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trauma-list Digest, Vol 68, Issue 6-Abdominal wound closure-Dr. Sise's 3 questions
Teperman, Sheldon Sheldon.Teperman at nbhn.netWed Feb 4 20:59:52 GMT 2009
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To Mike's 3 questions
First, I would like to introduce a new concept, "The Open Abdomen 2.0". That is to say , that for those of us who helped introduce "The Open Abdomen 1.0" , you will recall that we were so thrilled that these formally hopeless pts were now living, that we took horrific abd wall complications as just the cost of doing business in this new Open abdomen world.
But now we have been doing it for quite some time, and we have learned a thing or two. We can avoid a lot of those horrific fistula complications if we work hard to get the Abdomen closed, once the "leaving it open" has done its job. I have set an absolute policy at our place. The abdomen is closed by hook or by Crook at eight days. Whatever the cost, no matter how many tens of thousands of dollars in Alloderm- the Abdomen is closed- if it is at all physically and pysioloically possible to do so. In this I think I differ slightly with Dr. Duchense. A little bit of tension, a slight increase in Iap- I will gladly take ( with a watchful eye) as compared to the 9 months we just spent taking care of an open duodenal rosette fistula from another hospital.
Now the 3 questions: I have queried my partners. We only do interrupted closure on open abdomens. We have used retentions only once.
The most common suture is Vicryl ( if the pt is "healthy"). Not so healthy then PDS or Prolene.
Not so Health and skinny-then Ethibond.
AS I said earlier, yes to skin closure one of my partners hedges with a loose closure.
If there is some undermining to get skin closed ( then yes to a drain)...Shel
-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of trauma-list-request at trauma.org
Sent: Wednesday, February 04, 2009 3:00 PM
To: trauma-list at trauma.org
Subject: trauma-list Digest, Vol 68, Issue 6
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Today's Topics:
1. RE: skin closure (Sise, Mike MD)
2. RE: skin closure (Duchesne, Juan C )
3. Re: trauma-list Digest, Vol 67, Issue 43 (Ranjith Ellawala)
4. RE: trauma-list Digest, Vol 68, Issue 4-open abdomen -skin
closure (Teperman, Sheldon)
5. Re: skin closure (Karim Brohi)
6. RE: Maryland EMS (MIEMSS) Is Pressed To Share Triage Study
(Bjorn, Pret)
----------------------------------------------------------------------
Message: 1
Date: Wed, 4 Feb 2009 05:44:44 -0800
From: "Sise, Mike MD" <Sise.Mike at scrippshealth.org>
Subject: RE: skin closure
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<FEECA018557C774EB876F0D3BCB54E1B01103F67 at MSG02.corp.scripps.org>
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Regarding abdominal wound management following damage control: please consider and answer 3 questions in stable patient with non contaminated abdomen post op 24 to 72 hrs at first take back:
1. What kind of fascial closure if it comes together without tension: running or interrupted and what suture?
2. Any role for retention sutures?
3. Skin closure: when and how - complete closure , place wicks or drains?
Mike Sise
San Diego
________________________________
From: Ruy Cabello-Pasini [mailto:ruycabello at yahoo.com]
Sent: Tue 2/3/2009 8:42 PM
To: Trauma & Critical Care mailing list
Subject: Re: skin closure
I also always close the skin, if patient has a thick subcutaneous layer, I use a penrose drain over the aponeurosis and through the same incision, anybody?
Ruy Cabello-Pasini, MD
MEXICO
--- On Wed, 2/4/09, Robert Nitt <robertnitt at yahoo.com> wrote:
> From: Robert Nitt <robertnitt at yahoo.com>
> Subject: Re: trauma-list Digest, Vol 67, Issue 43
> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> Date: Wednesday, February 4, 2009, 3:35 AM
> Close skin whenever can. If damage control with extensive
> resuscitation or bowel spillage, pack open and delayed
> closure
>
> Kumash Patel, MD, FACS
> Scottsdale Surgical Specialists
> General / Acute Care / Trauma / Critical Care Surgery
>
>
>
>
> ________________________________
> From: "McSwain, Norman E Jr."
> <nmcswai at tulane.edu>
> To: trauma-list at trauma.org
> Sent: Tuesday, February 3, 2009 5:39:42 AM
> Subject: Re: trauma-list Digest, Vol 67, Issue 43
>
> This "older surgeon" would likely close the skin.
>
> Preferences & principles again...
>
> principle: skin needs to closed sometime.
>
> Preference - when?.........What is the condition of the
> wound. It is less than 72 hours; no bowel injury; was the
> patient overloaded with fluid?; how much pull on the skin to
> close?.
>
>
> Typed by the thumbs of
> Norman on his BlackBerry
>
> Norman McSwain, MD
> Tulane Univ Surgery
> 504 988-5111
>
> ________________________________
>
> From: trauma-list-bounces at trauma.org
> To: trauma-list at trauma.org
> Sent: Mon Feb 02 22:39:54 2009
> Subject: RE: trauma-list Digest, Vol 67, Issue 43
>
>
> 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
>
>
>
> Send trauma-list mailing list submissions to
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>
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------------------------------
Message: 2
Date: Wed, 4 Feb 2009 08:40:57 -0600
From: "Duchesne, Juan C " <jduchesn at tulane.edu>
Subject: RE: skin closure
To: "Trauma &" <trauma-list at trauma.org>, "Trauma & Critical
Care mailing list" <trauma-list at trauma.org>
Message-ID:
<93F431B4ABF11C43BDB776B643B691BCA2E586 at EX04.ad.tulane.edu>
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Mike-
1. What kind of fascial closure if it comes together without tension: running or interrupted and what suture?
- No statistical difference in general surgery patients, dont know if there is any data specific to damage control patients. My preference is Ethibond #1 CT needle interrupted
2. Any role for retention sutures?
- Not in first run. Although some of our faculty do retention sutures closures. In patients with fresh bowel repairs, severe intra-abdominal solid organ injuries closing the abdomen under tension will drive up your intra-abdominal pressures whish will decrease your abdominal perfusion pressures (APP). This lower APP will adversely impact any wound healing in the abdominal wall and / or intra-abdominal repairs. All this will increase the likelihood of SIRS and if not properly recognize (Abdominal Compartment Syndrome) tension abdominal wall closure will precipitate a second hit insult......all IATROGENIC.......
