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Thu Mar 20 02:55:43 GMT 2008

I think that the indications in the pediatric patient that your describe are different that than of this patient with the OR 40 minutes away to treat the primary condition

Norman

Norman McSwain MD
Trauma Director, Charity Hospital
Professor of Surgery, Tulane University
New Orleans LA
504 988 5111
norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu> 

________________________________

From: trauma-list-bounces at trauma.org on behalf of Sanjay Gupta MD
Sent: Wed 3/19/2008 6:00 PM
To: Trauma &amp, Critical Care mailing list
Subject: Re: NOt true trauma but a cool abdo case

There is no data in Adult Surgery about decompression
for a tension-pneumoperitoneum, as far as I am aware.
However, in Pediatric surgery in neonates with
necrotizing enterocolitis with either very poor
general condition or with a large amount of air and
fluid causing tension within the abdominal cavity,
percutaneous drainage and drain insertion is a very
well accepted procedure.  Infact there is a sign
called as "football sign" when the abdomen is very
severely distended with air and looks like a football.
 The causes of air can be NEC, or spontaneous
perforation or aggressive resuscitation at birth with
unclear pathway of air extravasation in the peritoneal
cavity.  Again, some of these neonates who are very
very ill and with almost a nil chance of survival,
make good recoveries with no further surgery.  My
feeling is that if it works in neonates, it might work
in adults - at least as a temporizing measure.
Although I must confess that I have never done that
yet in an adult.

Sanjay

--- "McSwain, Norman E Jr." <nmcswai at tulane.edu>
wrote:

> One only does tests or procedures that change the
> outcome. Decompression will not effect the outcome.
>
> This patient needs resuscitation and operation.
>
> Typed by the thumbs of
> Norman on his BlackBerry
>
> Norman McSwain, MD
> Tulane Univ Surgery
> 504 988-5111
>
> ----- Original Message -----
> From: trauma-list-bounces at trauma.org
> <trauma-list-bounces at trauma.org>
> To: Trauma &amp; Critical Care mailing list
> <trauma-list at trauma.org>
> Sent: Tue Mar 18 01:23:52 2008
> Subject: Re: NOt true trauma but a cool abdo case
>
> Sounds very like a case we had last week. Colon perf
> by scope ( done 
> at central london teaching hospital ). In your case
> I would have 
> waited for the surgeon to come in, and not tried to
> decompress. 
> Afterall, she now has the gas in the abdomen so the
> laparoscopy has 
> started <g>
> Nick
> On 15 Mar 2008, at 17:12, Andrew J Bowman wrote:
>
> > 55 year old female. PMH of L1 paraplegia from fall
> off roof 20 years 
> > ago,
> > paranoid schizophrenia.
> >
> > Had colonoscopy 2 days prior to ER visit for
> evaluation of "blood on 
> > tissue
> > paper".
> > Patient does not know details of procedure.
> (biopsy, problems, etc)
> > Presents with 2 days of increasing abdominal pain,
> bloating, nausea,
> > anorexia and dyspnea and decreased urine output.
> >
> > Has not called her doctor or her GI doctor.
> >
> > I find her to be awake and alert. Tachypneic at
> 32, pulse 120-130, 
> > BP 84/60.
> > Abdomen rounded, bloated, firm, diffusely tender
> and has loud 
> > tympany to
> > percussion. Foley placed with
> > 50ml urine returned. Breath sounds clear and
> equal, ? slightly 
> > diminished.
> >
> > Fluid resuscitation started with NS. Stat acute
> abdomen series.
> >
> > Marked amount of free air with elevated diaphragm
> and downward and 
> > medially
> > displaced liver. Double colon wall sign noted.
> >
> > BP came up with fluids. Still tachypneic but
> maintaining sats with 
> > nasal O2
> > at 4lpm.
> > Creatinine 2.5.
> >
> > I called surgeon and he came in about 45 minutes
> after call and off 
> > to the
> > OR about 30 minutes later (team is on call for
> this small community
> > hospital). BP labile in ER waiting for surgeon. As
> low as mid-80's 
> > and as
> > high as 110 systolic. Heart rate always 110-120.
> >
> > Nice tension pneumoperitoneum with presumed
> abdominal compartment 
> > syndrome.
> >
> > Should I have done a bedside decompression with a
> DPL catheter???
> >
> >
> > Andrew
> >
> > I will have images to share by Tuesday am (if the
> computer Gods are 
> > smiling)
> > --
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>
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Sanjay Gupta
Tel: 412 335 6304

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NOt true trauma but a cool abdo case