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Sun Sep 13 08:52:41 BST 2009

 Sometimes i feel like i am on another planet. 
I've been working in a radiology department for 37 years and dying there has been uncommon and no worse than any other place to die.
You must have really crappy radiologists or a really crappy relationship with them

This case reminds me of an interesting case we had last weekend in our house.

23 year old male sustained multiple gunshot wounds two months after release after nine years in prison. Yes, been incarcerated since age 14. 
There were through and through wounds of the right arm, the right forearm and the right wrist.pulses are intact.? The arm bullet looks like it entered the right chest in the posterior axillary line. Chest tube drained 200 ml of hemothorax. There was also an entry in the right upper quadrant of the abdomen and one in the left flank at the posterior axillary line. Initially hypotensive, he responded? rapidly to a small amount of fluid and remained normotensive.

Taken for exploratory laparotomy which was nontherapeutic. no inuries identified.
A bullet subsequently found in the soft tissues of the abdomen, indicating a tangential abdominal wall injury. There was nonexpanding hematoma of the right thigh. 

postop chest and abdomen/ppelvis attached. Appears that left buttock bullet fractured the right femur

Would a CT be of use here?
What about angiography for the extremity wounds. 

sal sclafani

-----Original Message-----
From: Tidewater001 <tidewater001 at aol.com>
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Sent: Sat, Sep 12, 2009 4:12 pm
Subject: Re: TRANSMEDIASTINAL GSW

Straight to OR....Radiology dept is a horrible place to die....L thoracotomy and 
ex lap....that was one lucky patient!!  What caliber of gun??

Gregory T. Squires, MD FACS
Clinical Assistant Professor of Surgery
Medical University of South Carolina
Director of Trauma
Trident Regional Medical Center
Charleston, SC

In a message dated 09/12/09 14:43:35 Eastern Daylight Time, moore677 writes:

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: second case