pelvic

> surgeon

> to avoid incision conflict for later reconstruction of

> the pelvis 

> 

> 

> 

> With kind regards,

> 

> Olav

> 

> Olav Røise

> 

> Division of Neuroscience and Muscoloskeletal Medicine,

> Ullevaal

> University

> Hospital, Oslo

> 

> Cellular phone;+4790895062

> E-mail;olro at uus.no or; olav.roise at medisin.uio.no 

> 

> -----Original Message-----

> From: trauma-list-bounces at trauma.org

> [mailto:trauma-list-bounces at trauma.org] 

> On Behalf Of KMATTOX at aol.com 

> Sent: 27. oktober 2007 15:44

> To: trauma-list at trauma.org 

> Cc: ccm-l at ccm-l.org 

> Subject: Re: Pelvic fracture

> 

> 

> In a message dated 10/27/2007 5:39:42 A.M. Central

> Daylight Time, 

> hpb.surgery at gmail.com writes:

> 

> 1. Pelvic fracture + suspected ongoing retro peritoneal

> venous bleed, 

> what

> surgical strategy would you employ?

> 2. If a rectal tear is suspected, without any perioneal

> trauma, how

> would

> you

> de-function, loop colostomy? Or end colostomy and mucous

> fistula?

> Would you

> try and establish the site of perforation - on-table

> flexible

> sigmoidoscopy

> etc.?

> 

> 

> 

> I agree with Bjorn regarding the excessive fluid

> administration. 

> 

> The patient appears to be hemodynamically stable. If 

> unstable, then

> one 

> of several tactics to impede ongoing blood loss is 

> indicated. I

> have

> never 

> been totally satisfied with arterial embolization for

> control of

> venous 

> bleeding. I also have not been satisfied with

> external fixation to

> reduce blood 

> loss. The orthopedic community is mixed in its support

> of external 

> 

> fixation. The new extra peritoneal packing as reported

> from Europe

> and

> from a 

> couple of centers in the United States bears watching. 

> I might have

> 

> considered such a procedure in this patient. It is a

> temporizing

> ("damage

> control") 

> tactic. 

> 

> With the case as you describe, I would consider going to

> OR for an 

> examination under anesthesia, looking mainly at the

> rectum. For

> this one

> does not 

> need to do a flexible sigmoidoscopy, as it is only the 

> rectum which is

> of 

> concern. This can be done with a straight short

> scope. Even a

> full 

> thickness injury might be missed, but your CT

> description is

> suggestive of

> a rectal 

> injury. I would strongly consider a LOOP colostomy,

> but to be

> sure

> that 

> the distal stoma is totally defunctionalized, unless the

> patient is

> obese 

> and the mesentery is foreshortened and to do a loop would

> create 

> vascular 

> compromise to the exteriorized

> segment. If the patient's pelvis

> was 

> operatively repaired, and he did not become febrile, I

> would study

> the

> distal rectum 

> via the loop colostomy and if NO LEAK, I would consider

> closing this

> colostomy 

> at the first hospitalization. 

> 

> k

> 

> 

> 

> ************************************** See what's new at

> http://www.aol.com 

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

Message: 4
Date: Sun, 28 Oct 2007 15:52:02 +0000
From: "Saboor Khan" 
Subject: Pelvic fracture - operative findings
To: "Trauma &, Critical Care mailing list" 
Message-ID:
<5a6885120710280852w4690731dnad7821b2d3947b39 at mail.gmail.com>
Content-Type: text/plain; charset=ISO-8859-1

Thanks to those who replied: Just to mention a few points:

1. I agree, with such an injury a urethrogram should have been
performed.
2. Cannot comment on whether the crystalloid resuscitation was
excessive.
3. The CT scan did not show a blush, however my (experienced)
orthopaedic

=== message truncated ===

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