My preference: by day 7 if I cant close loosely, tension free the abdominal wall, I do component separation with or without alloderm graft if no sign of intra-abdominal sepsis. Perpetuating the vicious cycle of abdominal washouts without an endpoint only creates more numbers for your residents and at the end a malnourished/imunocompromised patient. If positive signs of abdominal sepsis I continue washouts with later close the skin as described by the group in Orlando. No skin graft.
3. Skin closure: when and how - complete closure , place wicks or drains?
-complete closure if there was no evidence of enteric spillage and no sign of intra-abdominal sepsis.
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 Sise, Mike MD
Sent: Wed 2/4/2009 7:44 AM
To: Trauma & Critical Care mailing list
Subject: RE: skin closure
Regarding abdominal wound management following damage control: please consider and answer 3 questions in stable patient with non contaminated abdomen post op 24 to 72 hrs at first take back:
1. What kind of fascial closure if it comes together without tension: running or interrupted and what suture?
2. Any role for retention sutures?
3. Skin closure: when and how - complete closure , place wicks or drains?
Mike Sise
San Diego
________________________________
From: Ruy Cabello-Pasini [mailto:ruycabello at yahoo.com]
Sent: Tue 2/3/2009 8:42 PM
To: Trauma & Critical Care mailing list
Subject: Re: skin closure
I also always close the skin, if patient has a thick subcutaneous layer, I use a penrose drain over the aponeurosis and through the same incision, anybody?
Ruy Cabello-Pasini, MD
MEXICO
--- On Wed, 2/4/09, Robert Nitt <robertnitt at yahoo.com> wrote:
> From: Robert Nitt <robertnitt at yahoo.com>
> Subject: Re: trauma-list Digest, Vol 67, Issue 43
> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> Date: Wednesday, February 4, 2009, 3:35 AM
> Close skin whenever can. If damage control with extensive
> resuscitation or bowel spillage, pack open and delayed
> closure
>
> Kumash Patel, MD, FACS
> Scottsdale Surgical Specialists
> General / Acute Care / Trauma / Critical Care Surgery
>
>
>
>
> ________________________________
> From: "McSwain, Norman E Jr."
> <nmcswai at tulane.edu>
> To: trauma-list at trauma.org
> Sent: Tuesday, February 3, 2009 5:39:42 AM
> Subject: Re: trauma-list Digest, Vol 67, Issue 43
>
> This "older surgeon" would likely close the skin.
>
> Preferences & principles again...
>
> principle: skin needs to closed sometime.
>
> Preference - when?.........What is the condition of the
> wound. It is less than 72 hours; no bowel injury; was the
> patient overloaded with fluid?; how much pull on the skin to
> close?.
>
>
> Typed by the thumbs of
> Norman on his BlackBerry
>
> Norman McSwain, MD
> Tulane Univ Surgery
> 504 988-5111
>
> ________________________________
>
> From: trauma-list-bounces at trauma.org
> To: trauma-list at trauma.org
> Sent: Mon Feb 02 22:39:54 2009
> Subject: RE: trauma-list Digest, Vol 67, Issue 43
>
>
> 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
>
>
>
> Send trauma-list mailing list submissions to
> trauma-list at trauma.org
>
> To subscribe or unsubscribe via the World Wide Web, visit
>
> http://list.mistral.net/mailman/listinfo/trauma-list
> or, via email, send a message with subject or body
> 'help' to
> trauma-list-request at trauma.org
>
> You can reach the person managing the list at
> trauma-list-owner at trauma.org
>
> When replying, please edit your Subject line so it is more
> specific
> than "Re: Contents of trauma-list digest..."
>
>
> --
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> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
>
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------------------------------
Message: 3
Date: Wed, 4 Feb 2009 06:48:59 -0800 (PST)
From: Ranjith Ellawala <ranjithellawala at yahoo.com>
Subject: Re: trauma-list Digest, Vol 67, Issue 43
To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
Message-ID: <284583.23169.qm at web55002.mail.re4.yahoo.com>
Content-Type: text/plain; charset=utf-8
Close the skin; it is not difficult and to drain if abscess deveop in relation to superficial skin wound.
Ranjith Ellawala
Colombo
--- On Wed, 4/2/09, Robert Nitt <robertnitt at yahoo.com> wrote:
From: Robert Nitt <robertnitt at yahoo.com>
Subject: Re: trauma-list Digest, Vol 67, Issue 43
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Date: Wednesday, 4 February, 2009, 3:35 AM
Close skin whenever can. If damage control with extensive resuscitation or
bowel spillage, pack open and delayed closure
Kumash Patel, MD, FACS
Scottsdale Surgical Specialists
General / Acute Care / Trauma / Critical Care Surgery
________________________________
From: "McSwain, Norman E Jr." <nmcswai at tulane.edu>
To: trauma-list at trauma.org
Sent: Tuesday, February 3, 2009 5:39:42 AM
Subject: Re: trauma-list Digest, Vol 67, Issue 43
This "older surgeon" would likely close the skin.
Preferences & principles again...
principle: skin needs to closed sometime.
Preference - when?.........What is the condition of the wound. It is less than
72 hours; no bowel injury; was the patient overloaded with fluid?; how much pull
on the skin to close?.
Typed by the thumbs of
Norman on his BlackBerry
Norman McSwain, MD
Tulane Univ Surgery
504 988-5111
________________________________
From: trauma-list-bounces at trauma.org
To: trauma-list at trauma.org
Sent: Mon Feb 02 22:39:54 2009
Subject: RE: trauma-list Digest, Vol 67, Issue 43
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
Send trauma-list mailing list submissions to
trauma-list at trauma.org
To subscribe or unsubscribe via the World Wide Web, visit
http://list.mistral.net/mailman/listinfo/trauma-list
or, via email, send a message with subject or body 'help' to
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You can reach the person managing the list at
trauma-list-owner at trauma.org
When replying, please edit your Subject line so it is more specific
than "Re: Contents of trauma-list digest..."
