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Tue May 6 07:03:47 BST 2008

Sal

At least my suggestion was reasonable - the CT, I mean. I suspect Ken
was right about the contrast concentration. I would always do this under
bypass in a controlled fashion in a patient who has stabilized. This is
likely to be a case of mobilize and oversew rather than a resection and
graft, but I stand to be corrected.

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: 06 May 2008 04:14
To: trauma-list at trauma.org
Subject: Re: interesting zone I GSW

ken I, like you, have not jumped on the CTA bandwagon for vascular
trauma, although in the long run I think it will replace catheter based
angiography. i just havent found the data convincing. lots of anecodatal
reports, lots of focused prejudicial patient selection, etc. This case
did however show the value of CTA. 

after the aortogram,? esophagogram and venogram,?the cause of the
bleeding had not been identifed. Since he appeared to have stopped
bleeding and remained stable, he was brought to CT to evaluate his
thoracic spine injury. Contrary to the plan, the chief resident asked
for the spine CT with contrast media and that turned into a CTA.

The CTA showed that there was a large residual hematoma in the
mediastinum and through and through penetrations of the aorta. The
anterior hole was situated about five millimeters directly below the
origin of the left commoon carotid artery. The bullet traversed inside
the lumen of the aorta to exit the posterior wall of the top of the
descending aorta.(see attached)

I was struck by the quality of the images and by the beautiful way the
relationships were illustrated. The cardiothoracic surgeon said that his
comprehension of the injury was enhanced and that led to a more
assertive surgical plan.

I am surprised that the aortogram was normal and the CT was positive. It
is a very rare event that such injuries do not manifest better than
this. I suspect that thrombus contained the injries and that the
resuscitation increased his blood pressure and that led to popping the
clot.

to my surgical colleagues, i am curious about how they would approach
this injury. pump? bypass? clamp and sew? simple suturing?

sal

-----Original Message-----
From: KMATTOX at aol.com
To: trauma-list at trauma.org
Sent: Mon, 5 May 2008 8:41 pm
Subject: Re: interesting zone I GSW

I have been BURNED so many times by a CTA that I have totally lost faith
in  
them.     I see the same problem at many other institutions  where the
present 
cases to me when I am a visiting professor.     CTA for Chest vascular
injury 
is a VOMIT.  

k

In a message dated 5/5/2008 12:41:17 P.M. Central Daylight Time,  
paran620 at green.co.il writes:

I think  I would have started with a CT-angio in the first  place.

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interesting zone I GSW