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Sat Sep 12 21:03:15 BST 2009

He received 1:1:1 FFP:pRBC:platelet resuscitation preop and intraop plus around 4-5L crystalloid.  No inotropes.  Kept MAP 60-65.  He is currently on APRV/BiVent.

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

-----Original Message-----
From: Ante Ćorić <ante.coric85 at gmail.com>
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Sent: Sat, Sep 12, 2009 12:50 pm
Subject: Re: TRANSMEDIASTINAL GSW

what type of fluid resuscitation you did on this patient? what in pre-op
etting, what intra-op and in ICU? did you used any inotropic drugs?
ermissive hypotension?
n what type of vent is the patient on?
nte
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
=2
0the 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
 m
assive 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