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Wed Feb 4 01:45:36 GMT 2009

Dear Brad:

Regarding your important questions:

1)I am not particularly experienced in this area, but I would think bed-side
USS sufficient to rule out a subcutaneous collection if no external evidence
of wound infection/cellulitis? Do you extend this approach to other 'dirty'
procedures, emergency or otherwise?

yes- Physical exam is definitively essential to rule out SSI, unfortunately not all this complications read surgical textbooks, nor they are clearly evident on physical exam. US will tell you if there is a fluid collection between the tissue planes......a finding common to most of our surgical patients (seroma) not useful in this scenario. My preference is not to close the wound in this group of patients because of multifactorial etiologies that will add to poor wound healing: shock state, hypoxia, need of blood transfusions, gross contamination, tissue edema and hypothermia. Remember the damage control laparotomy patient already had an the first hit insult.......why we need to give them the second hit with surgical wound infection?..........In elective cases were most of this variables are well controlled, the presence of enteric spillage due to iatrogenic causes will not make me leave the wound open. This is my preference. 

2)I also humbly propose that a patient with sepsis day 5-7 post-damage control
laparotomy with enteric injury receiving a CT scan is most likely not a
VOMIT? :)

Great point.............Nor they needed to have their wound closed to begin with........that's why your patient will be in the CT scanner and mine not =0>

Hope this helps
j

Juan C. Duchesne MD, FACS, FCCP
Director Surgical Hospital Center 
Director Tulane Surgical Intensive Care Unit  
AMR Regional Director Louisiana Emergency Response Network

Division of Trauma and Critical Care Surgery
Tulane & LSU Department of Surgery and Anesthesiology 
1430 Tulane Ave., SL-22
New Orleans LA 70112-2699
Tel. 504-988-5111
Fax. 504-988-3683

________________________________

From: trauma-list-bounces at trauma.org on behalf of Bradley Morris
Sent: Tue 2/3/2009 6:34 PM
To: Trauma &amp, Critical Care mailing list
Subject: Re: trauma-list Digest, Vol 67, Issue 43

Dear Dr Juan,

In query and interest of your statement:

"I try my best here at Charity not to close skin in the presence of any
enteric injury in damage control patients. I personally leave the wound open
with delay closure prior to discharge. My rationale is the following: by
post-trauma day 5-7 when the patient start spiking fever then u have too
many variables to rule out the source of sepsis, which will increase the
need for unnecessary CT scans and VOMIT's. "

I am not particularly experienced in this area, but I would think bed-side
USS sufficient to rule out a subcutaneous collection if no external evidence
of wound infection/cellulitis? Do you extend this approach to other 'dirty'
procedures, emergency or otherwise?

I also humbly propose that a patient with sepsis day 5-7 post-damage control
laparotomy with enteric injury receiving a CT scan is most likely not a
VOMIT? :)

Kind regards,

Brad Morris
Surgical Registrar
Australia

On Wed, Feb 4, 2009 at 7:47 AM, tina <tinagaar at online.no> wrote:

> Tim
>
> ...you can add this part of Scandinavia to the "closing skin"
> tradition...staples or suture..
>
> Tina Gaarder
> Trauma and GI Surgery
> Head of Trauma Unit
> Oslo University Hospital, Norway
> (list lurker)
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:
> trauma-list-bounces at trauma.org]
> On Behalf Of Dr Timothy Hardcastle
> Sent: 03 February 2009 18:46
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: trauma-list Digest, Vol 67, Issue 43
>
> Mike wrote:
> > To all trauma-listers, a question from one of my partners:
> >
> > You have a damage control closure with a vac closure after a laparotomy
> > for trauma without bowel injury (ie just spleen or liver, mesentery,
> > whatever) - you take back in 24 to 48 hours and are able to close the
> > fascia.  What do you do with the skin?  Leave open or staple closed?
> >
> > We're having a debate over this in our group. Older surgeons pack skin
> and
> > subQ open, younger surgeons frequently close skin.
> >
> > Mike Sise
> > San Diego
> >
> > ________________________________
> >
> > From: trauma-list-bounces at trauma.org on behalf of
> > trauma-list-request at trauma.org
> > Sent: Tue 1/27/2009 12:35 AM
> > To: trauma-list at trauma.org
> > Subject: trauma-list Digest, Vol 67, Issue 43
> >
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> Dear Mike
>
> I close skin - as do most South African surgeons to my knowledge; the idea
> of leaving skin open is a very American thing, certainly never advocated
> in this country and to my knowledge not in the UK or Australia either.
>
> Tim
> Dr T C Hardcastle
> M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
> Principal Specialist Trauma Surgeon /
> Honorary Lecturer UKZN Dept Surgery
> Deputy Director - IALCH Trauma Service
> Durban - South Africa
>
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