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Tue Sep 4 21:42:56 BST 2007

I am not surprised that he had ongoing haemorrhage into his chest given the
output, or even that it was ongoing bleeding as a result of a lung
laceration (this is a fairly common finding when the haemorrhage has not
been controlled and "self-tamponaded" itself by adequate lung reinflation
early on after the injury.)

Right thoracotomy for a lung OR oesophageal injury is entirely appropriate
(if it had been a cardiac injury I would have preferred a sternotomy.) I
assume that the haemostasis with the autostapler was adequate after the
thoracotomy, that this stopped the haemorrhage and there was no further
bleeding? I also trust that his clotting is now within an acceptable range?
(Is this merely a presumption here Sal?)

Ignoring the issue of barium-v-gastrografin which has already been
discussed, I am not surprised that he has an oesophageal inury (or that he
will now develop a gastrografin induced pneumonitis) but I am surprised that
this injury was not picked up on the original thoracotomy.

It is clear even to me (remember I am not a radiologist!) that there is
extravasation of contrast which, I feel, indicated an injury which would
have been easily identifiable at surgery. [I have not long finished an
Ivor-Lewis oesophago-gastrectomy. This chap was 20 odd stone upwards and
both his abdominal and thoracic cavities were dark deep holes with seas of
fat. Despite this, we were still able to get great visualisation of all the
various structures without even looking for an injury; and in this case an
oesophageal injury was extremely high up on the list (if not the highest)
and so should have been actively investigated and identified.]

He needs to go back to the OR URGENTLY for a thoracotomy (unfortunately his
2nd.)

He needs a thorough washout to prevent mediastinitis (if not already
developed.) Any reason for not using barium is now dismissed because it
would also be washed out IMMEDIATELY - irrespective of barium or
gastrografin contrast.) He needs debridement of any non-viable oesophageal
tissue.

He needs either:-

1)     a resection and primary anastomosis (with numerous drains - in case
of a subsequent anastomotic leak/breakdown);

2)     bringing out the "leak" through the chest as a T-tube; or,

3)     oesophagostomy

I would be keen to hear others' views on this list regarding which procedure
they would perform (I am sure that there are people who sit STRONGLY in each
of the respective camps!)

At this point, I am fortunate to remember my priorities and recollect that I
was NOT happy with the original CT scan and therefore wanted an angiogram. I
would certainly want this straight away as I would want to plan for any
vascular repair of the thoracic cavity now and plan my options carefully
(consider a joint procedure and thereby obviate the need for a 3rd
thoracotomy!)

I am sure that things are going to get even worse with the twists in this
case which are still to come!

Matthew

-----Original Message-----
From: sjasmd at aol.com [mailto:sjasmd at aol.com] 
Sent: 04 September 2007 17:24
To: trauma-list at trauma.org
Subject: Re: GSW TO RIGHT CHEST. IT GETS WORSE

Haim, Matthew and Ken

We are all in agreement that this case is not going in the direction we
would have taken it. 

By the end of the one negative rigid esophaogoscopy, one equivocal flexible
eseophagogoscopy?and bronchoscopy, ?his chest tube output had continued to a
level that warranted operation. He then underwent right thoracotomy which
revealed bleeding from the through and through lung laceration. This was
managed by stapling the tract closed with hemostasis. Two chest tubes were
left in. 

He then went to? a small GI fluoroscopy room one floor away from the OR
(despite having an angiography suite next door to the trauma OR) where a
gastrograffin esophagogram was performed. You will note that the
gastrograffin is aspirated but the airway was protected by the endotracheal
tube.

I have attached it for your review

He is then transported BACK to the OR

what to do now

sal

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

From: Matthew Reeds <mgreeds at reeds.uk.com>

To: 'Trauma &amp; Critical Care mailing list' <trauma-list at trauma.org>

Sent: Mon, 3 Sep 2007 1:17 pm

Subject: GSW TO RIGHT CHEST. BARIUM CONTRAST STUDY PLEASE

I agree. I too would not be happy with the ultimate quality of the CT and,

as per my last posting, would want therefore want an angiogram at this point

(with the hindsight of having now reviewed the images on a proper screen.)

I also agree with requesting a barium contrast study (for the reasons

mentioned in my posting on Friday - better quality, fewer false positives

and negatives than gastrograffin etc.) The one side effect of barium will be

countermanded easily by a washout (rapidly in the OR if a leak has been

demonstrated) versus the many reasons for not using gastrograffin. The 3-0

argument is a suitable way of putting the relevant issues into context. Here

is some anecdotal evidence on gastrograffin. Over the past week, 3

non-trauma patients have had gastrograffin studies in our hospital (2

swallow, 1 enema.) All demonstrated no leak. However, all 3 had leaks which

were missed on the study!

Sal, I still remained concerned regarding his chest drain output but have

not, as yet, been provided with further information that I require to enable

me to make a decision regarding this. There must clearly now be an ongoing

bleed in this thoracic cavity which needs addressing. I need further

information though in order for me to make an appropriate management

decision on this. What is his clotting and vital signs etc.?

Matthew

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GSW TO RIGHT CHEST. IT GETS WORSE