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Message: 4
Date: Wed, 4 Feb 2009 13:14:14 -0500
From: "Teperman, Sheldon" <Sheldon.Teperman at nbhn.net>
Subject: RE: trauma-list Digest, Vol 68, Issue 4-open abdomen -skin
closure
To: "'trauma-list at trauma.org'" <trauma-list at trauma.org>
Message-ID:
<43CADDF7EC269A41AB6FAB23AA8346A804E6599254 at NBHNMAILBE2.nbhn.net>
Content-Type: text/plain; charset="us-ascii"
If the skin and Subq tissues don't look all that different then when you first opened 24 or 48hrs later, I would say that my partners and I , on the Average, are closing the skin. BTW -Mike-getting the Vac out in that time frame-a very, very good thing...Shel
-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of trauma-list-request at trauma.org
Sent: Tuesday, February 03, 2009 8:48 PM
To: trauma-list at trauma.org
Subject: trauma-list Digest, Vol 68, Issue 4
Send trauma-list mailing list submissions to
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Today's Topics:
1. Re: trauma-list Digest, Vol 67, Issue 43 (McSwain, Norman E Jr.)
2. Re: trauma-list Digest, Vol 67, Issue 43 (jduchesne1)
3. Re: trauma-list Digest, Vol 67, Issue 43 (Karim Brohi)
4. RE: trauma-list Digest, Vol 67, Issue 43 (Dr Timothy Hardcastle)
5. Point of Care urine HCG or lab processed blood HCG (Tracy Rogers)
6. Re: Point of Care urine HCG or lab processed blood HCG
(Krin135 at aol.com)
7. Re: Point of Care urine HCG or lab processed blood HCG
(William Bromberg)
8. RE: Point of Care urine HCG or lab processed blood HCG
(Marc Matthews - MedPro MMC X)
9. Re: Point of Care urine HCG or lab processed blood HCG
(jduchesne1)
10. Re: Point of Care urine HCG or lab processed blood HCG
(Krin135 at aol.com)
11. Re: Point of Care urine HCG or lab processed blood HCG
(William Bromberg)
12. Re: Lung Contusion (Robert Smith)
13. Re: trauma-list Digest, Vol 67, Issue 43 (Richard Wigle MD FACS)
14. Re: Point of Care urine HCG or lab processed blood HCG
(Larry Torrey)
15. Re: Point of Care urine HCG or lab processed blood HCG
(Larry Torrey)
16. RE: trauma-list Digest, Vol 67, Issue 43 (tina)
17. R: trauma-list Digest, Vol 67, Issue 43 (Peter)
18. Re: trauma-list Digest, Vol 67, Issue 43 (Bradley Morris)
19. RE: trauma-list Digest, Vol 67, Issue 43 (Duchesne, Juan C )
----------------------------------------------------------------------
Message: 1
Date: Tue, 3 Feb 2009 06:39:42 -0600
From: "McSwain, Norman E Jr." <nmcswai at tulane.edu>
Subject: Re: trauma-list Digest, Vol 67, Issue 43
To: <trauma-list at trauma.org>
Message-ID:
<B79C02DCC4FA074DB02381DF1C5D60BA0168F006 at EX07.ad.tulane.edu>
Content-Type: text/plain; charset="UTF-8"
This "older surgeon" would likely close the skin.
Preferences & principles again...
principle: skin needs to closed sometime.
Preference - when?.........What is the condition of the wound. It is less than 72 hours; no bowel injury; was the patient overloaded with fluid?; how much pull on the skin to close?.
Typed by the thumbs of
Norman on his BlackBerry
Norman McSwain, MD
Tulane Univ Surgery
504 988-5111
________________________________
From: trauma-list-bounces at trauma.org
To: trauma-list at trauma.org
Sent: Mon Feb 02 22:39:54 2009
Subject: RE: trauma-list Digest, Vol 67, Issue 43
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
Send trauma-list mailing list submissions to
trauma-list at trauma.org
To subscribe or unsubscribe via the World Wide Web, visit
http://list.mistral.net/mailman/listinfo/trauma-list
or, via email, send a message with subject or body 'help' to
trauma-list-request at trauma.org
You can reach the person managing the list at
trauma-list-owner at trauma.org
When replying, please edit your Subject line so it is more specific
than "Re: Contents of trauma-list digest..."
------------------------------
Message: 2
Date: Tue, 3 Feb 2009 15:31:31 +0000
From: "jduchesne1" <jduchesn at tulane.edu>
Subject: Re: trauma-list Digest, Vol 67, Issue 43
To: "Trauma &" <trauma-list at trauma.org>
Message-ID:
<303248937-1233675093-cardhu_decombobulator_blackberry.rim.net-628520888- at bxe157.bisx.prod.on.blackberry>
Content-Type: text/plain; charset="Windows-1252"
Mike- Good to hear from you.
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. Keep it simple :)
Juan
CharityOne-NO
Sent via BlackBerry by AT&T
-----Original Message-----
From: "Sise, Mike MD" <Sise.Mike at scrippshealth.org>
Date: Mon, 2 Feb 2009 22:39:54
To: <trauma-list at trauma.org>
Subject: RE: trauma-list Digest, Vol 67, Issue 43
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
Send trauma-list mailing list submissions to
??????? trauma-list at trauma.org
To subscribe or unsubscribe via the World Wide Web, visit
??????? http://list.mistral.net/mailman/listinfo/trauma-list <http://list.mistral.net/mailman/listinfo/trauma-list>
or, via email, send a message with subject or body 'help' to
??????? trauma-list-request at trauma.org
You can reach the person managing the list at
??????? trauma-list-owner at trauma.org
When replying, please edit your Subject line so it is more specific
than "Re: Contents of trauma-list digest..."
------------------------------
Message: 3
Date: Tue, 3 Feb 2009 16:04:56 +0000
From: Karim Brohi <karimbrohi at gmail.com>
Subject: Re: trauma-list Digest, Vol 67, Issue 43
To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<b8b351510902030804u4a6371a5n96932ccdad52a7f2 at mail.gmail.com>
Content-Type: text/plain; charset=ISO-8859-1
Staple closed.
On 02/03/2009, jduchesne1 <jduchesn at tulane.edu> wrote:
>
> Mike- Good to hear from you.
> 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. Keep it simple :)
> Juan
> CharityOne-NO
> Sent via BlackBerry by AT&T
>
> -----Original Message-----
> From: "Sise, Mike MD" <Sise.Mike at scrippshealth.org>
>
> Date: Mon, 2 Feb 2009 22:39:54
> To: <trauma-list at trauma.org>
> Subject: RE: trauma-list Digest, Vol 67, Issue 43
>
>
> 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
>
>
>
> Send trauma-list mailing list submissions to
> trauma-list at trauma.org
>
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------------------------------
Message: 4
Date: Tue, 3 Feb 2009 19:46:08 +0200 (SAST)
From: "Dr Timothy Hardcastle" <dr.tchardcastle at absamail.co.za>
Subject: RE: trauma-list Digest, Vol 67, Issue 43
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<50494.41.9.195.100.1233683168.squirrel at aiamail.lantic.net>
Content-Type: text/plain;charset=iso-8859-1
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
>
>
>
> Send trauma-list mailing list submissions to
> trauma-list at trauma.org
>
> To subscribe or unsubscribe via the World Wide Web, visit
> http://list.mistral.net/mailman/listinfo/trauma-list
> or, via email, send a message with subject or body 'help' to
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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
------------------------------
Message: 5
Date: Tue, 03 Feb 2009 12:35:42 -0600
From: "Tracy Rogers" <trogers at kumc.edu>
Subject: Point of Care urine HCG or lab processed blood HCG
To: <trauma-list at trauma.org>
Message-ID: <49883A1F.C017.0048.0 at kumc.edu>
Content-Type: text/plain; charset=US-ASCII
Which method for screening does your facility use on trauma activations:
point of Care urine HCG or lab processed blood HCG?
