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Mon May 5 05:27:03 BST 2008

I would do very careful exam to R/O any other GSW to abd, to help explain his hypotension which i think is due to hemorrhage and possible initial neurogenic origin.

  how about his LU pulse exam, any difference? any bruit over supraclavicular region , any arm swelling, that might suggest AVF with Hyperdynamic state that can explain his increased BP.

  the Chest Tube out put is 1600 ml Over how long time? or better how  much over the last 2-3 hours?

  if patient remained stable with decreasing CT out put, I would obesrve, if any Q about integrity of aorta I would have IVUS to evlaute.
  I would admit to ICU, get EKG and possible TEE and observe.unless become unstable.

  ss

sjasmd at aol.com wrote:

I would like to present a humbling case to the group.
a 16 year old boy sustained a gunshot wound to Zone I on the left side, medially. He presented with hypotension. A left chest tube evacuated about 800 ml and he began to stabilize. He appeared paraplegic. 
I was called to perform an arteriogram after a chest film revealed that a bullet was noted over the six thoracic vertebra. No clavicular fracture. Incomplete drainage of the chest. Transthoracic echo unremarkable.

I suggested exploration. Surgeon persisted? with request. 

I rushed and reached?the hospital fifteen minutes later. Blood pressure improving, BP 130/70?ish. ?Patient continued to bleed from chest tube. As our angio suite is next door to trauma OR, we went upstairs.

Thoracic aortography in three views with injection of 60 ml of Visipaque at 30cc per second did not show an injury to any arterial structure. . Left subclavian venogram also normal. see attached. Esophagogram normal. 

Total chst tube volume about 1600 ml but no further bleeding and BP 150/80 after three units Packed cells.

what to do?

sal
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interesting zone I GSW