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Sun Sep 2 16:24:27 BST 2007

In a message dated 9/1/2007 5:44:31 A.M. W. Europe Daylight Time,  
KMATTOX at aol.com writes:

My first  post was prior to looking at composite vascular  images.   I am  
still looking at them.   I am concerned about  the area of  the corina.   NOW 
, I 
want an arteriogram as this study   confuses me.      I still dont really 
think 
he has a   vascular injury. 

k

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

KEN

As I see this case it is a transmediastinal penetration with traversal of  
Zone I and Zone II of the neck. In my practice I would advocate angiography and  
esophagography for all stable patients with a Zone I gunshot wound. 

A simple angiogram and esophagogram would have addressed all these issues  in 
a shorter time than a congressman can change his opinion.

This CT scan answered practically nothing. Is anyone beside me clear  about 
the trajectory. The chest and neck film give more information about  that. We 
cannot exclude ANY of the injuries we are all looking for. We cannot  determine 
from CT whether any additional intervention is needed, which  compartment to 
enter and how to treat anything we go about doing it.

Objectively, this CT scan is flawed and it is problematic because of  several 
TECHNICAL errors.

I have re-attached the CT composite so we can analyze the errors  made  by 
the tech and radiology resident.

There are three problems in technique here: 1. motion, 2. contrast  
administration route and 3. metallic artefacts left on the chest.. 

The IV contrast was administered via an upper extremity venous access and  
the dense venous contrast is degrading the visualization of the arterial  
structures (V marks veins). Combine the streak artefacts resulting from leaving  
monitoring leads and perhaps other metalic objects  on the chest, with a  little 
respiratory motion and voila, we have all kinds of problems. . While  modern 
CT scanners should be able to "clean up" the streaking resulting from the  
metal, it is clear in this sequence, that streak artefacts are creating problems  
of interpretatation of intimal flaps and small areas of extravasation. 

Note the arrow on image 6. Is that an extravasation or artefact? I have  
definitely seen extravasation that looked like that. 

Have we missed an aortic injury on image 8? Too many artefacts from the  
venous contamination to be sure.

Anyone want to exclude an injury of the innominate bifurcation on images  3,4 
and 5? Not I, too many artefacts.

CT is only as good as the technique used. To be able to rely upon CT,  the  
CT technical and medical personnel and trauma surgeons are going to  have to 
pay more attention to the details of ct scanning. We have known for 20  years 
that ecg leads and wires cause artefacts, that arms need to be above the  field 
to avoid these problems. The contrast bolus would have been more  appropriate 
from a femoral vein line, which should have been an access in the  first place.

The only value this CT had was in showing where the bullet exited the right  
chest which was in the right lung apex. (See next email)

sal sclafani

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