Tracy Rogers, MSN, RN, CCRN
Trauma and Burn Program Manager
The University of Kansas Hospital
Office phone: 913-945-6853
Pager: 913-917-4391
email: trogers at kumc.edu
Mail stop Delp 1011
------------------------------
Message: 6
Date: Tue, 3 Feb 2009 13:57:00 EST
From: Krin135 at aol.com
Subject: Re: Point of Care urine HCG or lab processed blood HCG
To: trauma-list at trauma.org
Message-ID: <c82.398a56cc.36b9ed7c at aol.com>
Content-Type: text/plain; charset="US-ASCII"
at the trauma centers I have worked at in the past, the lab returns serum or
urine hCG results in near real time. Interestingly enough, at least two non
trauma centers (both less than 8K visits a year) did do urine hCG testing in
the department, as lab was often on call, not in house.
ck
Charles S. Krin, DO
In a message dated 2/3/2009 12:36:27 Central Standard Time, trogers at kumc.edu
writes:
Which method for screening does your facility use on trauma activations:
point of Care urine HCG or lab processed blood HCG?
**************Stay up to date on the latest news - from sports scores to
stocks and so much more. (http://aol.com?ncid=emlcntaolcom00000022)
------------------------------
Message: 7
Date: Tue, 03 Feb 2009 14:11:01 -0500
From: "William Bromberg" <brombwi1 at memorialhealth.com>
Subject: Re: Point of Care urine HCG or lab processed blood HCG
To: <trauma-list at trauma.org>
Message-ID: <49885075.85AB.003A.0 at memorialhealth.com>
Content-Type: text/plain; charset=UTF-8
Our lab has recently banned POC urine HCGs because they are "not
calibrated" ? see also POC urine dipsticks and Hemocrits
William J. Bromberg, MD, FACS
Savannah Surgical Group
912 350-7412
>>> <Krin135 at aol.com> 2/3/2009 1:57 PM >>>
at the trauma centers I have worked at in the past, the lab returns
serum or
urine hCG results in near real time. Interestingly enough, at least two
non
trauma centers (both less than 8K visits a year) did do urine hCG
testing in
the department, as lab was often on call, not in house.
ck
Charles S. Krin, DO
In a message dated 2/3/2009 12:36:27 Central Standard Time,
trogers at kumc.edu
writes:
Which method for screening does your facility use on trauma
activations:
point of Care urine HCG or lab processed blood HCG?
**************Stay up to date on the latest news - from sports scores
to
stocks and so much more. (http://aol.com?ncid=emlcntaolcom00000022)
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/
------------------------------
Message: 8
Date: Tue, 3 Feb 2009 12:19:29 -0700
From: "Marc Matthews - MedPro MMC X" <Marc_Matthews at medprodoctors.com>
Subject: RE: Point of Care urine HCG or lab processed blood HCG
To: "Trauma & Critical Care mailing list"
<trauma-list at trauma.org>, <trauma-list at trauma.org>
Message-ID:
<28907859B728CA469FCD77AB2DBB10EA47D2B4 at mpmail1.medprodoctors.com>
Content-Type: text/plain; charset="iso-8859-1"
Tracy,
MIHS uses lab only for HCG's. The only POC is in the NICU.
Respectfully,
MRM
________________________________
From: trauma-list-bounces at trauma.org on behalf of Tracy Rogers
Sent: Tue 2/3/2009 11:35 AM
To: trauma-list at trauma.org
Subject: Point of Care urine HCG or lab processed blood HCG
Which method for screening does your facility use on trauma activations:
point of Care urine HCG or lab processed blood HCG?
Tracy Rogers, MSN, RN, CCRN
Trauma and Burn Program Manager
The University of Kansas Hospital
Office phone: 913-945-6853
Pager: 913-917-4391
email: trogers at kumc.edu
Mail stop Delp 1011
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
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------------------------------
Message: 9
Date: Tue, 3 Feb 2009 19:30:32 +0000
From: "jduchesne1" <jduchesn at tulane.edu>
Subject: Re: Point of Care urine HCG or lab processed blood HCG
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<2004891693-1233689435-cardhu_decombobulator_blackberry.rim.net-1827629555- at bxe157.bisx.prod.on.blackberry>
Content-Type: text/plain
Tracy- we start with bedside urine dip if positive then we proceed with quantitative.
J
CharityOne-NO
Sent via BlackBerry by AT&T
-----Original Message-----
From: "Marc Matthews - MedPro MMC X" <Marc_Matthews at medprodoctors.com>
Date: Tue, 3 Feb 2009 12:19:29
To: Trauma & Critical Care mailing list<trauma-list at trauma.org>; <trauma-list at trauma.org>
Subject: RE: Point of Care urine HCG or lab processed blood HCG
Tracy,
MIHS uses lab only for HCG's. The only POC is in the NICU.
Respectfully,
MRM
________________________________
From: trauma-list-bounces at trauma.org on behalf of Tracy Rogers
Sent: Tue 2/3/2009 11:35 AM
To: trauma-list at trauma.org
Subject: Point of Care urine HCG or lab processed blood HCG
Which method for screening does your facility use on trauma activations:
point of Care urine HCG or lab processed blood HCG?
