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Sat Oct 27 17:04:15 BST 2007

A "moderate" retroperitoneal hematoma on CT and a "sag" in blood pressure  
after a transfer does not leave me breathless. I have a couple of "can't  
imagines"

1. cant imagine that a moderate hematoma due to venous bleeding won't sort  
itself out better than exposing the veins to the atmosphere

2. can't imagine how arteriographic embolization would do anything about a  
venous bleed except rule out associated arterial hemorrhage.

I wouldn't do anything for the bleeding unless it met my criteria for  
angiography, namely 4 units of transfusion within 24 hours or persistent  
hypotension or worsening base deficit.

I am concerned we are looking at a VOMIT, as ken would say

sal sclafani

In a message dated 10/27/2007 12:39:42 P.M. W. Europe Daylight Time,  
hpb.surgery at gmail.com writes:

Members,

I would appreciate your opinion on the following  'theoretical' scenario,
which might have happened in St.  Elsewhere:

36 yrs old male, motor bike accident, car pulled out in  front of them and he
came off his bike, cartwheeled several times. No LOC,  haemodynamically
stable. Transported to a local unit, fluid resuscitated  with
crystalloids, pelvic disruption suspected (pelvis secured -  temporary),
catheter inserted, some blood but urinary flow established. CT  - disruption
of symphysis, sliver of gas retroperitoneum mid rectum,  tracking anteriorly
to left thigh and anterior abdominal wall on the left,  moderate pelvic
haematoma

Patient transferred to tertiary care:  second CT 8 hrs after, findings much
the same, no change in haematoma, no  intra-abdominal mischief. Patient
hypotensive (98/60, pulse 102) -  resuscitated. My questions are:

1. Pelvic fracture + suspected ongoing  retroperitoneal venous bleed, what
surgical strategy would you  employ?
2. If a rectal tear is suspected, without any perineal 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.?

Details of op-findings later.

Best  Wishes,
Saboor Khan
Coventry
UK

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