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Sat Sep 1 04:18:35 BST 2007

The patient remained normotensive with continued hemorrhage from the chest  
tube. As our CT scanner is next door to the trauma room, he was scanned 
througho  the neck and chest with intravenous contrast media.

I did not agree with strategy. I thoughot that continued bleeding from a  
transmediastinal bullet wound warranted angiography as the next step. My  
reasoning is that vascular injury is the most immediately life threatening and  
should be therefore the first diagnosis made or excluded. Beside an angio suite  is 
an excellent location for esophagography. The rooms are always bigger, and  
better prepared for problems than the GI Radiology suite located in the 
recesses  of the department. In ours we can barely get 2-3 people, let alone a crash 
cart,  ventilator etc.

I must admit I am surprised that the consensus of the list so far has been  
to look for aerodigestive injury. The logic escapes me but i am interested to  
hear the rationale that led so many to suggest this first. Was it gut? was it  
trajectory? Was it the appearance on the chest film?

At any rate a CT was done. I have tried to piece together a number of  images 
of that study so that the group can comment on it. I will show the airway  
images on this post and the vascular images on the next

let me know whether this technique of composite imaging is useful to the  
group discussion.

sal
I have beenIn a message dated 8/31/2007 9:53:21 P.M. W. Europe Daylight  
Time, mgreeds at reeds.uk.com writes:

Having  now read others comments on this case (and Sal's further info and rpt
CXR),  my further observations are:-

1.    Obvious surgical  emphysema on left side of rpt CXR (I cannot see
this on the previous CXR -  may be due to the poor quality of images on my
mobile) I presume this to be  evolving/rapidly developing. Is this a correct
assumption?;
2.   Bullet on left side - makes me  question
tracheal/bronchial/oesophageal/cardiac/pulmonary/aortic injury.  Assuming
patient is haemodynamically stable, I would first evaluate for  an
oesophagheal and tracheal injury and proceed from there;
3.   Surgical emphysema would lead me to question a  broncho-pleural
fistula - did the patient show any sign of  this?;
4.    Regarding the persistent haemothorax - is the right  ICD still
draining? If so, what is the content/output? Is it draining  adequately or
does it need replacing/resiting? What are the patient's  current
observations? I would like to know this before I would decide what  to do
next.

For now I shall wait and observe. I would not  wish to proceed to
thoracotomy/sternotomy at this point (based solely on  the current
information.) I would maintain that to perform either procedure  merely to
retrieve the bullet is inappropriate and not in the patient's  best interests
(unless there are good CLINICAL reasons for doing  so.)

As a side issue, what are the list's views on sternotomy  -v- thoracotomy and
the indications for each? If surgery is required, which  would people perform
and why?

I shall read with interest  further comments from the list.

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GSW TO RIGHT CHEST. CT of airway