Tracy Rogers, MSN, RN, CCRN
Trauma and Burn Program Manager
The University of Kansas Hospital
Office phone: 913-945-6853
Pager: 913-917-4391
email: trogers at kumc.edu
Mail stop Delp 1011
--
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------------------------------
Message: 10
Date: Tue, 3 Feb 2009 14:36:39 EST
From: Krin135 at aol.com
Subject: Re: Point of Care urine HCG or lab processed blood HCG
To: trauma-list at trauma.org
Message-ID: <cd0.37223eba.36b9f6c7 at aol.com>
Content-Type: text/plain; charset="UTF-8"
I find this interesting, as all three of the test were considered 'waivered'
tests under CLIA, and can be done in any clinic office with little or no
oversight. Add in the relatively inexpensive automated dipstick readers, and
what this seems to be is a billing protection issue, not a 'patient safety
issue.' It's bad enough that some labs are trying to claim fingerstick blood
glucose measurements, but at least that requires periodic control samples...with
the modern urine hCG dipsticks, there is a built in control on every test.
In a message dated 2/3/2009 13:12:16 Central Standard Time,
brombwi1 at memorialhealth.com writes:
Our lab has recently banned POC urine HCGs because they are "not
calibrated" ? see also POC urine dipsticks and Hemocrits
William J. Bromberg, MD, FACS
Savannah Surgical Group
912 350-7412
**************Stay up to date on the latest news - from sports scores to
stocks and so much more. (http://aol.com?ncid=emlcntaolcom00000022)
------------------------------
Message: 11
Date: Tue, 03 Feb 2009 14:39:45 -0500
From: "William Bromberg" <brombwi1 at memorialhealth.com>
Subject: Re: Point of Care urine HCG or lab processed blood HCG
To: <trauma-list at trauma.org>
Message-ID: <49885731.85AB.003A.0 at memorialhealth.com>
Content-Type: text/plain; charset=UTF-8
Ha, YOU try talking to our clipboard carriers. They are a totally
different breed of stubborn.
William J. Bromberg, MD, FACS
Savannah Surgical Group
912 350-7412
>>> <Krin135 at aol.com> 2/3/2009 2:36 PM >>>
I find this interesting, as all three of the test were considered
'waivered'
tests under CLIA, and can be done in any clinic office with little or
no
oversight. Add in the relatively inexpensive automated dipstick
readers, and
what this seems to be is a billing protection issue, not a 'patient
safety
issue.' It's bad enough that some labs are trying to claim fingerstick
blood
glucose measurements, but at least that requires periodic control
samples...with
the modern urine hCG dipsticks, there is a built in control on every
test.
In a message dated 2/3/2009 13:12:16 Central Standard Time,
brombwi1 at memorialhealth.com writes:
Our lab has recently banned POC urine HCGs because they are "not
calibrated" ? see also POC urine dipsticks and Hemocrits
William J. Bromberg, MD, FACS
Savannah Surgical Group
912 350-7412
**************Stay up to date on the latest news - from sports scores
to
stocks and so much more. (http://aol.com?ncid=emlcntaolcom00000022)
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/
------------------------------
Message: 12
Date: Tue, 3 Feb 2009 15:10:23 -0500
From: Robert Smith <rfsmithmd at comcast.net>
Subject: Re: Lung Contusion
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <99A75EE7-DFBB-4D1B-B4EE-D569A01F6007 at comcast.net>
Content-Type: text/plain; charset=US-ASCII; format=flowed; delsp=yes
Hi Ron,
I"m listing you as someone who has knowledge of my clinical abilities
for my credentials reappointment if that's OK. Can you send me your
mailing address?
Rob
On Feb 1, 2009, at 8:01 AM, Gross, Ronald wrote:
> Tim,
>
> For what it is worth, I am hoping to get the study funded - not sure
> how that is gonna affect my international colleagues (IF this is
> funded by some govt agency), but lets see how it plays out.....
>
> Ron
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org
> ] On Behalf Of Dr Timothy Hardcastle
> Sent: Sunday, February 01, 2009 7:26 AM
> To: Trauma & Critical Care mailing list
> Subject: Re: Lung Contusion
>
> Charles wrote
>> well, with at least six outfits involved, that only means 50 patients
>> each....considering how busy Charity and Ben Taub are (not to
>> mention the
>> folks
>> down in ZA...Dr. Hardcastle?), that should take about a year to
>> enroll
>> enough...
>>
>> ck
>>
>>
> Charles
>
> The only catch is getting the study to have sponsored gadgets to
> use. The
> unit I work at now has seen just under 200 major chest injuries in the
> first 18 months since opening; we are about to embark on an extensive
> review of these. I can off-hand think of 4 or 5 patients we
> discussed that
> we would like to fix - if we had access to these gadgets, which we
> don't
> as we are a public hospital wth out equipment dependant upone the
> national
> health tender,\.
>
> 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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------------------------------
Message: 13
Date: Tue, 3 Feb 2009 12:39:18 -0800 (PST)
From: Richard Wigle MD FACS <rlwigle at yahoo.com>
Subject: Re: trauma-list Digest, Vol 67, Issue 43
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <317197.10357.qm at web111505.mail.gq1.yahoo.com>
Content-Type: text/plain; charset=us-ascii
Mike
I have in the past on many occasions closed the skin after damage control fascial closure without any problem and I'm an old surgeon. I also in the past have closed over a catheter and intimately irrigated and sucked with good results. Now days though if I'm the least little bit unsure I'll put a wound vac in and come back in a couple of days and close it. The one thing I don't like although I've done it in the remote past is a "loose closure" with packing between the stitches.
R. Wigle MD FACS
----- Original Message ----
From: jduchesne1 <jduchesn at tulane.edu>
To: Trauma & <trauma-list at trauma.org>
Sent: Tuesday, February 3, 2009 9:31:31 AM
Subject: Re: trauma-list Digest, Vol 67, Issue 43
Mike- Good to hear from you.
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. Keep it simple :)
Juan
CharityOne-NO
Sent via BlackBerry by AT&T
-----Original Message-----
From: "Sise, Mike MD" <Sise.Mike at scrippshealth.org>
Date: Mon, 2 Feb 2009 22:39:54
To: <trauma-list at trauma.org>
Subject: RE: trauma-list Digest, Vol 67, Issue 43
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
Send trauma-list mailing list submissions to
trauma-list at trauma.org
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------------------------------
Message: 14
Date: Tue, 3 Feb 2009 20:54:21 +0000
From: "Larry Torrey" <ltorrey at maine.rr.com>
Subject: Re: Point of Care urine HCG or lab processed blood HCG
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<1703222425-1233694454-cardhu_decombobulator_blackberry.rim.net-406138186- at bxe153.bisx.prod.on.blackberry>
Content-Type: text/plain; charset="utf-8"
We do them in the ER, as an extention of the lab. In short, we do them using devices provided by the lab.
