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Sat Sep 12 20:50:29 BST 2009

what type of fluid resuscitation you did on this patient? what in pre-op
setting, what intra-op and in ICU? did you used any inotropic drugs?
permissive hypotension?
on what type of vent is the patient on?
Ante

2009/9/12 McSwain, Norman E Jr. <nmcswai at tulane.edu>

> sorry I type too fast I would have not gotten a CT but gone directly to the
> OR. I would explore the abd after the L thoracotomy
>
> 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 McSwain, Norman E Jr.
> Sent: Sat 9/12/2009 2:30 PM
> To: Trauma-List [TRAUMA.ORG]
> Subject: RE: TRANSMEDIASTINAL GSW
>
>
> 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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