List Archives

Wed Dec 10 15:08:11 GMT 2008

"Portable Ct brain in OR vs. Ct brain when hemodinamically stable for transport fron ICU"

WOW!! I guess the health care business in Florida is booming!  We can't find the $$$ for a new fixed CT, and y'all have a nice new portable one!!  Lookin' for a new trauma doc????........Just kiddin'!
Take care,
Ron

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of michael parra
Sent: Wednesday, December 10, 2008 9:23 AM
To: trauma-list at trauma.org
Subject: Re: trauma-list Digest, Vol 66, Issue 13

1. OR
2. Supraumbilical Exploratory Laparotomy- Correct and control all intra-abdominal sources of bleeding and injuries.
3. Infraumbilical Preperitoneal Pelvic Packing
4. +/- Pelvic Ex-Fix
5. If Stable = Damage Control Vac and transfer to ICU for rewarming and correction of coagulopathy. If unstable = Angio.
6. Portable Ct brain in OR vs. Ct brain when hemodinamically stable for transport fron ICU

Michael W. Parra, MD
Trauma/Critical Care Surgeon
Broward General Medical Center
Fort Lauderdale, Fl

--- On Wed, 12/10/08, trauma-list-request at trauma.org <trauma-list-request at trauma.org> wrote:

From: trauma-list-request at trauma.org <trauma-list-request at trauma.org>
Subject: trauma-list Digest, Vol 66, Issue 13
To: trauma-list at trauma.org
Date: Wednesday, December 10, 2008, 7:00 AM

Send trauma-list mailing list submissions to
        trauma-list at trauma.org

To subscribe or unsubscribe via the World Wide Web, visit
        http://list.mistral.net/mailman/listinfo/trauma-list
or, via email, send a message with subject or body 'help' to
        trauma-list-request at trauma.org

You can reach the person managing the list at
        trauma-list-owner at trauma.org

When replying, please edit your Subject line so it is more specific
than "Re: Contents of trauma-list digest..."
Today's Topics:

   1. Re: unstable pt with low GCS (khumar huseynova)
   2. Re: unstable pt with low GCS (harthy1973 at yahoo.ca)

Thanks for all the responses.

We took the pt for head CT first, the rationale being the fact that if his head
was cooked or he had a huge hemorrhage/shift then this would change the
management (e.g., dont do anything except for palliative measures if head is
gone; or invite neurosx intot he OR for simultaneous multiple-body parts-work).
During the CT, he was relatively stable; it was towards the end of it that he
started dropping BP. We rished hi to OR, did the usual packing. Removed the
spleen which had grade 2 injury. Repaired a huge L diaphragmatic hole. Placed in
a R sided CT. He also had Zone I-III retroperitoneal hematomas-non explanding.
We cheked the major vessels-no bleed. Checked pelvis-large hematoma. Packed the
abdomen and pelvis (not extraperitoneally), covered the belly with a plastic bag
and took him to angio since he had alrady had 11-13 U of PBCs, FFP, Plts and
wasnt actively bleeding by then and was stable relatively. I should mention that
his trauma pelvos CT
 showed active extrav in the pelvis, likely from the left (?iliacs-ext/int).
But in angio, no active extrav could be found. His L internal was embolized
anyway (so called empiric embolization given the story) and he was taken to ICU.

He subsequently had CTA of chest which didnt show explansion of his thoracic
aortic aneurysm. The ilemma now was the cutoff for his BP-for the aneurysm he
required an SBP of 80-90 (although I think this is too low-one can keep it below
120), while for his head, it would have to be 120-130 or lightly above to keep
his MAP>65. We tried to keeo SBP at 120.
His CT head did not show any major injury the first time. We thought his very
low GCS was probably the result of a generalized hypotension/hypoxemia.
However, he still hasnt woken up. Neurosx created a free bone flap with and ICP
monitor. No difference.
We have closed his abdomen, his CTs are not draining much, from all
perspectives other than head he is stable.

K

--- On Sun, 12/7/08, khumar huseynova <khumarhuse at yahoo.ca> wrote:

From: khumar huseynova <khumarhuse at yahoo.ca>
Subject: unstable pt with low GCS
To: "Trauma Trauma" <trauma-list at trauma.org>
Received: Sunday, December 7, 2008, 3:31 PM

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

Yahoo! Canada Toolbar : Search from anywhere on the web and bookmark your
favourite sites. Download it now!

