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Sat Dec 13 09:58:14 GMT 2008

Interesting, hmmm.

What are your indications / criteria for a bone flap / decomp craniectomy.  We are doing that more frequently and I would highly appreciate knowing what everyone is doing.

Sanjay Gupta

--- On Tue, 12/9/08, harthy1973 at yahoo.ca <harthy1973 at yahoo.ca> wrote:

> From: harthy1973 at yahoo.ca <harthy1973 at yahoo.ca>
> Subject: Re: unstable pt with low GCS
> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> Date: Tuesday, December 9, 2008, 9:13 PM
> 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® 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
> 
> 
> 
> 
> 
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unstable pt with low GCS