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Sat Jun 20 08:30:53 BST 2009

Yeah - what he said.  
K just got to the keypad befor me!!

Ron
________________________________________
From: trauma-list-bounces at trauma.org [trauma-list-bounces at trauma.org] On Behalf Of KMATTOX at aol.com [KMATTOX at aol.com]
Sent: Friday, June 19, 2009 10:51 PM
To: trauma-list at trauma.org
Subject: Re: A trauma case...impaled branch

Thanks.   First I have concern for the CTA.    Increasingly we are being
burned by CTAs, as are many hospitals.   The  results are often misleading.
A negative CTA does not rule out a  vascular injury.   IF YOU ARE CONCERNED
ABOUT A VASCULAR INJURY GET A  FORMAL REAL ARTERIOGRAM.

Second.    The wound should have been explored, extensively  within the
hour of presentation to the EC.    The possibility of  a foreign body still
being present is huge.

Third.    Several infectious conditions are real  possibilities, even
without any dishwater.     It is  too soon for tetanus, but this is a tetanus
prone wound and should have been  treated accordingly.      Clostridia
infection is a  real possibility, even in the absence of gas in the tissue.

To the OR.   Open widely and to the base of the  penetration.
Intraoperative cultures and immediate  SMEARS.   Surgeon to go look at the slides of
the immediate gram  stains of the deep tissue.   Look for gram positive rods
with spores  at one end.

Until proven otherwise, this is a sepsis from a virulent  organism.   Call
ID and treat with your best BIG GUN.

Put on your surgery QA meeting .   CLOSE THE DOOR and do a real  analysis
as to why this case was not in the OR immediately after arrival at the
hospital.    The purpose of the ER in this patient's care was to  wave to the
patient on the way from the way from the ambulance dock to the  OR.
Determine why a CTA was done.    It did not  really add anything to the known
information or to the decision, but added risks  and costs.

Get an immediate blood culture.

k

In a message dated 6/19/2009 9:36:44 P.M. Central Standard Time,
SSherry at LHS.ORG writes:

CTA neg.  CXR clear

concern for wound. wound explored in or no "dishwater"  appearance no
fevers. taken back. later that afternoon. the wbc drops from 9  to 3. plts drop.
redness in L arm.

what next? thoughts...

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A trauma case...impaled branch