List Archives

Sat Sep 12 20:58:12 BST 2009

PTX on right chest --> R chest tube placed (sorry said L last time).? Patient was doing very well with resuscitation (BD decreasing), although I was prepared at any time to go straight to OR, especially if he didn't respond or was not responding.? Didn't solely rely on EGD as when we explored L chest diaphragm was without injury.

Is there no value in assessing the great vessels with CT if patient is "stable"?? I perfomed FAST on him x 2 --> no pericardial tamponade, no free fluid in abdomen.

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

-----Original Message-----
From: McSwain, Norman E Jr. <nmcswai at tulane.edu>
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Sent: Sat, Sep 12, 2009 12:30 pm
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 thoracot
omy 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

--
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 settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

List Archives

For your convenience, find the Trauma List Archive Below

TRANSMEDIASTINAL GSW