trauma-list Digest, Vol 76, Issue 35-Selective Conservativestabs of the Abdomen

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I

Sent from my iPhone

On 27/10/2009, at 5:07 PM, "Pret Bjorn" <p.bjorn at tds.net> wrote:

> Dr. Teperman, unless your patient has consented to this discussion  
> (see BTW,
> below), it is probably in violation of federal HIPAA restrictions.    
> The
> penalties can be severe.
>
> We would all do well to take a lesson: the details of these cases  
> belong to
> the patients, not us.
>
> 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 Teperman, Sheldon
> Sent: Monday, October 26, 2009 3:39 PM
> To: 'trauma-list at trauma.org'
> Subject: RE: trauma-list Digest, Vol 76, Issue 35-Selective
> Conservativestabs of the Abdomen
>
>
>
> Its funny-We have been trying to answer this very question up here  
> in the
> Bronx. The question came about when we hired a bright young Surgeon  
> who  did
> his Trauma Fellowship at UC -Davis. Sal Ahmad came to us with a very
> aggressive bent on how to manage anterior stab wounds-that is to  
> say- he
> wanted to operate on most of them -and that perhaps the air up here   
> was too
> thin and we were not getting it right. So we made a bet.
>        Sal spent the last three years looking at close to two  
> hundred of
> these pts( isolated anterior stab wounds)- and we are in the process  
> of
> submission.  He did some fancy Artificial Neural Network Modeling- 
> which I
> don't presume to understand.  But bottom line- It would appear that  
> Carter
> Nance and those that followed got it right.  With conservative and  
> selective
> management and  with Liberal CT scanning ( which he says had a high  
> positive
> predictive value-atleast for us). We managed not to loose a single  
> Pt and
> had nary a missed injury.  I agree with Dr. Brohi- that it has a lot  
> to do
> with resources and how comfortable your people are with penetrating  
> trauma.
> But clearly if your paying attention, you can watch lots of people  
> without
> hurting them- and the CT helps with the watching
>
> ....Sheldon Teperman
>
>
>        BTW - although we are presently writing about Stab wounds- We  
> do
> specialize in another form of penetrating trauma in the Bronx... If  
> you have
> been following the news coming out of NYC. A 92 year old Lady took a  
> stray
> bullet through her living room window last week ( a gang thing maybe)-
> landing her in my OR. How that bullet found her retro hepatic cava  
> is a
> mystery to me- but an even bigger mystery is how we think its fine  
> that an
> 18 year old boy becomes a murderer with a  gun, which if they ever  
> find it,
> will have an over 90% chance of having gotten to him from a state  
> with lax
> gun safety laws. Likely from a disreputable dealer or just as likely  
> from an
> unregulated sale at a gun show.
>        My older  brother Lew is a Transplant surgeon- and he likes  
> to say
> that when a trauma surgeon is looking at the Retrohepatic Cava- he is
> looking at the Pt's soul- which is Ascending to heaven.  I think we  
> all lost
> a bit of our collective souls that day...
>
> -----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: Monday, October 26, 2009 12:45 PM
> To: trauma-list at trauma.org
> Subject: trauma-list Digest, Vol 76, Issue 35
>
> Send trauma-list mailing list submissions to
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> When replying, please edit your Subject line so it is more specific
> than "Re: Contents of trauma-list digest..."
>
>
> Today's Topics:
>
>   1. RE: selectice conservative management of stab injury abdomen-
>      (Gross, Ronald)
>   2. RE: selectice conservative management of stab injury abdomen-
>      (McSwain, Norman E Jr.)
>   3. RE: selectice conservative management of stab injury abdomen-
>      (Gross, Ronald)
>   4. RE: selectice conservative management of stab injury abdomen-
>      (McSwain, Norman E Jr.)
>   5. Re: selectice conservative management of stab injury abdomen-
>      (Krin135 at aol.com)
>   6. RE: selectice conservative management of stab injury abdomen-
>      (Gross, Ronald)
>   7. Re: selectice conservative management of stab injury abdomen-
>      (Krin135 at aol.com)
>   8. RE: selectice conservative management of stab injury abdomen-
>      (McSwain, Norman E Jr.)
>   9. RE: selectice conservative management of stab injury abdomen-
>      (Gross, Ronald)
>  10. RE: selectice conservative management of stab injury abdomen-
>      (Gross, Ronald)
>  11. Selective Conservative Management of ant/flank abdominal stab
>      wounds:   summary (Krin135 at aol.com)
>  12. Re: Selective Conservative Management of ant/flank abdominal
>      stab      wounds: sum... (Krin135 at aol.com)
>  13. RE: Selective Conservative Management of ant/flank abdominal
>      stab      wounds:summary (McSwain, Norman E Jr.)
>  14. RE: Selective Conservative Management of ant/flank abdominal
>      stabwounds: sum... (McSwain, Norman E Jr.)
>
>
> ----------------------------------------------------------------------
