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Mon May 5 19:47:42 BST 2008

In response to sal's case, would not a high Chest drain output be an indication for a thoracotomy?

Zunorain Dodhy

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Sent: Monday, 5 May, 2008 2:00:14 PM
Subject: trauma-list Digest, Vol 59, Issue 6

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Today's Topics:

   1. Re: interesting zone I GSW (saad shebrain)
   2. RE: trauma-list Digest (Timothy Craig Hardcastle)
   3. RE: unusual case (Timothy Craig Hardcastle)
   4. RE: unusual case (Timothy Craig Hardcastle)
   5. RE: interesting zone I GSW (Timothy Craig Hardcastle)
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http://www.trauma.org/index.php?/community/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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Suggested temp is 28'C (sorry not sure of the Farhenheit)

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 Patrick McSherry
Sent: 01 May 2008 14:58
To: trauma-list at trauma.org
Subject: RE: trauma-list Digest

Hello,

We are designing a new dedicated trauma O.R. in the mid-Atlantic states.
We have a question for which members of this group may be able to
provide some insight.

Specifically, the question of room temperature was discussed. The staff
has indicated a desire for the ability to raise the temperature of the
space above the usual norms, indicating that trauma patients are often
already compromised, often with an already low body temperature. The
desire is to not have the room contribute to a continuing lowering of
the patient's body temperature.

Our question is, what is the optimum high temperature your members
desire to see in their trauma operatories.

Thanks!

Patrick McSherry

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Mickey - agree

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 Michael Stein M.D.
Sent: 01 May 2008 18:38
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: unusual case

Not enough cuts from the CTA but...
If Neuro don't want him STAT in the OR, perform FORMAL Arch + 4 vessel
Angiography and go on from there.
Mickey

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of daniel simon
Sent: Thursday, May 01, 2008 6:29 PM
To: trauma-list at trauma.org
Subject: unusual case

43 year old motorcycle crash victim , on scene intubation for GCS of 5.
On
admission intubated and ventilated, B.P 130/80 P 82 sat 100% , GCS 7 (T)
.
PE: skin lacerations and  central hematoma anterior neck - zone 1.
Head CT - SAH, Frontal contusions,small Frontal SDH, many skull
fractures.
C-spine:  fracture of C1
Chest XR and relevant cuts from the chest  CTA included.
Abdominal CT normal
What would you do now?

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Daniel

Looks to me as a relative observer that the RCCA is cut off and there
may be an abnormality of the arch too. Suggest a formal angio BEFORE you
play with stents!

What is his neuro status now?

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 daniel simon
Sent: 01 May 2008 17:29
To: trauma-list at trauma.org
Subject: unusual case

43 year old motorcycle crash victim , on scene intubation for GCS of 5.
On
admission intubated and ventilated, B.P 130/80 P 82 sat 100% , GCS 7 (T)
.
PE: skin lacerations and  central hematoma anterior neck - zone 1.
Head CT - SAH, Frontal contusions,small Frontal SDH, many skull
fractures.
C-spine:  fracture of C1
Chest XR and relevant cuts from the chest  CTA included.
Abdominal CT normal
What would you do now?

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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