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Sat Sep 12 20:30:21 BST 2009

As you present the case I would assume that there was nothing on the  R chest on CXR. therefore no R thoracotomy

I would have gone directly to the OR----no C. I avoid the 'death ray department' if the patient is in shock (as this one way) 

I would have explored the abdomen after the R chest. I would NOT rely on the EGD to R/O abdominal injuries. This is especially true when your CT showed IA injury. A negative lap takes 20 minutes. A positive lap finds and fixed injuries. Very important to know the status of the abdomen

Norman

Norman McSwain MD
Trauma Director, Charity Hospital
Professor of Surgery, Tulane University
New Orleans LA
504 988 5111
norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu> 

________________________________

From: trauma-list-bounces at trauma.org on behalf of moore677 at aol.com
Sent: Sat 9/12/2009 1:42 PM
To: trauma-list at trauma.org
Subject: TRANSMEDIASTINAL GSW

Two patients arrived with GSW's, first with GSW L shoulder to L chest (didn't require chest tube though) and second with GSW L shoulder, through L chest, mediastinum, lodging in R chest.? Hypotensive, placed 2 left chest tubes (first failed to evacuate HTX) and one left chest tube, MTP protocol initiated.? Prepping chest for ED thoracotomy as pressure initially in 40's, but responded to blood products.? Managed to resusc to get CT scan which showed persistent large L HTX despite 2 chest tubes, ? esophag injury, ? L SCL artery injury.? CT's initially out about 1000, with second tube 200, and by finishing?CAT scan?about 1800-2000.? ? intra-abd injury on CT.

Would any of you went straight to OR without CT knowing this could provide invaluable information regarding trajectory (great vessel injury, etc.)?

?

In OR, started with L anterolateral thoracotomy to explore L chest for massive HTX.? Multiple injuries to LUL and LLL but didn't require anything, obvious injury to esophagus at T2/T3 level.? Bronch clean, EGD shows possibly 2 full thickness injuries.?

Would any of you extend the?L thoracotomy to a clamshell or do a?R posterolateral thoracotomy??

We examined L diaphragm and didn't identify any breaches/injury and EGD didn't reveal any gastric injury so did not pursue exlap (CT with ? fragments below diaphragm, possibly anterior to stomach).? Patient very stable with resuscitation (used 1:1:1), no FVIIA.

Dell..............

Forrest "Dell" Moore, MD, FACS

Director, Trauma/Surgical Critical Care

St. Joseph's Hospital and Medical Center

Phoenix, AZ

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TRANSMEDIASTINAL GSW