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Mon Dec 8 01:18:00 GMT 2008

The presence of hypotension with a distended abdomen after blunt trauma and a positive FAST exam are strong indications for abdominal exploration.  A positive FAST with fluid in hepatorenal space and hypotension still mandates exploration, FAST doesn't give you any information regarding retroperitoneal name vessels injuries away from retroperitoneal Zone III OBPF bleeding. If there is any question we like to proceed with quick DPA, in this case it would of been done above the umbilicus. Angiosuite is not the place to find out massive contrast extravasation in the abdomen.....the OR is :)......the key here is rapid evaluation and management.......unless you have an aggressive in-house IR team, awaiting for them to perform a diagnostic angiogram will not benefit this patient with traumatic brain injury and intra-abdominal exsanguination.
Juan
CharityOne

Juan C. Duchesne MD, FACS, FCCP
Director Surgical Hospital Center 
Director Tulane Surgical Intensive Care Unit  
AMR Regional Director Louisiana Emergency Response Network

Division of Trauma and Critical Care Surgery
Tulane & LSU Department of Surgery and Anesthesiology 
1430 Tulane Ave., SL-22
New Orleans LA 70112-2699
Tel. 504-988-5111
Fax. 504-988-3683

________________________________

From: trauma-list-bounces at trauma.org on behalf of harthy1973 at yahoo.ca
Sent: Sun 12/7/2008 5:34 PM
To: Trauma &amp; Critical Care mailing list
Subject: Re: unstable pt with low GCS

Very good case,
I do agree that the unstable pt. Should be in the OR, however a word of caution, this is a complicated case that does require a lot of experience, and not a dogmatic approach. In my limited experience preperitoneal packing is not easy as it sounds, especially when your adrenaline is pumping, let alone the patients. Packing the pelvis from within, with an open book pelvis fracture is also very limiting. Now I know that we don't usually quantify fluid in a standard FAST (it is either positive or negative) but I think that this is one of those cases, that we should, if the pt. Is unstable, then he should have a POSITIVE FAST and not just some fluid in the hepatorenal recess.  
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-----Original Message-----
From: khumar huseynova <khumarhuse at yahoo.ca>

Date: Sun, 7 Dec 2008 12:31:27
To: Trauma Trauma<trauma-list at trauma.org>
Subject: unstable pt with low GCS

47M post-MVA, comes in with GCS=8-9 which drops to 5, SBP in the low 80's, HR=129-135. Intubated, primary survey reveals, reduced L breath sounds, distended abdo and unstable pelvis. FAST pos, CXR shows widened mediastinum w NG in the L thorax, pelvic XR-open book fracture. Sheet around the pelvis, L CT inserted, fluids given, pts BP slowly comes back up to 100-110 but still labile with fast HR. Everything is done within minutes. What would be your FIRST step:
1.Do CT head since pt is responding to ivf (albeit partially) which means there is still time to r/o intracranial bleed/SAH etc pre-op
2. Angio given pt's open book fracture, which is likely the source of intraabdo/pelvic bleed and hypotension
3. Direct to OR; deal with CT head and angio afterwards.

Thanks. K

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unstable pt with low GCS