>
> Message: 1
> Date: Mon, 26 Oct 2009 08:44:47 -0400
> From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
> Subject: RE: selectice conservative management of stab injury abdomen-
> To: "'Trauma-List [TRAUMA.ORG]'" <trauma-list at trauma.org>
> Message-ID:
>        <FD2BE6867A90F543AAD02E429F878633014D37A0DB7B at bhsexc11.bhs.org>
> Content-Type: text/plain; charset="us-ascii"
>
> I will get a CT if I am suspicious for peritoneal involvement, but I  
> do
> personally examine these patients on admission and every 4-6 hrs  
> thereafter
> for 18-24 hours, after which they are sent home.  My residents  
> follow a
> similar exam schedule, but on alternate times, so that in reality the
> patients are seen almost every 2-3 hours.
> Ron
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list- 
> bounces at trauma.org]
> On Behalf Of Sanjay Gupta
> Sent: Sunday, October 25, 2009 9:37 PM
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: selectice conservative management of stab injury abdomen-
>
> Well,now that someone has brought this point up:
>
> How many of the trauma surgeons who are Professors in a University,  
> actually
> admit the stable patients with penetrating trauma and with no  
> peritoneal
> signs, and do not do a CT scan, and examine them at admission and  
> every 4
> hours PERSONALLY thereafter, until the patient has either been  
> cleared or a
> laparotomy has been decided upon.  (or is the job delegated to the  
> Trauma
> Chief resident who in turn delegates the job to the trauma intern).
>
> I ask the above question because in a typical level II trauma center  
> in a
> community hospital in the US, there is a single trauma surgeon who  
> covers
> trauma, the surgical ICU and the surgical emergencies.  He or she also
> cannot delegate the above responsibility to anyone else.
>
>
> Also, in those rare instances, when laparotomy is decided to be done  
> in a
> delayed fashion, what is your opinion about the medico-legal risk.
>
>
> Sanjay Gupta
>
>
> (No blackberry or I-phone.Do not care for one either)
>
>
>
> ----- Original Message ----
> From: caesar ursic <cmursic at gmail.com>
> To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
> Sent: Sun, October 25, 2009 3:47:14 PM
> Subject: Re: selectice conservative management of stab injury abdomen-
>
> "*There are many paths that lead to the summit of one and the same  
> mountain*
> "
>
> -Buddha
>
>
>
>
>
>
> On Sun, Oct 25, 2009 at 8:17 AM, Karim Brohi <karimbrohi at gmail.com>  
> wrote:
>
>> How you management the patient with a stabbed abdomen who is
>> haemodynamically normal and has no peritonitis is one of the simplest
>> but hardest questions in modern trauma care.   Fundamentally there  
>> are
>> a number of ways of managing these patients.  The reason why it
>> generates such debate is because it's fundamentally a question not of
>> the patient but of the resources and expertise available.
>>
>> If you're in a hospital with lots of doctors & nurses, enough beds  
>> and
>> low quality imaging or imaging expertise, then admission with regular
>> haemodynamic observation and serial clinical examination has been
>> shown to be safe and effective.  This is the case in South Africa
>> where this management plan originated and also in many parts of the
>> world.  It should be considered the safe fall-back option.
>>
>> In our situation, beds are at a premium (especially monitored beds),
>> few doctors on call and a high possibility that patients will not be
>> reviewed by a surgeon until the next morning.  We also have 2
>> high-spec scanners on site and good on-call radiology coverage.  So  
>> we
>> use CT as a screening tool.  NOT to diagnosis bowel injury (although
>> the new scanners are pretty good) but because if the wound track
>> clearly goes nowhere near anything important then we can discharge  
>> the
>> patient.
>>
>> The literature does not support laparoscopy for these patients.
>> HOWEVER if you are in a hospital and there is an experienced
>> laparoscopic surgeon on call perhaps they can identify bowel
>> perforation (early) reliably.  (I don't believe you should be looking
>> at laparoscopy for just diagnosing peritoneal penetration).  But this
>> does require beds and operating room space etc etc.
>>
>> I also don't believe local wound exploration is a good test.  Nor  
>> do I
>> think FAST is useful in these patients.  MRI??  Never seen any
>> literature to support it but it seems, for the moment at least, like
>> expensive overkill (compared to a high-quality CT).
>>
>> So - how you manage these patient depends less on the patient and  
>> more
>> on clinical expertise and hospital resources at your disposal.  Hence
>> the arguments - we're all looking at this from different starting
>> points.
>>
>> Karim
> --
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> ------------------------------
>
> Message: 2
> Date: Mon, 26 Oct 2009 08:29:39 -0500
> From: "McSwain, Norman E Jr." <nmcswai at tulane.edu>
> Subject: RE: selectice conservative management of stab injury abdomen-
