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Mon May 5 14:54:35 BST 2008

Naveed

Please explain the need to operate purely for bullet location? This has
been  discredited as a reason for operation in a number of studies. The
only indications for surgery would be ongoing bleeding from a lung
laceration or an injury to the vascular tree or the esophagus. While we
have yet to rule out the pulmonary side of the vascular tree (hence my
request to do CT), unless there is ongoing bleeding from the pleural
catheter there is NO reason to open him up, in my opinion.

Tim
Dr Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA)
Principal Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care
Deputy director: Trauma Unit and Trauma ICU
Inkosi Albert Luthuli Central Hospital / UKZN
800 Bellair Road
Mayville, Durban

Postal: PostNet Suite 27
Private Bag X05
Malvern, 4055
KwaZulu Natal

timothyhar at ialch.co.za 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Ahmed, Naveed 
Sent: 05 May 2008 14:58
To: Trauma &amp; Critical Care mailing list
Subject: RE: interesting zone I GSW

Dr Hardcastle,

A lateral film. Bullet is deformed quite a bit (hit the spine, it has!),
but why blood in the chest, I have no problems in getting an angio or
better still CT, but he needs to be in the OR if bullet or its fragments
are infront of the thoracic vertebra. Subclavian vein, may be. If you
did end up taking him to the OR, would you go through a median
sternotomy or lateral thoracotomy?

Naveed Ahmed 

-----Original Message-----
From: Timothy Craig Hardcastle [mailto:TimothyHar at ialch.co.za] 
Sent: Monday, May 05, 2008 1:58 AM
To: Trauma &amp; Critical Care mailing list
Subject: RE: interesting zone I GSW

Sal

You have not visualized the pulmonary outflow tract - bullet could well
be there. If esophagus normal and arch, as well as pericardium normal
and he is paraplegic, maybe missed everything. Could well benefit from
early CT to visualist the rest of the chest / bullet tract and see if
there is a point of bleeding from the chest. If you view this as a
transmediastinal shot then CT together with contrast swallow is current
diagnostic sequence of choice. MRI possible once determine if bullet
lead (not magnetic) or metal jacketed (maybe should not MRI).

Tim
Dr Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA) Principal
Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care Deputy
director: Trauma Unit and Trauma ICU Inkosi Albert Luthuli Central
Hospital / UKZN 800 Bellair Road Mayville, Durban

Postal: PostNet Suite 27
Private Bag X05
Malvern, 4055
KwaZulu Natal

timothyhar at ialch.co.za 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of sjasmd at aol.com
Sent: 05 May 2008 02:43
To: trauma-list at trauma.org
Subject: interesting zone I GSW

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