Saves a lot of time, and it's quick and easy enough not to be a workload issue for the ER staff.
LT
Sent from my Verizon Wireless BlackBerry
-----Original Message-----
From: "William Bromberg" <brombwi1 at memorialhealth.com>
Date: Tue, 03 Feb 2009 14:11:01
To: <trauma-list at trauma.org>
Subject: Re: Point of Care urine HCG or lab processed blood HCG
Our lab has recently banned POC urine HCGs because they are "not
calibrated" ? see also POC urine dipsticks and Hemocrits
William J. Bromberg, MD, FACS
Savannah Surgical Group
912 350-7412
>>> <Krin135 at aol.com> 2/3/2009 1:57 PM >>>
at the trauma centers I have worked at in the past, the lab returns
serum or
urine hCG results in near real time. Interestingly enough, at least two
non
trauma centers (both less than 8K visits a year) did do urine hCG
testing in
the department, as lab was often on call, not in house.
ck
Charles S. Krin, DO
In a message dated 2/3/2009 12:36:27 Central Standard Time,
trogers at kumc.edu
writes:
Which method for screening does your facility use on trauma
activations:
point of Care urine HCG or lab processed blood HCG?
**************Stay up to date on the latest news - from sports scores
to
stocks and so much more. (http://aol.com?ncid=emlcntaolcom00000022)
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/
--
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------------------------------
Message: 15
Date: Tue, 3 Feb 2009 20:56:24 +0000
From: "Larry Torrey" <ltorrey at maine.rr.com>
Subject: Re: Point of Care urine HCG or lab processed blood HCG
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<1162326281-1233694570-cardhu_decombobulator_blackberry.rim.net-597656027- at bxe153.bisx.prod.on.blackberry>
Content-Type: text/plain
Same at my hospital in Boston.
LT
Sent from my Verizon Wireless BlackBerry
-----Original Message-----
From: "jduchesne1" <jduchesn at tulane.edu>
Date: Tue, 3 Feb 2009 19:30:32
To: Trauma & Critical Care mailing list<trauma-list at trauma.org>
Subject: Re: Point of Care urine HCG or lab processed blood HCG
Tracy- we start with bedside urine dip if positive then we proceed with quantitative.
J
CharityOne-NO
Sent via BlackBerry by AT&T
-----Original Message-----
From: "Marc Matthews - MedPro MMC X" <Marc_Matthews at medprodoctors.com>
Date: Tue, 3 Feb 2009 12:19:29
To: Trauma & Critical Care mailing list<trauma-list at trauma.org>; <trauma-list at trauma.org>
Subject: RE: Point of Care urine HCG or lab processed blood HCG
Tracy,
MIHS uses lab only for HCG's. The only POC is in the NICU.
Respectfully,
MRM
________________________________
From: trauma-list-bounces at trauma.org on behalf of Tracy Rogers
Sent: Tue 2/3/2009 11:35 AM
To: trauma-list at trauma.org
Subject: Point of Care urine HCG or lab processed blood HCG
Which method for screening does your facility use on trauma activations:
point of Care urine HCG or lab processed blood HCG?
Tracy Rogers, MSN, RN, CCRN
Trauma and Burn Program Manager
The University of Kansas Hospital
Office phone: 913-945-6853
Pager: 913-917-4391
email: trogers at kumc.edu
Mail stop Delp 1011
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------------------------------
Message: 16
Date: Tue, 3 Feb 2009 22:47:43 +0100
From: "tina" <tinagaar at online.no>
Subject: RE: trauma-list Digest, Vol 67, Issue 43
To: "'Trauma & Critical Care mailing list'"
<trauma-list at trauma.org>
Message-ID: <004d01c98649$0e39e6a0$2aadb3e0$@no>
Content-Type: text/plain; charset="us-ascii"
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 & 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
>
>
>
> Send trauma-list mailing list submissions to
> trauma-list at trauma.org
>
> To subscribe or unsubscribe via the World Wide Web, visit
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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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------------------------------
Message: 17
Date: Tue, 3 Feb 2009 23:51:48 +0100
From: "Peter" <taliente at tiscalinet.it>
Subject: R: trauma-list Digest, Vol 67, Issue 43
To: "'Trauma & Critical Care mailing list'"
<trauma-list at trauma.org>
Message-ID: <FBCMCL01B05GCIFoPkG00096cd5 at FBCMCL01B05.fbc.local>
Content-Type: text/plain; charset="iso-8859-1"
I much prefer to close the skin, I keep a close watch on the wound and any
sign of an important infection, open up the wound again. I am rarely
disappointed( I am not that young!!)
Peter
_____
Da: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
Per conto di Sise, Mike MD
Inviato: marted? 3 febbraio 2009 5.40
A: trauma-list at trauma.org
Oggetto: RE: trauma-list Digest, Vol 67, Issue 43
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
Send trauma-list mailing list submissions to
trauma-list at trauma.org
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------------------------------
Message: 18
Date: Wed, 4 Feb 2009 10:34:39 +1000
From: Bradley Morris <bradleypmorris at gmail.com>
Subject: Re: trauma-list Digest, Vol 67, Issue 43
To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<70996400902031634h64e77ff0v70dca6c86047006 at mail.gmail.com>
Content-Type: text/plain; charset=ISO-8859-1
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 & 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
> >
> >
> >
> > Send trauma-list mailing list submissions to
> > trauma-list at trauma.org
> >
> > To subscribe or unsubscribe via the World Wide Web, visit
> > http://list.mistral.net/mailman/listinfo/trauma-list
> > or, via email, send a message with subject or body 'help' to
> > trauma-list-request at trauma.org
> >
> > You can reach the person managing the list at
> > trauma-list-owner at trauma.org
> >
> > When replying, please edit your Subject line so it is more specific
> > than "Re: Contents of trauma-list digest..."
> >
> >
> >
> > "Scripps Information Security"
> >
>
> ----------------------------------------------------------------------------
> --
> > This e-mail and any files transmitted with it may contain privileged and
> > confidential information and are intended solely for the use of the
> > individual or entity to which they are addressed. If you are not the
> > intended recipient or the person responsible for delivering the e-mail to
> > the intended recipient, you are hereby notified that any dissemination or
> > copying of this e-mail or any of its attachment(s) is strictly
> prohibited.
> > If you have received this e-mail in error, please immediately notify the
> > sending individual or entity by e-mail and permanently delete the
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> > e-mail and attachment(s) from your computer system. Thank you for your
> > cooperation.