      __________________________________________________________________
Yahoo! Canada Toolbar: Search from anywhere on the web, and bookmark your
favourite sites. Download it now at
http://ca.toolbar.yahoo.com.
So was there a lot of intraperitoneal blood, or do you think that his pelvis was
the main culprit for his hypotension?
Another question to the group, how often have you seen hypotension from blunt
cardiac injury. 'Cause I've seen a couple of crush inj. Pt. With no
obvious source for hypovolemic shock.
Abdullah Al- Harthy

Sent from my BlackBerry(r) smartphone from Oman Mobile!

-----Original Message-----
From: khumar huseynova <khumarhuse at yahoo.ca>

Date: Tue, 9 Dec 2008 20:08:56
To: Trauma Trauma<trauma-list at trauma.org>
Subject: Re: unstable pt with low GCS

Thanks for all the responses.

We took the pt for head CT first, the rationale being the fact that if his head
was cooked or he had a huge hemorrhage/shift then this would change the
management (e.g., dont do anything except for palliative measures if head is
gone; or invite neurosx intot he OR for simultaneous multiple-body parts-work).
During the CT, he was relatively stable; it was towards the end of it that he
started dropping BP. We rished hi to OR, did the usual packing. Removed the
spleen which had grade 2 injury. Repaired a huge L diaphragmatic hole. Placed in
a R sided CT. He also had Zone I-III retroperitoneal hematomas-non explanding.
We cheked the major vessels-no bleed. Checked pelvis-large hematoma. Packed the
abdomen and pelvis (not extraperitoneally), covered the belly with a plastic bag
and took him to angio since he had alrady had 11-13 U of PBCs, FFP, Plts and
wasnt actively bleeding by then and was stable relatively. I should mention that
his trauma pelvos CT
 showed active extrav in the pelvis, likely from the left (?iliacs-ext/int).
But in angio, no active extrav could be found. His L internal was embolized
anyway (so called empiric embolization given the story) and he was taken to ICU.

He subsequently had CTA of chest which didnt show explansion of his thoracic
aortic aneurysm. The ilemma now was the cutoff for his BP-for the aneurysm he
required an SBP of 80-90 (although I think this is too low-one can keep it below
120), while for his head, it would have to be 120-130 or lightly above to keep
his MAP>65. We tried to keeo SBP at 120.
His CT head did not show any major injury the first time. We thought his very
low GCS was probably the result of a generalized hypotension/hypoxemia.
However, he still hasnt woken up. Neurosx created a free bone flap with and ICP
monitor. No difference.
We have closed his abdomen, his CTs are not draining much, from all
perspectives other than head he is stable.

K

--- On Sun, 12/7/08, khumar huseynova <khumarhuse at yahoo.ca> wrote:

From: khumar huseynova <khumarhuse at yahoo.ca>
Subject: unstable pt with low GCS
To: "Trauma Trauma" <trauma-list at trauma.org>
Received: Sunday, December 7, 2008, 3:31 PM

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

Yahoo! Canada Toolbar : Search from anywhere on the web and bookmark your
favourite sites. Download it now!

__________________________________________________________________
Yahoo! Canada Toolbar: Search from anywhere on the web, and bookmark your
favourite sites. Download it now at
http://ca.toolbar.yahoo.com.
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/
-----------------------------------------
CONFIDENTIALITY NOTICE: This email communication and any
attachments may contain confidential and privileged information for
the use of the designated recipients named above. If you are not
the intended recipient, you are hereby notified that you have
received this communication in error and that any review,
disclosure, dissemination, distribution or copying of it or its
contents is prohibited. If you have received this communication in
error, please reply to the sender immediately or by telephone at
(413) 794-0000 and destroy all copies of this communication and any
attachments. For further information regarding Baystate Health's
privacy policy, please visit our Internet web site at
http://www.baystatehealth.com.

List Archives

For your convenience, find the Trauma List Archive Below

trauma-list Digest, Vol 66, Issue 13