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Sun Oct 28 05:29:09 GMT 2007

I am of the opinion that the "contrast blush" is an overblown CT  sign.  When 
I have performed angiography primariliy because of a contrast  blush, my 
yield of angiography is much lower that when I use the clinical  indications my 
surgeons and I arbitrarily stated in 1977. 

I think that the contrast blush represents a variety of entities
1. dense high attenuation clot
2. venous extravasation or pooling
3. arterial extravasation
4. occluded veins or arteries with stasis in the vessels
5. even normal arteries seen en face

It must be the training i received from Gerry Shaftan that washed the  
radiologist mindset out of me, but I am inclined to rely on clinical signs to  
determine the need for pelvic angiography, not contrast blushes or fracture  
patterns.

sal 
a message dated 10/27/2007 11:37:22 P.M. W. Europe Daylight Time,  
jamiller444 at yahoo.com writes:

We have  two CT scans 8 hours apart. There was no change in size of the  
hematoma.
The blood pressure of 98/60 with a pulse of 102,  8 hours  later is not very 
impressive. How much narcotic has he received?
We'd watch  him carerfully in a step-down unit or ICU.

I agree with Sal: this  patient does not seem to warrant intervention for 
pelvic bleeding.  We  would add contrast blush on CT in the presence of 
hemodynamic embarrassment to  Sal's indications for pelvic angiography.

I would want to look at the  films myself, but based on the description, 
would investigate the rectum with  rigid sigmoidoscopy.

Julie Miller
Melbourne

-----  Original Message ----
From: "SJASMD at aol.com" <SJASMD at aol.com>
To:  trauma-list at trauma.org
Sent: Sunday, October 28, 2007 3:04:15  AM
Subject: Re: Pelvic fracture

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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