> >
> >
> >
>
> ============================================================================
> ==
> > --
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> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> 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
>
> --
> trauma-list : TRAUMA.ORG <http://trauma.org/>
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
> --
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> http://www.trauma.org/index.php?/community/
>
------------------------------
Message: 19
Date: Tue, 3 Feb 2009 19:45:36 -0600
From: "Duchesne, Juan C " <jduchesn at tulane.edu>
Subject: RE: trauma-list Digest, Vol 67, Issue 43
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<93F431B4ABF11C43BDB776B643B691BCA2E57F at EX04.ad.tulane.edu>
Content-Type: text/plain; charset="iso-8859-1"
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 &, 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 & 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
> >
> >
> >
> > Send trauma-list mailing list submissions to
> > trauma-list at trauma.org
> >
> > To subscribe or unsubscribe via the World Wide Web, visit
> > http://list.mistral.net/mailman/listinfo/trauma-list
> > or, via email, send a message with subject or body 'help' to
> > trauma-list-request at trauma.org
> >
> > You can reach the person managing the list at
> > trauma-list-owner at trauma.org
> >
> > When replying, please edit your Subject line so it is more specific
> > than "Re: Contents of trauma-list digest..."
> >
> >
> >
> > "Scripps Information Security"
> >
>
> ----------------------------------------------------------------------------
> --
> > This e-mail and any files transmitted with it may contain privileged and
> > confidential information and are intended solely for the use of the
> > individual or entity to which they are addressed. If you are not the
> > intended recipient or the person responsible for delivering the e-mail to
> > the intended recipient, you are hereby notified that any dissemination or
> > copying of this e-mail or any of its attachment(s) is strictly
> prohibited.
> > If you have received this e-mail in error, please immediately notify the
> > sending individual or entity by e-mail and permanently delete the
> original
> > e-mail and attachment(s) from your computer system. Thank you for your
> > cooperation.
> >
> >
> >
>
> ============================================================================
> ==
> > --
> > trauma-list : TRAUMA.ORG <http://trauma.org/>
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> 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
>
> --
> trauma-list : TRAUMA.ORG <http://trauma.org/>
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
> --
> trauma-list : TRAUMA.ORG <http://trauma.org/>
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
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Message: 5
Date: Wed, 4 Feb 2009 19:13:36 +0000
From: Karim Brohi <karimbrohi at gmail.com>
Subject: Re: skin closure
To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<b8b351510902041113x67338c96qfc7e3be5e13c436e at mail.gmail.com>
Content-Type: text/plain; charset=ISO-8859-1
>
> 1. What kind of fascial closure if it comes together without tension:
> running or interrupted and what suture?
1 loop PDS continuous mass closure
(There's solid evidence for this in G/Surg literature
> 2. Any role for retention sutures?
Never ever ever
>
> 3. Skin closure: when and how - complete closure , place wicks or drains?
Skin clips always. Never drain.
(occasionally you have to open a few clips if there is some superficial
infection. This is almost always a very small part of the wound and heals
well)
Karim
------------------------------
Message: 6
Date: Wed, 4 Feb 2009 15:00:05 -0500
From: "Bjorn, Pret" <pbjorn at emh.org>
Subject: RE: Maryland EMS (MIEMSS) Is Pressed To Share Triage Study
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Message-ID:
<9CCE32ECAAFDEB4DA01EC771B6AD951B036A7C8C at VALIER.me.emh.org>
Content-Type: text/plain; charset="us-ascii"
ThinkSharp and the Sacco Triage Method have been discussed on the List
before. In 2005, I detailed my concerns as follows:
"The Sacco Triage Method (STM) strikes as an over-solution, a digital
Rube Goldberg device. It's an entrepreneurial snazzification of an
inherently and importantly simple process. It concerns or annoys me on
several levels:
"1. It's reasonable to speculate that a purely physiologic triage
instrument may produce increased survival in large-scale mass casualty
incidents; but the AEM article discusses no more than a mathematical
model (which is not proven by a PRCT, or even supported by a respectable
moulage exercise).
"2. In Dr. Sacco's research, I'm troubled by the assumption that a
longitudinal survey of a state trauma system bears any useful
resemblance to an MCI patient mix. Are a thousand traumas distributed
across a state system over ten years inherently comparable to a thousand
victims of a civilian disaster on a single summer afternoon? I have
serious doubts.
"3. Which begs the observation: in spite of decades of meticulously
documented real-world disasters suggesting otherwise, Sacco convened a
Delphi panel to support the assumption of significant deterioration
among "delayeds." Hell, he projected a five-fold impact on
survivability! Can anybody cite even one recent REAL disaster where
other triage methods bred close to this degree of preventable death?
"4. Getting back to #1: Outside of large-scale disasters, physiologic
triage alone completely ignores anatomic imperatives important to daily
triage in a multi-hospital community: when thirty folks are dying, any
OR will probably do; but when one guy has a cord injury with spinal
shock and bradycardia, you'd better know which hospital has the
neurosurgeons.
"5. I'm ever wary of gizmos. I like tools that can't break, or work
even when they do. PDA's and wireless communications and database
systems have never failed to disappoint me under fire. Using one
complex system to simplify another seems to me an invitation to regret.
Paying tens of thousands of dollars for it (while half of the ambulances
in Maine need new tires), doubly so.
"6. Finally, and perhaps mostly, I'm saddened by the commercialization
of triage. Had Dr. Sacco made a case in the journals for his RPM
formula, and published the severity indices instead of marketing them as
a "secret formula," then I might be happier to play with his software
product. But the fact that he's put together a PR strategy even before
the unqualified publication of his numbers makes it hard for me to shake
the impression of shameless hucksterism."
I see nothing in this recent report which changes my mind. ThinkSharp
has at least 3.9 million reasons to stir up community outrage in
Maryland. I'd be tempted to side with MIEMMS until the rest of the
story is known.
Pret Bjorn, RN
Bangor, ME USA
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of janeangelasmith
Sent: Tuesday, February 03, 2009 11:39 AM
To: trauma-list at trauma.org
Subject: Fw: Maryland EMS (MIEMSS) Is Pressed To Share Triage Study
I would think that those in "power" would do their utmost to have
"emergency
care" at its highest level of efficiency so that "to triage" would not
have
hurtful consequences for anyone. Who knows who will be "triaged". It
could
be one of us one day.
Jobs to help boost our economy and keep more people safe.
Hoarding information eventually hurts the hoarders who will possibly one
day
need "emergency care" or "triaging".