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Message-ID:
>        <B79C02DCC4FA074DB02381DF1C5D60BA02C74916 at EX07.ad.tulane.edu>
> Content-Type: text/plain;       charset="us-ascii"
>
> Ron
> Why do you get a CT if you are " suspicious for peritoneal  
> involvement"?
> What does it all? Does it change your treatment?
>
> 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 Gross, Ronald
> Sent: Monday, October 26, 2009 7:45 AM
> To: 'Trauma-List [TRAUMA.ORG]'
> Subject: RE: selectice conservative management of stab injury abdomen-
>
> I will get a CT if I am suspicious for peritoneal involvement, but I  
> do
> personally examine these patients on admission and every 4-6 hrs
> thereafter for 18-24 hours, after which they are sent home.  My
> residents follow a similar exam schedule, but on alternate times, so
> that in reality the patients are seen almost every 2-3 hours.
> Ron
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Sanjay Gupta
> Sent: Sunday, October 25, 2009 9:37 PM
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: selectice conservative management of stab injury abdomen-
>
> Well,now that someone has brought this point up:
>
> How many of the trauma surgeons who are Professors in a University,
> actually admit the stable patients with penetrating trauma and with no
> peritoneal signs, and do not do a CT scan, and examine them at  
> admission
> and every 4 hours PERSONALLY thereafter, until the patient has either
> been cleared or a laparotomy has been decided upon.  (or is the job
> delegated to the Trauma Chief resident who in turn delegates the job  
> to
> the trauma intern).
>
> I ask the above question because in a typical level II trauma center  
> in
> a community hospital in the US, there is a single trauma surgeon who
> covers trauma, the surgical ICU and the surgical emergencies.  He or  
> she
> also cannot delegate the above responsibility to anyone else.
>
>
> Also, in those rare instances, when laparotomy is decided to be done  
> in
> a delayed fashion, what is your opinion about the medico-legal risk.
>
>
> Sanjay Gupta
>
>
> (No blackberry or I-phone.Do not care for one either)
>
>
>
> ----- Original Message ----
> From: caesar ursic <cmursic at gmail.com>
> To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
> Sent: Sun, October 25, 2009 3:47:14 PM
> Subject: Re: selectice conservative management of stab injury abdomen-
>
> "*There are many paths that lead to the summit of one and the same
> mountain*
> "
>
> -Buddha
>
>
>
>
>
>
> On Sun, Oct 25, 2009 at 8:17 AM, Karim Brohi <karimbrohi at gmail.com>
> wrote:
>
>> How you management the patient with a stabbed abdomen who is
>> haemodynamically normal and has no peritonitis is one of the simplest
>> but hardest questions in modern trauma care.   Fundamentally there  
>> are
>> a number of ways of managing these patients.  The reason why it
>> generates such debate is because it's fundamentally a question not of
>> the patient but of the resources and expertise available.
>>
>> If you're in a hospital with lots of doctors & nurses, enough beds  
>> and
>> low quality imaging or imaging expertise, then admission with regular
>> haemodynamic observation and serial clinical examination has been
>> shown to be safe and effective.  This is the case in South Africa
>> where this management plan originated and also in many parts of the
>> world.  It should be considered the safe fall-back option.
>>
>> In our situation, beds are at a premium (especially monitored beds),
>> few doctors on call and a high possibility that patients will not be
>> reviewed by a surgeon until the next morning.  We also have 2
>> high-spec scanners on site and good on-call radiology coverage.  So  
>> we
>> use CT as a screening tool.  NOT to diagnosis bowel injury (although
>> the new scanners are pretty good) but because if the wound track
>> clearly goes nowhere near anything important then we can discharge  
>> the
>> patient.
>>
>> The literature does not support laparoscopy for these patients.
>> HOWEVER if you are in a hospital and there is an experienced
>> laparoscopic surgeon on call perhaps they can identify bowel
>> perforation (early) reliably.  (I don't believe you should be looking
>> at laparoscopy for just diagnosing peritoneal penetration).  But this
>> does require beds and operating room space etc etc.
>>
>> I also don't believe local wound exploration is a good test.  Nor  
>> do I
>> think FAST is useful in these patients.  MRI??  Never seen any
>> literature to support it but it seems, for the moment at least, like
>> expensive overkill (compared to a high-quality CT).
>>
>> So - how you manage these patient depends less on the patient and  
>> more
>> on clinical expertise and hospital resources at your disposal.  Hence
>> the arguments - we're all looking at this from different starting
>> points.
>>
>> Karim
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
>
>
> --
> trauma-list : TRAUMA.ORG
> To change your

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