New GSW case

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I would have explored that patient on first presentation to the
resuscitation room, resected the damaged portion of the trachea( if more
that 40% circumference of the trachea was involved and closed it
primarily. If  less that 40%, done a primary repair without resection.
Either way, I would position the ET tube so that it was below the
repair. In addition I would have explored the esophagus. 

Old data from our institution by Noyes et al, demonstrates that either
an esophagoscope or a esophagram (with barium) is only 80% accurate
each. Together they approach 100% .  A trip to the OR would fix the
trachea and answer the question about the esophagus.

Norman
 
Norman McSwain MD
Professor, Tulane School of Medicine
Trauma Director, Charity Hospital Trauma Center
norman.mcswain at tulane.edu
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Jose Luis Danguilan
Sent: Monday, March 16, 2009 4:28 PM
To: Trauma & Critical Care mailing list
Subject: Re: New GSW case

The patient may have an esophageal injury considering an anteroposterior
trajectory.

Jose Luis J. Danguilan, MD

On Mon, Mar 16, 2009 at 11:45 PM, D. R. Gill <d_gill911 at yahoo.com>
wrote:

> You should also try Hyaluronic acid (HA). It has shown successful in
> treating tracheal injuries and in post-op. HA is essential in
preventing
> tracheal stenosis.
>
> Just a thought,
> D. R. Gill
> Mercer University
>
>
> --- On Mon, 3/16/09, kmattox at aol.com <kmattox at aol.com> wrote:
>
> From: kmattox at aol.com <kmattox at aol.com>
> Subject: Re: New GSW case
> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> Date: Monday, March 16, 2009, 10:42 AM
>
> Concerned that there IS an esophageal injury still.  Did you use
> gastrograffin
> or Barium. Barium is preferred.  A negative esophageal swallow does
not
> rule out
> an injury.   This patient will need a permanent tracheostomy.
> ------Original Message------
> From: William Bromberg
> Sender:
> To: trauma-list at trauma.org
> ReplyTo: Trauma & Critical Care mailing list
> Sent: Mar 16, 2009 9:32 AM
> Subject: New GSW case
>
> Hello all - I have a case I'd like your opinions on:
>
> 11 y.o female, 60kg. Sustained a GSW ( .380 handgun) directly through
> and through the trachea and spinal cord. Spinal injury is complete at
T3
> - fairly straightforward.
>
> The tracheal injury consists of two very clean holes directly anterior
> and posterior (I will admit to having perc. trachs less perfectly
> placed) at 4-5 cm above the carina. There was minimal mediastinal air
on
> the CT, no esophageal or great vessel injury (Ba swallow and CT angio
> respectively). The patient is temporarily intubated past the injury
(via
> bronchoscopy) and sedated in the PICU.
>
> Does it have to be fixed or can it be managed non-operatively with
> temporary intubation?
>
>
> Thanks,
> Bill
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