----- Original Message -----
From: James Richardson <jimmnn at comcast.net>
To: 'Trauma & Critical Care mailing list' <trauma-list at trauma.org>
Cc: <Paramedicine at yahoogroups.com>; <EMS-L at EMS-L.org>
Sent: Monday, February 02, 2009 9:06 PM
Subject: Maryland EMS (MIEMSS) Is Pressed To Share Triage Study
> Md. EMS Is Pressed To Share Triage Study
>
> By Rosalind S. Helderman
> Washington Post Staff Writer
> Monday, February 2, 2009; B01
>
> As Maryland lawmakers wrestle with the future of the state's emergency
> medical service following the fatal crash of a state helicopter taking
> accident victims to a hospital, a private company has come forward
with a
> new concern about the independent agency.
>
> The company accuses state EMS leaders of dragging their feet in
releasing
> the results of a study of a new method for triaging patients in mass
> casualty incidents, a method that company leaders believe could save
lives.
>
> In a Jan. 19 letter, Thomas B. McCord, the chief executive of Bel
Air-based
> ThinkSharp, wrote that the Maryland Institute for Emergency Medical
Services
> System, the group that oversees all emergency medicine in the state,
had
> displayed "disregard, disbelief and delay" about the results of the
April
> 2007 study that the company conducted jointly with the state group.
>
> "To me, it's just wrong to sit on this information for this long,"
McCord
> said in an interview about the 22 months that have passed since the
study
> was done. "No matter what your reasons are -- it's wrong."
>
> Institute Executive Director Robert R. Bass said the agency is still
> interested in publishing a paper with ThinkSharp on the test of the
> company's triage method and said the delay stemmed from discussions
about
> what the paper should say. He said that the method requires further
study
> and that some paramedics have found the method to be confusing and
difficult
> to use.
>
> Maryland has one of the nation's most centralized systems for
conducting
> emergency medicine. All state ambulance services and hospitals are
overseen
> by the institute, which is led by a director hired by an 11-member
board
of
> gubernatorial appointees. The system has long been considered a
national
> model for coordination between first responders and hospitals.
>
> However, the agency also oversees the Maryland State Police medical
> helicopter program, which has been under scrutiny since the Sept. 27
crash
> that killed four people in Prince George's County. Flights since the
crash
> have decreased significantly, with no immediate adverse impact on
trauma
> victims, leading some lawmakers to question the size of the program.
They
> say they believe that the institute, once a national leader, has
become
> resistant to change.
>
> "These are the most politically wired interest groups in the state,
and
they
> are aligned to prevent change," said Sen. E.J. Pipkin (R-Queen
Anne's),
who
> is pushing a bill to replace Bass with a Cabinet secretary who answers
to
> the governor. "Whether it's this company or another, I think the
question
> they raise about MIEMSS are valid," he said.
>
> The helicopter issue has also highlighted national discussions about
how
> triage decisions are made. The family of a car accident victim killed
in
the
> helicopter crash has questioned whether her injuries warranted an
airlift
in
> the first place.
>
> ThinkSharp developed the triage method under study and estimates that
it
> would cost Maryland about $3.9 million over three years to adopt it.
The
> method is designed to use statistical data of survivability rates of
people
> with certain symptoms to help paramedics decide the order in which to
> dispatch injured patients to hospitals in mass casualty events.
Examples
of
> such an event include train accidents and natural disasters, plus more
> routine accidents in rural areas where a serious car crash could swamp
> emergency resources and force workers to prioritize care.
>
> Paramedics are trained to use a variety of factors, including physical
> condition of a patient and how an injury occurred to assign patients a
> color-coded tag -- red, yellow or green. Red indicates immediate need
of
> attention, green signals minor injuries. But some studies have shown
> inconsistency in paramedics' tagging decisions.
>
> ThinkSharp's method is designed to eliminate guesswork by assigning
each
> patient a number, derived by adding up scores tied to different
physical
> symptoms. The scores are based on a mathematical formula developed by
> William J. Sacco, a statistician long involved in trauma care, and are
> designed to take into account the chances that a patient treated
quickly
> will survive given different patient characteristics, such as pulse.
>
> "In the middle of an incident, people get excited," said William B.
Long,
> trauma medical director at Legacy Emanuel Hospital in Portland, Ore.
Long,
> who has done some work on contract for ThinkSharp, supports the
method.
"We
> were looking for ways to get a mathematical, better way to determine
how
to
> treat people -- to take away some of the anxiety."
>
> After agreeing that the method held promise, ThinkSharp and the state
agency
> organized a drill in April 2007. Paramedics first used the current
protocol,
> then ThinkSharp's Sacco method, to decide the order in which to send
dozens
> of "patients" to hospitals.
>
> Later analysis showed that under the current protocol, paramedics sent
only
> two of the 13 most seriously injured patients to the hospital in the
first
> 13 ambulances they dispatched. Under ThinkSharp's method, the 13 most
> seriously injured patients were sent to the hospital in the first
seven
> ambulances dispatched.
>
> "The results of the MIEMSS exercise are overwhelming," McCord said.
"People
> who had never seen it before or used it before actually did far better
than
> the protocol they've used since 1995."
>
> He said he believes the nearly two years that have passed since the
drill
> was conducted is an unreasonably long time for the state agency to
agree
to
> a draft of a paper on the study to submit for publication in academic
> journals.
>
> But surveys from the drill also showed that after brief training,
first
> responders thought the current protocol was easier to use and remember
than
> ThinkSharp's method. Paramedics' concerns are problematic for the
method,
> Bass said.
>
> "Triage needs to be something that is easy to teach, easy to remember
and
> logistically easy to do in the field," he said.
>
> ThinkSharp officials said their method is no more confusing than the
> protocol paramedics learn now. They said that during the 2007 drill,
the
> first responders received only 20 minutes of training in the new
method --
> the same amount of time devoted to a refresher session for the current
> protocol.
>
> Bass said the delay is a result of negotiations between the state
agency
and
> ThinkSharp on what, exactly, the study showed -- but he said that even
after
> the results are published, Maryland would be unlikely to adopt the
method
> without a national consensus that the technique is better. He said
adopting
> a method different from what other states use would be challenging
because
> it would make sharing first responders in a major crisis difficult.
>
> "We're not saying this concept doesn't have validity," Bass said.
"What
> we're saying is that there isn't any consensus at the national level
that
> this is the way to go, and if we went that way, it would incur
additional
> expense and put us out of step with the rest of the nation."
>
>
>
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